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Lu HJ, Guo D, Wei QQ. Potential of Neuroinflammation-Modulating Strategies in Tuberculous Meningitis: Targeting Microglia. Aging Dis 2024; 15:1255-1276. [PMID: 37196131 PMCID: PMC11081169 DOI: 10.14336/ad.2023.0311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/11/2023] [Indexed: 05/19/2023] Open
Abstract
Tuberculous meningitis (TBM) is the most severe complication of tuberculosis (TB) and is associated with high rates of disability and mortality. Mycobacterium tuberculosis (M. tb), the infectious agent of TB, disseminates from the respiratory epithelium, breaks through the blood-brain barrier, and establishes a primary infection in the meninges. Microglia are the core of the immune network in the central nervous system (CNS) and interact with glial cells and neurons to fight against harmful pathogens and maintain homeostasis in the brain through pleiotropic functions. However, M. tb directly infects microglia and resides in them as the primary host for bacillus infections. Largely, microglial activation slows disease progression. The non-productive inflammatory response that initiates the secretion of pro-inflammatory cytokines and chemokines may be neurotoxic and aggravate tissue injuries based on damages caused by M. tb. Host-directed therapy (HDT) is an emerging strategy for modulating host immune responses against diverse diseases. Recent studies have shown that HDT can control neuroinflammation in TBM and act as an adjunct therapy to antibiotic treatment. In this review, we discuss the diverse roles of microglia in TBM and potential host-directed TB therapies that target microglia to treat TBM. We also discuss the limitations of applying each HDT and suggest a course of action for the near future.
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Affiliation(s)
- Huan-Jun Lu
- Institute of Special Environmental Medicine, Nantong University, Jiangsu, China
| | - Daji Guo
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qian-Qi Wei
- Department of Infectious Diseases, General Hospital of Tibet Military Command, Xizang, China
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Kurosaki F, Kuroki T, Nomura Y, Numao T, Bando M, Maemondo M. Prolonged paradoxical reaction requiring over 5 years of corticosteroid administration in a patient with severe tuberculous meningitis. J Infect Chemother 2024; 30:357-361. [PMID: 37922986 DOI: 10.1016/j.jiac.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/21/2023] [Accepted: 10/31/2023] [Indexed: 11/07/2023]
Abstract
Tuberculous meningitis (TBM) is a rare disease in low-incidence countries like Japan, where general physicians have fewer experience with TBM. Despite its proper treatment and early improvement of the condition, TBM often causes paradoxical reactions (PRs), which can lead to severe complications such as stroke. As PRs in the brain are difficult to detect without regular neuroimaging surveillance and have a later onset than in other organs, delayed treatment can be fatal. We report a case of a 54-year-old, human immunodeficiency virus (HIV)-negative man who presented with TBM and miliary tuberculosis (TB) in an unconscious state. Standard anti-tuberculous therapy with adjunctive systemic high-dose dexamethasone brought rapid clinical and microbiological improvement, which allowed the dexamethasone to be tapered. However, he developed cerebral infarction with left hemiplegia due to a TBM-related PR five months after admission. Therefore, the initial high-dose dexamethasone was again added to the anti-tuberculous drugs, achieving the significant effects on the PR-related lesions. Anti-tuberculous drugs had been administered for 3 years and the dexamethasone was carefully tapered. Nevertheless, enlargement of PR-related lesions in the brain recurred 5 years later. Accordingly, the dose of corticosteroid was again increased, resulting in resolving the lesions. It is important to note that severe TBM may cause prolonged PRs, which require a long-term neuroimaging follow-up and anti-inflammatory drugs for the successful management of the TBM-related PR.
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Affiliation(s)
- Fumio Kurosaki
- Division of Pulmonary Medicine, Department of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan; Department of Pulmonary Medicine, National Hospital Organization Utsunomiya National Hospital, Utsunomiya, Tochigi, Japan.
| | - Tomonori Kuroki
- Division of Pulmonary Medicine, Department of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan; Department of Pulmonary Medicine, National Hospital Organization Utsunomiya National Hospital, Utsunomiya, Tochigi, Japan
| | - Yushi Nomura
- Department of Pulmonary Medicine, National Hospital Organization Utsunomiya National Hospital, Utsunomiya, Tochigi, Japan
| | - Toshio Numao
- Department of Pulmonary Medicine, National Hospital Organization Utsunomiya National Hospital, Utsunomiya, Tochigi, Japan
| | - Masashi Bando
- Division of Pulmonary Medicine, Department of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Makoto Maemondo
- Division of Pulmonary Medicine, Department of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
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Isaiah S, Loots DT, van Furth AMT, Davoren E, van Elsland S, Solomons R, van der Kuip M, Mason S. Urinary markers of Mycobacterium tuberculosis and dysbiosis in paediatric tuberculous meningitis cases undergoing treatment. Gut Pathog 2024; 16:14. [PMID: 38475868 DOI: 10.1186/s13099-024-00609-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/29/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND The pathogenesis of tuberculous meningitis (TBM) involves infection by Mycobacterium tuberculosis in the meninges and brain. However, recent studies have shown that the immune response and inflammatory processes triggered by TBM can have significant effects on gut microbiota. Disruptions in the gut microbiome have been linked to various systemic consequences, including altered immunity and metabolic dysregulation. Inflammation caused by TBM, antibiotic treatment, and changes in host immunity can all influence the composition of gut microbes. This complex relationship between TBM and the gut microbiome is of great importance in clinical settings. To gain a deeper understanding of the intricate interactions between TBM and the gut microbiome, we report innovative insights into the development of the disease in response to treatment. Ultimately, this could lead to improved outcomes, management strategies and quality of life for individuals affected by TBM. METHOD We used a targeted liquid chromatography-tandem mass spectrometry (LC-MS/MS) approach to investigate metabolites associated with gut metabolism in paediatric participants by analysing the urine samples collected from a control group (n = 40), and an experimental group (n = 35) with confirmed TBM, which were subdivided into TBM stage 1 (n = 8), stage 2 (n = 11) and stage 3 (n = 16). FINDINGS Our metabolomics investigation showed that, of the 78 initially selected compounds of microbiome origin, eight unique urinary metabolites were identified: 2-methylbutyrlglycine, 3-hydroxypropionic acid, 3-methylcrotonylglycine, 4-hydroxyhippuric acid, 5-hydroxyindoleacetic acid, 5-hydroxyhexanoic acid, isobutyrylglycine, and phenylacetylglutamine as urinary markers of dysbiosis in TBM. CONCLUSION These results - which are supported by previous urinary studies of tuberculosis - highlight the importance of gut metabolism and of identifying corresponding microbial metabolites as novel points for the foundation of improved management of TBM patients.
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Affiliation(s)
- Simon Isaiah
- Human Metabolomics, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom, South Africa
| | - Du Toit Loots
- Human Metabolomics, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom, South Africa
| | - A Marceline Tutu van Furth
- Vrije Universiteit, Pediatric Infectious Diseases and Immunology, Amsterdam University Medical Centers, Emma Children's Hospital, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Elmarie Davoren
- Centre for Human Metabolomics, North-West University, Potchefstroom, South Africa
| | - Sabine van Elsland
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Regan Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Martijn van der Kuip
- Vrije Universiteit, Pediatric Infectious Diseases and Immunology, Amsterdam University Medical Centers, Emma Children's Hospital, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Shayne Mason
- Human Metabolomics, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom, South Africa.
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Pakhan AA, Raghumahanti R. Targeted Six-Week Intensive Physiotherapy for a Case of Tuberculous Meningitis With a Syndrome of Inappropriate Antidiuretic Hormone Secretion. Cureus 2024; 16:e55214. [PMID: 38558619 PMCID: PMC10981514 DOI: 10.7759/cureus.55214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
Tuberculous meningitis (TBM) is a severe form of extrapulmonary tuberculosis (TB) characterized by the invasion of Mycobacterium tuberculosis into the meninges surrounding the brain and spinal cord. It triggers an intense inflammatory response, leading to neurological complications if not promptly and adequately managed. TBM often precipitates muscle weakness, neurological deficits, respiratory challenges, swallowing difficulties, joint contractures, and pain. Physiotherapy intervention is essential in treating these problems by personalized treatment strategies and treatment plans to enhance muscle strength, motor control, coordination, and overall mobility. This case report aims to highlight the significant role of physiotherapy in improving the quality of life (QOL) and functional abilities of patients with TBM. The current case report reviews the case of a 73-year-old male who presented with complaints of generalized weakness and difficulty in swallowing. The patient had a history of fever for the last six months. Magnetic resonance imaging (MRI) and high-resolution computed tomography (HRCT) diagnosed the case as TBM with miliary TB. Six weeks of targeted intensive rehabilitation program was designed according to the patient's impairments initiated from the intensive care unit (ICU) phase. The main goals of physiotherapy were to start early bed mobility, maintain joint integrity, improve postural strength and swallowing, and make the patient independent in transfer and activities of daily living (ADLs). After a six-week intensive physiotherapy (TIP-6) program, the patient exhibited significant improvements in muscle strength and independence in ADLs. This case highlights the critical role of physiotherapy in enhancing the QOL and functional abilities of patients with severe TB-related conditions.
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Affiliation(s)
- Arjavi A Pakhan
- Neurophysiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Raghuveer Raghumahanti
- Neurophysiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Antonescu F, Butnariu I, Antonescu-Ghelmez D, Tuta S, Voinescu BA, Manea MC, Bucur AI, Chelmambet AS, Moraru A. Neuro-Behçet's Disease Onset in the Context of Tuberculous Meningoencephalitis: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2163. [PMID: 38138266 PMCID: PMC10744592 DOI: 10.3390/medicina59122163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023]
Abstract
Behçet's disease (BD) is a systemic vasculitis that frequently presents with a relapsing-remitting pattern. CNS involvement (Neuro-Behçet) is rare, affecting approximately 10% of patients. Its etiological mechanisms are not yet fully understood. The most commonly accepted hypothesis is that of a systemic inflammatory reaction triggered by an infectious agent or by an autoantigen, such as heat shock protein, in genetically predisposed individuals. Mycobacterium tuberculosis is known to be closely interconnected with BD, both affecting cell-mediated immunity to a certain extent and probably sharing a common genetic background. We present the case of a 34-year-old Caucasian woman who had been diagnosed with tuberculous meningitis 15 months prior, with significant neurological deficits and lesional burden on MRI with repeated relapses whenever treatment withdrawal was attempted. These relapses were initially considered as reactivation of tuberculous meningoencephalitis, and symptoms improved after a combination of antituberculous treatment and corticosteroid therapy. After the second relapse, the diagnosis was reconsidered, as new information emerged about oral and genital aphthous lesions, making us suspect a BD diagnosis. HLA B51 testing was positive, antituberculous treatment was stopped, and the patient was started on high doses of oral Cortisone and Azathioprine. Consequently, the evolution was favorable, with no further relapses and slow improvements in neurological deficits. To our knowledge, this is the first report of Neuro-Behçet's disease onset precipitated by tuberculous meningitis. We include a review of the available literature on this subject. Our case reinforces the fact that Mycobacterium tuberculosis infection can precipitate BD in genetically predisposed patients, and we recommend HLA B51 screening in patients with prolonged or relapsing meningoencephalitis, even if an infectious agent is apparently involved.
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Affiliation(s)
- Florian Antonescu
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy, 020023 Bucharest, Romania (M.C.M.)
- Department of Neurology, National Institute of Neurology and Neurovascular Diseases, 041915 Bucharest, Romania
| | - Ioana Butnariu
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy, 020023 Bucharest, Romania (M.C.M.)
- Department of Neurology, National Institute of Neurology and Neurovascular Diseases, 041915 Bucharest, Romania
| | - Dana Antonescu-Ghelmez
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy, 020023 Bucharest, Romania (M.C.M.)
- Department of Neurology, National Institute of Neurology and Neurovascular Diseases, 041915 Bucharest, Romania
| | - Sorin Tuta
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy, 020023 Bucharest, Romania (M.C.M.)
- Department of Neurology, National Institute of Neurology and Neurovascular Diseases, 041915 Bucharest, Romania
| | - Bianca Adriana Voinescu
- “Victor Babes” Clinical Hospital for Infectious and Tropical Diseases, 030303 Bucharest, Romania
| | - Mihnea Costin Manea
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy, 020023 Bucharest, Romania (M.C.M.)
- “Prof. Dr. Alexandru Obregia” Clinical Psychiatry Hospital, 041915 Bucharest, Romania
| | - Amanda Ioana Bucur
- Department of Neurology, National Institute of Neurology and Neurovascular Diseases, 041915 Bucharest, Romania
| | - Altay Sercan Chelmambet
- Department of Neurology, National Institute of Neurology and Neurovascular Diseases, 041915 Bucharest, Romania
| | - Adriana Moraru
- Department of Neurology, National Institute of Neurology and Neurovascular Diseases, 041915 Bucharest, Romania
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Asare-Baah M, Johnston L, Ramirez-Hiller T, Séraphin MN, Lauzardo M. Central Nervous System Tuberculosis: Risk Factors for Mortality in a Propensity Score-Matched Case-Control Study. Open Forum Infect Dis 2023; 10:ofad559. [PMID: 38088977 PMCID: PMC10715679 DOI: 10.1093/ofid/ofad559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Indexed: 12/30/2023] Open
Abstract
Background Despite advancements in tuberculosis (TB) control and treatment in the United States (US), patients with central nervous system TB (CNS-TB) continue to experience significantly higher mortality rates than those without CNS-TB. This raises concerns regarding clinical management and the need for a deeper understanding of the risk factors contributing to these deaths. This study aimed to determine the predictors of mortality in patients with CNS-TB. Methods We conducted a retrospective 1:2 propensity score-matched case-control study. Cases were TB patients diagnosed with TB of the meninges, brain, spinal cord, or peripheral nerves, as documented in the Florida Department of Health (FDOH) TB registry, between 2009 and 2021. Controls were TB patients without CNS-TB, also reported in the FDOH TB registry during the same timeframe. We employed conditional logistic regression models to investigate the factors contributing to mortality in cases compared with controls. Results We analyzed data from 116 cases and 232 matched controls. Patients with CNS-TB had a 5.69-fold higher risk of death than those without CNS-TB (adjusted odds ratio [aOR], 5.69 [95% confidence interval {CI}, 2.91-11.6]). Increased risk of death was associated with human immunodeficiency virus (HIV) coinfection (aOR, 1.93 [95% CI, .82-4.37]) and diabetes (aOR, 3.13 [95% CI, 1.28-7.47]). Miliary TB and non-HIV immunosuppression were significantly associated with being a case, while cavitary TB was less likely to be associated with being a case. Conclusions Clinical management should prioritize screening and close monitoring of patients with HIV coinfection and diabetes to improve patient outcomes.
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Affiliation(s)
- Michael Asare-Baah
- Department of Epidemiology, College of Public Health and Health Professions, College of Medicine, University of Florida,Gainesville, Florida, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
| | - Lori Johnston
- Bureau of Tuberculosis Control, Florida Department of Health, Tallahassee, Florida, USA
| | - Tatiana Ramirez-Hiller
- Pediatric Research Hub, Department of Pediatrics, College of Medicine, University of Florida,Gainesville, Florida, USA
| | - Marie Nancy Séraphin
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
- Division of Infectious Diseases and Global Medicine, College of Medicine, University of Florida,Gainesville, Florida, USA
| | - Michael Lauzardo
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
- Division of Infectious Diseases and Global Medicine, College of Medicine, University of Florida,Gainesville, Florida, USA
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Kimuda S, Kasozi D, Namombwe S, Gakuru J, Mugabi T, Kagimu E, Rutakingirwa MK, Leon KE, Chow F, Wasserman S, Boulware DR, Cresswell FV, Bahr NC. Advancing Diagnosis and Treatment in People Living with HIV and Tuberculosis Meningitis. Curr HIV/AIDS Rep 2023; 20:379-393. [PMID: 37947980 PMCID: PMC10719136 DOI: 10.1007/s11904-023-00678-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE OF REVIEW Tuberculous meningitis (TBM) is the most severe form of tuberculosis. Inadequate diagnostic testing and treatment regimens adapted from pulmonary tuberculosis without consideration of the unique nature of TBM are among the potential drivers. This review focuses on the progress being made in relation to both diagnosis and treatment of TBM, emphasizing promising future directions. RECENT FINDINGS The molecular assay GeneXpert MTB/Rif Ultra has improved sensitivity but has inadequate negative predictive value to "rule-out" TBM. Evaluations of tests focused on the host response and bacterial components are ongoing. Clinical trials are in progress to explore the roles of rifampin, fluoroquinolones, linezolid, and adjunctive aspirin. Though diagnosis has improved, novel modalities are being explored to improve the rapid diagnosis of TBM. Multiple ongoing clinical trials may change current therapies for TBM in the near future.
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Affiliation(s)
- Sarah Kimuda
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Derrick Kasozi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Suzan Namombwe
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Timothy Mugabi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Kristoffer E Leon
- Departments of Neurology and Medicine (Infectious Diseases), University of California San Francisco, San Francisco, CA, USA
| | - Felicia Chow
- Departments of Neurology and Medicine (Infectious Diseases), University of California San Francisco, San Francisco, CA, USA
| | - Sean Wasserman
- Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Fiona V Cresswell
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- HIV Interventions, MRC/UVRI-LSHTM Uganda Research Unit, Entebbe, Uganda
- Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, KS, USA.
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Dian S, Ganiem AR, Te Brake LH, van Laarhoven A. Current Insights into Diagnosing and Treating Neurotuberculosis in Adults. CNS Drugs 2023; 37:957-972. [PMID: 37978095 DOI: 10.1007/s40263-023-01047-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 11/19/2023]
Abstract
Neurotuberculosis has the highest morbidity and mortality risk of all forms of extrapulmonary tuberculosis (TB). Early treatment is paramount, but establishing diagnosis are challenging in all three forms of neurotuberculosis: tuberculous meningitis (TBM), spinal TB and tuberculomas. Despite advancements in diagnostic tools and ongoing research aimed at improving TB treatment regimens, the mortality rate for neurotuberculosis remains high. While antituberculosis drugs were discovered in the 1940s, TB treatment regimens were designed for and studied in pulmonary TB and remained largely unchanged for decades. However, new antibiotic regimens and host-directed therapies are now being studied to combat drug resistance and contribute to ending the TB epidemic. Clinical trials are necessary to assess the effectiveness and safety of these treatments, addressing paradoxical responses in neurotuberculosis cases and ultimately improving patient outcomes. Pharmacokinetic-pharmacodynamic analyses can inform evidence-based dose selection and exposure optimization. This review provides an update on the diagnosis and treatment of neurotuberculosis, encompassing both sensitive and resistant antituberculosis drug approaches, drawing on evidence from the literature published over the past decade.
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Affiliation(s)
- Sofiati Dian
- Department of Neurology, Dr. Hasan Sadikin Hospital, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia.
- Research Centre for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia.
| | - Ahmad Rizal Ganiem
- Department of Neurology, Dr. Hasan Sadikin Hospital, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
- Research Centre for Care and Control of Infectious Diseases, Universitas Padjadjaran, Bandung, Indonesia
| | - Lindsey Hm Te Brake
- Radboudumc Centre for Infectious Disease (RCI), Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Arjan van Laarhoven
- Radboudumc Centre for Infectious Disease (RCI), Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
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Ghimire B, Thapaliya I, Yadav J, Bhandari S, Paudyal MB, Mehta N, Bhandari S, Adhikari YR, Sapkota S, Bhattarai M. Diagnostic challenges in tuberculous meningitis: a case report with negative genexpert result. Ann Med Surg (Lond) 2023; 85:5731-5735. [PMID: 37915698 PMCID: PMC10617837 DOI: 10.1097/ms9.0000000000001332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 09/08/2023] [Indexed: 11/03/2023] Open
Abstract
Introduction Tuberculous meningitis (TBM) is a severe form of tuberculosis affecting the meninges, primarily caused by Mycobacterium tuberculosis. Diagnosis of TBM poses numerous challenges due to its nonspecific clinical presentation and the limitations of diagnostic tests like GeneXpert. Case presentation The authors report a case of a 22-year-old female from Eastern Nepal presenting with acute-onset fever, headache, vomiting, and neck pain. Cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis, elevated protein, low glucose levels, and cobweb coagulum indicative of TBM. However, the GeneXpert test revealed negative results. Discussion In resource-limited settings like Nepal, where access to GeneXpert MTB/Rif is limited, CSF analysis and clinical algorithms play a crucial role in diagnosing TBM. Relying solely on GeneXpert results may lead to false negatives, so a high level of suspicion based on patient risk factors is essential. Prompt initiation of empirical antitubercular therapy is vital for a favorable outcome in TBM cases. Conclusion Negative MTB PCR results from CSF can be misleading in diagnosis of tubercular meningitis. Therefore, comprehensive evaluations, including detailed patient history, physical examination, and CSF fluid analysis, are crucial in high tuberculous prevalence countries to ensure accurate and timely diagnosis.
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Affiliation(s)
- Bardan Ghimire
- College of Medical Sciences Teaching Hospital, Kathmandu University, Bharatpur
| | | | - Jeshika Yadav
- Tribhuvan University, Institute of Medicine, Maharajgunj
| | | | - Man B. Paudyal
- Tribhuvan University, Institute of Medicine, Maharajgunj
| | - Neha Mehta
- Tribhuvan University, Institute of Medicine, Maharajgunj
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Shi Y, Zhang C, Pan S, Chen Y, Miao X, He G, Wu Y, Ye H, Weng C, Zhang H, Zhou W, Yang X, Liang C, Chen D, Hong L, Su F. The diagnosis of tuberculous meningitis: advancements in new technologies and machine learning algorithms. Front Microbiol 2023; 14:1290746. [PMID: 37942080 PMCID: PMC10628659 DOI: 10.3389/fmicb.2023.1290746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/09/2023] [Indexed: 11/10/2023] Open
Abstract
Tuberculous meningitis (TBM) poses a diagnostic challenge, particularly impacting vulnerable populations such as infants and those with untreated HIV. Given the diagnostic intricacies of TBM, there's a pressing need for rapid and reliable diagnostic tools. This review scrutinizes the efficacy of up-and-coming technologies like machine learning in transforming TBM diagnostics and management. Advanced diagnostic technologies like targeted gene sequencing, real-time polymerase chain reaction (RT-PCR), miRNA assays, and metagenomic next-generation sequencing (mNGS) offer promising avenues for early TBM detection. The capabilities of these technologies are further augmented when paired with mass spectrometry, metabolomics, and proteomics, enriching the pool of disease-specific biomarkers. Machine learning algorithms, adept at sifting through voluminous datasets like medical imaging, genomic profiles, and patient histories, are increasingly revealing nuanced disease pathways, thereby elevating diagnostic accuracy and guiding treatment strategies. While these burgeoning technologies offer hope for more precise TBM diagnosis, hurdles remain in terms of their clinical implementation. Future endeavors should zero in on the validation of these tools through prospective studies, critically evaluating their limitations, and outlining protocols for seamless incorporation into established healthcare frameworks. Through this review, we aim to present an exhaustive snapshot of emerging diagnostic modalities in TBM, the current standing of machine learning in meningitis diagnostics, and the challenges and future prospects of converging these domains.
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Affiliation(s)
- Yi Shi
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
- The First School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Chengxi Zhang
- School of Materials Science and Engineering, Shandong Jianzhu University, Jinan, China
| | - Shuo Pan
- The First School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Yi Chen
- The First School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Xingguo Miao
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
- Department of Infectious Diseases, Wenzhou Sixth People’s Hospital, Wenzhou, China
- Wenzhou Key Laboratory of Diagnosis and Treatment of Emerging and Recurrent Infectious Diseases, Wenzhou, China
| | - Guoqiang He
- Postgraduate Training Base Alliance of Wenzhou Medical University, Wenzhou, China
- Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, China
| | - Yanchan Wu
- School of Electrical and Information Engineering, Quzhou University, Quzhou, China
| | - Hui Ye
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
- Department of Infectious Diseases, Wenzhou Sixth People’s Hospital, Wenzhou, China
- Wenzhou Key Laboratory of Diagnosis and Treatment of Emerging and Recurrent Infectious Diseases, Wenzhou, China
| | - Chujun Weng
- The Fourth Affiliated Hospital Zhejiang University School of Medicine, Yiwu, China
| | - Huanhuan Zhang
- School and Hospital of Stomatology, Wenzhou Medical University, Wenzhou, China
| | - Wenya Zhou
- School and Hospital of Stomatology, Wenzhou Medical University, Wenzhou, China
| | - Xiaojie Yang
- Wenzhou Medical University Renji College, Wenzhou, China
| | - Chenglong Liang
- The First School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Dong Chen
- Wenzhou Key Laboratory of Diagnosis and Treatment of Emerging and Recurrent Infectious Diseases, Wenzhou, China
- Wenzhou Central Blood Station, Wenzhou, China
| | - Liang Hong
- Department of Infectious Diseases, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Feifei Su
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
- Department of Infectious Diseases, Wenzhou Sixth People’s Hospital, Wenzhou, China
- Wenzhou Key Laboratory of Diagnosis and Treatment of Emerging and Recurrent Infectious Diseases, Wenzhou, China
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11
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van Toorn R, Solomons R. Diagnosis and Management of Tuberculous Meningitis in Children- an Update. Semin Pediatr Neurol 2023; 47:101071. [PMID: 37919031 DOI: 10.1016/j.spen.2023.101071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 07/30/2023] [Indexed: 11/04/2023]
Abstract
UPDATE ON THE DIAGNOSIS AND MANAGEMENT OF TUBERCULOUS MENINGITIS IN CHILDREN: Ronald van Toorn, Regan Solomons Seminars in Pediatric Neurology Volume 21, Issue 1, March 2014, Pages 12-18 Tuberculous meningitis (TBM), the most devastating manifestation of tuberculosis, is often missed or overlooked because of nonspecific symptoms and difficulties in diagnosis. It continues to be an important cause of neurologic handicap in resource-poor countries. Owing to the suboptimal performance of diagnostic tests of TBM, diagnosis relies on thorough history, clinical examination, and relevant investigations. The development of affordable, accurate diagnostic tests for TBM in resource-poor settings remains a priority. Short intensified treatment is safe and effective in both human immunodeficiency virus (HIV)-infected and HIV-uninfected children. Treatment of tuberculous hydrocephalus depends on the level of the cerebrospinal fluid obstruction. Corticosteroids reduce risk of neurodisability and death in HIV-uninfected children. Thalidomide should be considered in children compromised by tuberculosis abscesses and tuberculous-related optochiasmic arachnoiditis. In resource-poor countries, home-based TBM treatment after initial in-hospital stabilization is feasible in carefully selected patients. Early diagnosis and treatment of TBM is the single most important factor determining outcome.
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Affiliation(s)
- Ronald van Toorn
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Regan Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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12
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How do we solve a problem like tuberculosis? Nat Microbiol 2023; 8:1601-1602. [PMID: 37648946 DOI: 10.1038/s41564-023-01477-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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13
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Yang YH, Hou J, He Y, Zhang YA, Wang MS. Interferon-γ release assay and mantoux response in infants with tuberculous meningitis in low and intermediate burden countries. BMC Infect Dis 2023; 23:364. [PMID: 37254061 DOI: 10.1186/s12879-023-08327-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 05/13/2023] [Indexed: 06/01/2023] Open
Abstract
AIM Until now, the performance of interferon-γ release assay (IGRA) and Mantoux tests remains unclear in infant tuberculous meningitis (TBM). Therefore, a systematic review is performed to evaluate the sensitivity of IGRA and Mantoux tests for the diagnosis of infant TBM in low and intermediate tuberculosis (TB) burden countries, while following PRISMA. METHODS Several databases, including PubMed, EBSCO, Embase, Scopus, Web of Science, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials, were searched. Articles describing the results of IGRA or Mantoux tests among infant TBM were included for analysis. Data, such as age, sex, Mantoux test or IGRA, and cerebrospinal fluid (CSF) microbiological examinations (such as acid-fast bacilli (AFB) smear, TB PCR, and TB culture), were extracted from each study. RESULTS A total of 31 articles were enrolled for further analysis, including 48 cases. The mean age was 9.4 ± 5.8 months and boys accounted for 57.1% of infants (24/42). Mantoux test was positive in 57.4% (27/47) of tested infants and IGRA was positive in 77.8% (7/9) of infants. In addition, among the infants with confirmed TB, 18 (52.9%, 18/34) of them have positive Mantoux responses and 7 (20.0%, 7/35) have positive IGRA results. CONCLUSIONS In low or intermediate TB burden countries, the Mantoux test has a poor performance for diagnosing TBM among infants, and IGRAs appear to have a moderate sensitivity for the diagnosis of infant TBM.
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Affiliation(s)
- Yan-Hua Yang
- The Immunetech Institute of Guilin, Guilin, 541004, China
| | - Jie Hou
- Department of Intensive Care, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, 250011, China
| | - Yu He
- Department of Clinical Laboratory, First Affiliated Hospital of Guangxi Medical University, Nanning, 530012, China.
| | - Yan-An Zhang
- Department of Cardiovascular Surgery, Shandong Public Health Clinical Center, Shandong University, 46# Lishan Road, Jinan, 250013, PR China.
- Shandong Key Laboratory of Infectious Respiratory Disease, Jinan, Shandong, China.
| | - Mao-Shui Wang
- Shandong Key Laboratory of Infectious Respiratory Disease, Jinan, Shandong, China.
- Department of Lab Medicine, Shandong Public Health Clinical Center, Shandong University, 46# Lishan Road, Jinan, 250013, PR China.
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Yee AC, Wong TTJ. An atypical presentation of CNS tuberculosis manifesting with meningoencephalitis and tuberculoma in a New York taxi driver. IDCases 2023; 32:e01810. [PMID: 37273845 PMCID: PMC10238830 DOI: 10.1016/j.idcr.2023.e01810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/18/2023] [Accepted: 05/22/2023] [Indexed: 06/06/2023] Open
Abstract
Mycobacterium Tuberculous (MTb) meningitis is a rare manifestation of extrapulmonary tuberculosis (Tb) but remains the most common form of Central Nervous System (CNS) manifestation of tuberculosis. It is associated with significant morbidity and mortality yet difficult to diagnose given the low sensitivity and specificity of diagnostic testing with cerebral spinal fluid (CSF) analysis which typically shows CSF findings of lymphocytic pleocytosis, elevated protein, and low glucose and is confirmed by acid fast bacillus (AFB) culture. Here, we describe a case of severe meningoencephalopathy in the setting of disseminated tuberculosis with atypical radiological findings of tuberculoma.
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Affiliation(s)
- Aaron C. Yee
- Correspondence to: 506 6th St, Brooklyn, NY 11215, USA.
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Patel S, Dadheech M, Maurya AK, Singh J, Purwar S, Rai N, Sarawagi R, Joshi A, Khadanga S. Assessment of the Diagnostic Utility of GeneXpert Mycobacterium tuberculosis/Rifampicin (MTB/RIF) Assay in the Suspected Cases of Tuberculous Meningitis. Cureus 2023; 15:e37761. [PMID: 37213979 PMCID: PMC10193876 DOI: 10.7759/cureus.37761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2023] [Indexed: 05/23/2023] Open
Abstract
INTRODUCTION Tuberculous meningitis (TBM) is a manifestation of extrapulmonary tuberculosis (EPTB) caused by Mycobacterium tuberculosis (MTB). The central nervous system is involved in about 1%-2% of all current tuberculosis (TB) cases and about 7%-8% of all EPTB. if not treated early, TBM leads to a high rate of neurological sequelae and mortality. OBJECTIVE This study aimed to assess the diagnostic performance of the GeneXpert MTB/rifampicin (RIF) assay in patients with TBM. METHODS A total of 100 suspected TBM cases were enrolled from various departments at tertiary care hospital, Bhopal, Madhya Pradesh, India, and classified as definite, possible, or probable TBM. The clinical samples were tested for microbiological and other cerebrospinal fluid (CSF) testing. RESULTS Out of 100 cases, 14 (14%) were classified as definite TBM, 15 (15%) were having probable TBM, and 71 (71%) were having possible TBM. Out of a total of 100 participants, all were negative for acid-fast bacilli (AFB) staining. Of the 100 cases, 11 (11%) were positive by mycobacterium growth indicator tube (MGIT) culture, of which only four (36.36%) were positive by GeneXpert MTB/RIF. GeneXpert MTB/RIF detected three (3%) cases that were negative by MGIT culture. Ten (90.9%) of the 11 MGIT-positive culture isolates were found to be RIF sensitive while one (9.1%) was found to be RIF resistant. Three cases tested positive/sensitive by the GeneXpert MTB/RIF but negative by MGIT culture. Six (85%) of the seven GeneXpert MTB/RIF positive cases were RIF sensitive while one (15%) was RIF resistant. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were 36.36% (95% Confidence Interval (CI) (10.93% to 69.21%)), 96.63% (95% CI (90.46% to 99.30%)), 57.14% (95% CI (25.50% to 83.85%)), 92.47% (95% CI (88.70% to 95.06%)) and 90% (95% CI (82.38% to 95.10%)) for GeneXpert MTB/RIF assay, compared with MGIT culture as the reference standard. CONCLUSION Our study found that the sensitivity is lower when compared to culture, so using GeneXpert MTB/RIF alone is not recommended. Overall performance of GeneXpert MTB/RIF assay is noteworthy. The GeneXpert MTB/RIF assay is a potentially accepted test for obtaining an earlier diagnosis, and if it tested positive, the treatment should begin immediately. However, culture must be performed in GeneXpert MTB/RIF negative cases.
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Affiliation(s)
- Sakshi Patel
- Department of Microbiology, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Malti Dadheech
- Department of Microbiology, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Anand K Maurya
- Department of Microbiology, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Jitendra Singh
- Department of Translational Medicine Center, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Shashank Purwar
- Department of Microbiology, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Nirendra Rai
- Department of Neurology, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Radha Sarawagi
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Ankur Joshi
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Sagar Khadanga
- Department of General Medicine, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
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Altered Mental Status and Abnormal Fundus Findings in a Case of Infective Meningitis. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2023. [DOI: 10.1097/ipc.0000000000001230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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Wen A, Cao WF, Liu SM, Zhou YL, Xiang ZB, Hu F, Wu LF, Cai W, Leng EL. Incidence and Risk Factors of Cranial Nerve Palsy in Patients with Tuberculous Meningitis: A Retrospective Evaluation. Infect Drug Resist 2023; 16:829-841. [PMID: 36820083 PMCID: PMC9938703 DOI: 10.2147/idr.s396022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/03/2023] [Indexed: 02/16/2023] Open
Abstract
Objective Tuberculous meningitis (TBM) is a common form of central nervous system (CNS) tuberculosis (TB). Cranial nerve palsy is a serious complication of TBM. Literature regarding this subject is still limited in China. This study evaluated the incidence of cranial nerve palsy in patients with TBM in South China, its association with the clinical forms of TB, and other patient characteristics. Methods A retrospective chart review of patients with a diagnosis of TBM between January 2004 and December 2019 was conducted, and the demographic characteristics, clinical characteristics, and laboratory results of 114 patients were collected and followed up for 3 months. A multivariate logistic regression analysis model was used to explore the risk factors of cranial nerve palsy in patients with TBM. Results A total of 114 patients were enrolled in this study. Cranial nerve palsy was observed in approximately 38 (33.3%) of TBM patients. Among them, 13 (28.3%) had optic nerve palsy, 24 (52.2%) had oculomotor nerve palsy, 5 (10.9%) had abducens nerve palsy, 2 (4.3%) had auditory nerve palsy, 1 (2.2%) had glossopharyngeal nerve palsy, and 1 (2.2%) had vagus nerve palsy. Using logistic regression analysis, focal neurological deficit, extracranial TB and cerebrospinal fluid (CSF) total white cell count (WCC) were shown to be risk factors for cranial nerve palsy. Conclusion The prevalence rate of cranial nerve palsy was 33.3% in patients with TBM. Focal neurological deficits, extracranial TB and CSF total WCC are important predictors of cranial nerve palsy in patients with TBM.
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Affiliation(s)
- An Wen
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China,Institution of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
| | - Wen-Feng Cao
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China,Institution of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
| | - Shi-Min Liu
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China,Institution of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
| | - Yong-Liang Zhou
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China,Institution of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
| | - Zheng-Bing Xiang
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China,Institution of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
| | - Fan Hu
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China,Institution of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
| | - Ling-Feng Wu
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China,Institution of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
| | - Wen Cai
- Department of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China,Institution of Neurology, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China
| | - Er-Ling Leng
- Department of Pediatrics, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, People’s Republic of China,Correspondence: Er-Ling Leng, Department of Pediatrics, Jiangxi Provincial People’s Hospital (The First Affiliated Hospital of Nanchang Medical College), No.92 Aiguo Road, Nanchang, 330006, People’s Republic of China, Tel +86791-8772-1401, Email
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18
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Huang M, Ma Y, Ji X, Jiang H, Liu F, Chu N, Li Q. A study of risk factors for tuberculous meningitis among patients with tuberculosis in China: An analysis of data between 2012 and 2019. Front Public Health 2023; 10:1040071. [PMID: 36777786 PMCID: PMC9911662 DOI: 10.3389/fpubh.2022.1040071] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/21/2022] [Indexed: 01/29/2023] Open
Abstract
Purpose The present study aimed to explore the risk factors for tuberculous meningitis (TBM) among patients with tuberculosis (TB). Methods This retrospective study was conducted on patients with TB who were hospitalized in Beijing Chest Hospital between January 2012 and December 2019. Demographic and clinical data of patients with TB were extracted from electronic medical records using a standardized data collection system. Logistic regression was used to analyze the risk factors associated with TBM. Results Of the total number of 22,988 cases enrolled, 3.1% were cases of TBM, which included 127 definite and 581 probable TBM, respectively. Multivariate analysis showed that definite TBM was significantly associated with patients aged < 30 years [adjusted odds ratio (aOR) = 3.015, 95% confidence interval (CI): (1.451-6.266)], who were farmers [aOR = 1.490, 95%CI: (1.020-2.177)], with miliary pulmonary TB [aOR = 105.842, 95%CI: (71.704-156.235)], and with malnutrition [aOR = 2.466, 95%CI: (1.110-5.479)]. Additionally, probable TBM was significantly associated with patients aged < 30 years [aOR = 2.174, 95% CI: (1.450-3.261)], aged 30-59 years [aOR = 1.670, 95% CI: (1.222-2.282)], who were farmers [aOR = 1.482, 95%CI: (1.203-1.825)], with miliary pulmonary TB [aOR = 108.696, 95%CI: (87.122-135.613)], and with a digestive system TB [aOR = 2.906, 95%CI: (1.762-4.793)]. Conclusion An age of < 30 years, being a farmer, and having miliary pulmonary TB were risk factors for TBM among patients with TB. Further screening of patients with TB with aforementioned characteristics could facilitate clinicians to identify patients with TBM at an early stage.
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Affiliation(s)
- Mailing Huang
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Yan Ma
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xinyu Ji
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Hui Jiang
- Division of Science and Technology, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Fangchao Liu
- Division of Science and Technology, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Naihui Chu
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing, China,Naihui Chu ✉
| | - Qi Li
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing, China,Clinical Center on Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing, China,*Correspondence: Qi Li ✉
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Lu L, Li T, Chen H, Zhang L, Chen M, Peng Q, Qin X. Meningitis patients with pneumonia: correlation between blood parameters and clinical features. Biomark Med 2022; 16:1269-1278. [PMID: 36861490 DOI: 10.2217/bmm-2022-0565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
Background: This research aimed to explore the possible relationship between the main experimental parameters and clinical status in meningitis patients with pneumonia infection. Methods: A retrospective analysis of the demographic characteristics, clinical features and laboratory parameters of meningitis patients was performed. Results: D-dimer, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) exhibited good diagnostic ability for meningitis complicated with pneumonia. Additionally, we observed a positive correlation between D-dimer and CRP in cases of meningitis with pneumonia infection. D-dimer, ESR and Streptococcus pneumoniae (S. pneumoniae) were independently associated with meningitis patients with pneumonia infection. Conclusion: D-dimer, CRP, ESR and S. pneumoniae infection may effectively anticipate disease progression and adverse consequences in meningitis patients with pneumonia infection.
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Affiliation(s)
- Liuyi Lu
- Department of Clinical Laboratory, First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Taijie Li
- Department of Laboratory Medicine, Wuming Hospital of Guangxi Medical University, Nanning, 530199, Guangxi, China
| | - Huaping Chen
- Department of Clinical Laboratory, First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Linyan Zhang
- Department of Clinical Laboratory, First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Mingxing Chen
- Department of Clinical Laboratory, First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Qiliu Peng
- Department of Clinical Laboratory, Guangxi International Zhuang Medicine Hospital, Nanning, 530201, Guangxi, China
| | - Xue Qin
- Department of Clinical Laboratory, First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
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He Y, Huang Y, Wu D, Wu Y, Wang M. Clinical Management of Pathogen-Negative Tuberculous Meningitis in Adults: A Series Case Study. J Clin Med 2022; 11:6250. [PMID: 36362480 PMCID: PMC9656908 DOI: 10.3390/jcm11216250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/05/2022] [Accepted: 10/12/2022] [Indexed: 07/22/2023] Open
Abstract
Tuberculosis remains a serious world public health problem. Tuberculous meningitis (TBM) is the one of most severe forms of extrapulmonary tuberculosis. However, the insensitivity and time-consuming requirement of culturing the pathogen Mycobacterium tuberculosis, the traditional "gold standard" diagnostic test for TBM, often delays timely diagnosis and treatment, resulting in high disability and mortality rates. In our series case study, we present five pathogen-negative TBM cases who received empirical anti-tuberculosis therapy with a good clinical outcome. We describe in detail the clinical symptoms, laboratory test results, and imaging findings of the five patients from symptom onset to dynamic follow-up. We then summarize the similarities of the clinical characteristics of the presented patients, as well as shared features in laboratory and imaging tests, and proceed to analyze the challenges in the timely diagnosis of TBM. Finally, we argue that monitoring of cerebrospinal fluid markers and imaging are critical for the diagnosis and treatment of TBM, and emphasize the importance of differential diagnosis in cases when tuberculous meningitis is highly suspected despite negative findings for that etiology.
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Affiliation(s)
- Yuqin He
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Yanzhu Huang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Di Wu
- Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Yingying Wu
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Minghuan Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
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Zandvakili A, Kobayashi T, Kaewpoowat Q, Parsons MG, Ford B, Barker JH, Johnson M. Pelvic and central nervous system tuberculosis complicated by a paradoxical response manifesting as a spinal tuberculoma: a case report. BMC Infect Dis 2022; 22:750. [PMID: 36153478 PMCID: PMC9509540 DOI: 10.1186/s12879-022-07731-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 09/14/2022] [Indexed: 11/14/2022] Open
Abstract
Background The post-partum period is a risk factor for tuberculosis (TB), possibly including the period after miscarriage as illustrated here. This case demonstrates how non-specific symptoms can hide widely disseminated TB. Case presentation A healthy 26-year-old female with a history of recent miscarriage presented to the emergency department with non-specific symptoms of headache, abdominal pain, and sub-acute fevers. She had immigrated to the United States from the Marshall Islands 9 years prior. Two months prior to presentation she had a miscarriage at 18 weeks of pregnancy. On admission, transvaginal ultrasound revealed retained products of conception and abdominal computed tomography revealed findings consistent with tubo-ovarian abscesses and peritonitis. The obstetrics and gynecology service performed dilation and curettage (D&C) to remove retained products of conception. Acid-fast bacilli cultures from cerebrospinal fluid as well as specimens from D&C and intra-abdominal abscesses subsequently all grew TB. She was diagnosed with TB meningitis, peritonitis, endometritis, and tubo-ovarian abscesses. Her treatment course was complicated by a paradoxical response resulting in a spinal tuberculoma causing lower extremity weakness. The tuberculoma was treated with surgical decompression as well as continuation of treatment with anti-tubercular chemotherapy and steroids. Conclusion Disseminated and extrapulmonary TB can present with non-specific symptoms. Recognition of risk factors for TB is critical for prompt diagnostic evaluation and treatment of this deadly disease. A paradoxical reaction needs to be taken into consideration when any new neurological symptoms occur during TB treatment.
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Shi F, Qiu X, Yu M, Huang Y. Tuberculosis-specific antigen stimulated and unstimulated interferon-γ for tuberculous meningitis diagnosis: A systematic review and meta-analysis. PLoS One 2022; 17:e0273834. [PMID: 36040925 PMCID: PMC9426936 DOI: 10.1371/journal.pone.0273834] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/17/2022] [Indexed: 11/25/2022] Open
Abstract
Objective Tuberculous meningitis (TBM) is one of the most devastating TB. Accurate identification of TBM is helpful to eliminate TB. Therefore, we assessed the performance of TBAg stimulated IFN-γ (IGRA) and unstimulated IFN-γ in blood and cerebrospinal fluid (CSF) for diagnosing TBM. Methods We searched Web of Science, PubMed, Embase and the Cochrane Library databases until March 2022. Bivariate and hierarchical summary receiver operating characteristic models were employed to compute summary estimates for diagnostic accuracy parameters of IGRA and unstimulated IFN-γ in blood and CSF for diagnosing TBM. Results 28 studies including 1,978 participants and 2,641 samples met the inclusion criteria. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and area under the curve (AUROC) of blood IGRA were separately as 0.73, 0.83, 4.32, 0.33, 13.22 and 0.86, indicating a good diagnostic accuracy of blood IGRA for detecting TBM. The summary sensitivity, specificity, PLR, NLR, DOR and AUROC of CSF IGRA were separately as 0.77, 0.91, 8.82, 0.25, 34.59 and 0.93, indicating good diagnostic accuracy of CSF IGRA for detecting TBM. The summary sensitivity, specificity, PLR, NLR, DOR and AUROC of CSF IFN-γ were separately as 0.86, 0.92, 10.27, 0.16, 65.26 and 0.95, suggesting CSF IFN-γ provided excellent accuracy for diagnosing TBM. Conclusions For differentiating TBM from non-TBM individuals, blood and CSF IGRA are good assays and unstimulated CSF IFN-γ is an auxiliary excellent marker.
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Affiliation(s)
- Fangyu Shi
- Department of Health Management Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xia Qiu
- Department of Pediatrics, West China Second University Hospital, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
| | - Mingjing Yu
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Huang
- Department of Health Management Center, West China Hospital, Sichuan University, Chengdu, China
- * E-mail:
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Ariza-Vioque E, Ello F, Andriamamonjisoa H, Machault V, González-Martín J, Calvo-Cortés MC, Eholié S, Tchabert GA, Ouassa T, Raberahona M, Rakotoarivelo R, Razafindrakoto H, Rahajamanana L, Wilkinson RJ, Davis A, Maxebengula M, Abrahams F, Muzoora C, Nakigozi N, Nyehangane D, Nanjebe D, Mbega H, Kaitano R, Bonnet M, Debeaudrap P, Miró JM, Anglaret X, Rakotosamimanana N, Calmy A, Bonnet F, Ambrosioni J. Capacity Building in Sub-Saharan Africa as Part of the INTENSE-TBM Project During the COVID-19 Pandemic. Infect Dis Ther 2022; 11:1327-1341. [PMID: 35767219 PMCID: PMC9244532 DOI: 10.1007/s40121-022-00667-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/13/2022] [Indexed: 02/04/2023] Open
Abstract
Tuberculous meningitis (TBM) is the most severe and disabling form of tuberculosis (TB), with at least 100,000 cases per year and a mortality rate of up to 50% in individuals co-infected with human immunodeficiency virus type 1 (HIV-1). To evaluate the efficacy and safety of an intensified anti-tubercular regimen and an anti-inflammatory treatment, the INTENSE-TBM project includes a phase III randomised clinical trial (TBM-RCT) in four countries in sub-Saharan Africa (SSA). Within this framework, we designed a comprehensive capacity-building work package ensuring all centres had, or would acquire, the ability to conduct the TBM-RCT and developing a network of skilled researchers, clinical centres and microbiology laboratories. Here, we describe these activities, identify strengths/challenges and share tools adaptable to other projects, particularly in low- and lower-middle income countries with heterogeneous settings and during the coronavirus disease 2019 (COVID-19) pandemic. Despite major challenges, TBM-RCT initiation was achieved in all sites, promoting enhanced local healthcare systems and encouraging further clinical research in SSA. In terms of certified trainings, the achievement levels were 95% (124/131) for good clinical practice, 91% (39/43) for good clinical laboratory practice and 91% (48/53) for infection prevention and control. Platform-based research, developed as part of capacity-building activities for specific projects, may be a valuable tool in fighting future infectious diseases and in developing high-level research in Africa. The INTENSE-TBM project aimed to design a comprehensive work-package on capacity building, ensuring all centres would acquire the ability to conduct a phase III randomised clinical trial on TBM in sub-Saharan Africa, to reduce tuberculous meningitis mortality and morbidity in patients with/without HIV-1 co-infection. Therefore, the INTENSE-TBM project is an example of how an international clinical research consortium can provide opportunities to enhance local capacity building and promote centres without previous experience in clinical research. This article provides practical approaches for implementing effective capacity-building programmes. We highlight how to overcome limitations imposed by the COVID-19 pandemic to successfully complete clinics, laboratory set-ups and personnel training, so as to optimise resources and empower African institutions on a local level. At the same time, our experience shows how capacity-building programmes can deliver long-lasting impact that extends beyond the original aims of the project (e.g. HIV and TB), and support local health systems in fighting other infectious disease (e.g. COVID-19). Research projects in low- and lower-middle income countries with heterogeneous settings could stand to benefit the most.
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Affiliation(s)
- E Ariza-Vioque
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - F Ello
- Programme ANRS Coopération Côte d'Ivoire (PAC-CI), Abidjan, Ivory Coast
| | | | - V Machault
- INSERM U1219, Bordeaux Population Health (BPH), Université de Bordeaux, Bordeaux, France
| | - J González-Martín
- Servei de Microbiologia, Centre de Diagnòstic Biomèdic (CDB), Hospital Clínic de Barcelona, Barcelona, Spain
- Institut de Salut Global (ISGlobal), Barcelona, Spain
- Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
| | - M C Calvo-Cortés
- Agence Nationale de Recherche sur le SIDA et les Hépatites Virales (ANRS), Maladies Infectieuses Émergentes, Paris, France
| | - S Eholié
- Centre Hospitalier Universitaire (CHU) Treichville, Abidjan, Ivory Coast
| | - G A Tchabert
- Programme ANRS Coopération Côte d'Ivoire (PAC-CI), Abidjan, Ivory Coast
| | - T Ouassa
- Centre de Diagnostic et de Research sur le SIDA et les autres maladies infectieuses (CeDReS), Abidjan, Ivory Coast
| | - M Raberahona
- Centre d'Infectiologie Charles Mérieux (CICM), Antananarivo, Madagascar
- Université d'Antananarivo, Antananarivo, Madagascar
- Centre Hospitalier Universitaire (CHU) Joseph Raseta Befalatanana, Antananarivo, Madagascar
| | - R Rakotoarivelo
- Université de Fianarantsoa, Fianarantsoa, Madagascar
- Centre Hospitalier Universitaire (CHU) Tambohobe, Fianarantsoa, Madagascar
| | - H Razafindrakoto
- Centre d'Infectiologie Charles Mérieux (CICM), Antananarivo, Madagascar
| | - L Rahajamanana
- Centre d'Infectiologie Charles Mérieux (CICM), Antananarivo, Madagascar
| | - R J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Cape Town, Republic of South Africa
- Francis Crick Institute, London, UK
- Department Infectious Diseases, Imperial College London, London, UK
| | - A Davis
- Wellcome Centre for Infectious Diseases Research in Africa, Cape Town, Republic of South Africa
| | - M Maxebengula
- Wellcome Centre for Infectious Diseases Research in Africa, Cape Town, Republic of South Africa
| | - F Abrahams
- Wellcome Centre for Infectious Diseases Research in Africa, Cape Town, Republic of South Africa
| | - C Muzoora
- Médecins Sans Frontières (MSF) Epicentre, Mbarara, Uganda
- Mbarara University of Science and Technology (MUST), Mbarara, Uganda
| | - N Nakigozi
- Médecins Sans Frontières (MSF) Epicentre, Mbarara, Uganda
| | - D Nyehangane
- Médecins Sans Frontières (MSF) Epicentre, Mbarara, Uganda
| | - D Nanjebe
- Médecins Sans Frontières (MSF) Epicentre, Mbarara, Uganda
| | - H Mbega
- Médecins Sans Frontières (MSF) Epicentre, Mbarara, Uganda
| | - R Kaitano
- Médecins Sans Frontières (MSF) Epicentre, Mbarara, Uganda
| | - M Bonnet
- Université de Montpellier, Montpellier, France
- Recherches Translationnelles sur le VIH et les Maladies Infectieuses (TransVIHMI), Institut de Recherche pour le Développement (IRD), INSERM, Paris, France
| | - P Debeaudrap
- Recherches Translationnelles sur le VIH et les Maladies Infectieuses (TransVIHMI), Institut de Recherche pour le Développement (IRD), INSERM, Paris, France
| | - J M Miró
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
- HIV Unit, Infectious Diseases Service, Hospital Clínic de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - X Anglaret
- Programme ANRS Coopération Côte d'Ivoire (PAC-CI), Abidjan, Ivory Coast
- INSERM U1219, Bordeaux Population Health (BPH), Université de Bordeaux, Bordeaux, France
| | | | - A Calmy
- Université de Genève (UNIGE), Geneva, Switzerland
| | - F Bonnet
- INSERM U1219, Bordeaux Population Health (BPH), Université de Bordeaux, Bordeaux, France
- Service de Médecine Interne et Maladies Infectieuses, Saint-André Hospital, Centre Hospitalier Universitaire (CHU) de Bordeaux, Bordeaux, France
| | - J Ambrosioni
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
- Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain.
- HIV Unit, Infectious Diseases Service, Hospital Clínic de Barcelona, Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain.
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Stadelman AM, Ssebambulidde K, Buller A, Tugume L, Yuquimpo K, Bakker CJ, Boulware DR, Bahr NC. Cerebrospinal fluid AFB smear in adults with tuberculous meningitis: A systematic review and diagnostic test accuracy meta-analysis. Tuberculosis (Edinb) 2022; 135:102230. [PMID: 35779498 PMCID: PMC9378497 DOI: 10.1016/j.tube.2022.102230] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/13/2022] [Accepted: 06/21/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) Ziehl-Neelsen acid-fast bacilli (AFB) smear is a rapid, cheap, widely available test for tuberculous meningitis (TBM). Yet, reported test sensitivity is highly variable. We performed a systematic review and meta-analysis for CSF AFB smear vs. other mycobacterial tests to diagnose TBM. METHODS We searched MEDLINE and Embase for studies reporting sensitivity and specificity of AFB smear against mycobacterial tests (reference standard) in adults (≥15 years) with suspected TBM. We used the QUADAS-2 tool to assess risk of bias. We estimated pooled sensitivity and specificity of AFB smear versus the reference standard using random-effects bivariate modeling. We used the I2 statistic to assess heterogeneity between studies. RESULTS Of 981 articles identified, 11 were eligible for inclusion with a total of 1713 participants. Seven studies were from high-TB burden settings and 4 from low-TB burden settings. The pooled sensitivity and specificity of CSF AFB smear were 8% (95%CI 3-21) and 100% (95%CI 90-100), with substantial heterogeneity in diagnostic performance (I2 >95% for both) and reference standards. CONCLUSION CSF AFB smear has poor sensitivity in most settings. If other more sensitive tests are available, those should be used preferentially rather than CSF AFB smear.
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Affiliation(s)
- Anna M Stadelman
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, PO Box 22418, Kampala, Uganda
| | - Alexandria Buller
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Lillian Tugume
- Infectious Diseases Institute, College of Health Sciences, Makerere University, PO Box 22418, Kampala, Uganda
| | - Kyle Yuquimpo
- Department of Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Caitlin J Bakker
- Health Sciences Library, University of Minnesota, Minneapolis, MN, USA
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, KS, USA
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MacLean EL, Kohli M, Köppel L, Schiller I, Sharma SK, Pai M, Denkinger CM, Dendukuri N. Bayesian latent class analysis produced diagnostic accuracy estimates that were more interpretable than composite reference standards for extrapulmonary tuberculosis tests. Diagn Progn Res 2022; 6:11. [PMID: 35706064 PMCID: PMC9202094 DOI: 10.1186/s41512-022-00125-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 03/30/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Evaluating the accuracy of extrapulmonary tuberculosis (TB) tests is challenging due to lack of a gold standard. Latent class analysis (LCA), a statistical modeling approach, can adjust for reference tests' imperfect accuracies to produce less biased test accuracy estimates than those produced by commonly used methods like composite reference standards (CRSs). Our objective is to illustrate how Bayesian LCA can address the problem of an unavailable gold standard and demonstrate how it compares to using CRSs for extrapulmonary TB tests. METHODS We re-analyzed a dataset of presumptive extrapulmonary TB cases in New Delhi, India, for three forms of extrapulmonary TB. Results were available for culture, smear microscopy, Xpert MTB/RIF, and a non-microbiological test, cytopathology/histopathology, or adenosine deaminase (ADA). A diagram was used to define assumed relationships between observed tests and underlying latent variables in the Bayesian LCA with input from an inter-disciplinary team. We compared the results to estimates obtained from a sequence of CRSs defined by increasing numbers of positive reference tests necessary for positive disease status. RESULTS Data were available from 298, 388, and 230 individuals with presumptive TB lymphadenitis, meningitis, and pleuritis, respectively. Using Bayesian LCA, estimates were obtained for accuracy of all tests and for extrapulmonary TB prevalence. Xpert sensitivity neared that of culture for TB lymphadenitis and meningitis but was lower for TB pleuritis, and specificities of all microbiological tests approached 100%. Non-microbiological tests' sensitivities were high, but specificities were only moderate, preventing disease rule-in. CRSs' only provided estimates of Xpert and these varied widely per CRS definition. Accuracy of the CRSs also varied by definition, and no CRS was 100% accurate. CONCLUSION Unlike CRSs, Bayesian LCA takes into account known information about test performance resulting in accuracy estimates that are easier to interpret. LCA should receive greater consideration for evaluating extrapulmonary TB diagnostic tests.
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Affiliation(s)
- Emily L MacLean
- McGill International TB Centre, Research Institute of the McGill University Health Centre, Montréal, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Canada
| | | | - Lisa Köppel
- Division of Tropical Medicine, Center of Infectious Diseases, Heidelberg University, Heidelberg, Germany
| | - Ian Schiller
- Department of Medicine, McGill University Health Centre, Montréal, Canada
| | - Surendra K Sharma
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Madhukar Pai
- McGill International TB Centre, Research Institute of the McGill University Health Centre, Montréal, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Canada
| | - Claudia M Denkinger
- McGill International TB Centre, Research Institute of the McGill University Health Centre, Montréal, Canada
- Division of Tropical Medicine, Center of Infectious Diseases, Heidelberg University, Heidelberg, Germany
| | - Nandini Dendukuri
- McGill International TB Centre, Research Institute of the McGill University Health Centre, Montréal, Canada.
- Department of Medicine, McGill University Health Centre, Montréal, Canada.
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Huynh J, Donovan J, Phu NH, Nghia HDT, Thuong NTT, Thwaites GE. Tuberculous meningitis: progress and remaining questions. Lancet Neurol 2022; 21:450-464. [PMID: 35429482 DOI: 10.1016/s1474-4422(21)00435-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 10/03/2021] [Accepted: 11/25/2021] [Indexed: 12/23/2022]
Abstract
Tuberculous meningitis is a devastating brain infection that is caused by Mycobacterium tuberculosis and is notoriously difficult to diagnose and treat. New technologies characterising the transcriptome, proteome, and metabolome have identified new molecules and pathways associated with tuberculous meningitis severity and poor outcomes that could offer novel diagnostic and therapeutic targets. The next-generation GeneXpert MTB/RIF Ultra assay, when used on CSF, offers diagnostic sensitivity for tuberculous meningitis of approximately 70%, although it is not widely available and a negative result cannot rule out tuberculous meningitis. Small trials indicate that clinical outcomes might be improved with increased doses of rifampicin, the addition of linezolid or fluoroquinolones to standard antituberculosis therapy, or treatment with adjunctive aspirin combined with corticosteroids. Large phase 3 clinical trials are underway worldwide to address these and other questions concerning the optimal management of tuberculous meningitis; these studies also form a platform for studying pathogenesis and identifying novel diagnostic and treatment strategies, by allowing the implementation of new genomic, transcriptomic, proteomic, and metabolomic technologies in nested substudies.
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Affiliation(s)
- Julie Huynh
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK; Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Joseph Donovan
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK; Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Nguyen Hoan Phu
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK; Vietnam National University School of Medicine, Ho Chi Minh City, Vietnam
| | - Ho Dang Trung Nghia
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Nguyen Thuy Thuong Thuong
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK; Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Guy E Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK; Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam.
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Wen A, Liu SM, Cao WF, Zhou YL, Luo CQ, Xiang ZB, Hu F, Zhang P, Leng EL. A New Scoring System to Differentially Diagnose and Distinguish Tuberculous Meningitis and Bacterial Meningitis in South China. Front Neurol 2022; 13:830969. [PMID: 35432172 PMCID: PMC9006614 DOI: 10.3389/fneur.2022.830969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/08/2022] [Indexed: 11/15/2022] Open
Abstract
Background Tuberculous meningitis (TBM) is the most serious form of extrapulmonary tuberculosis caused by Mycobacterium tuberculosis, and is characterized by high morbidity and mortality. Unfortunately, it is difficult to distinguish TBM from bacterial meningitis (BM) based on clinical features alone. The latest diagnostic tests and neuroimaging methods are still not available in many developing countries. This study aimed to develop a simple diagnostic algorithm based on clinical and laboratory test results as an early predictor of TBM in South China. Methods A retrospective study was conducted to compare the clinical and laboratory characteristics of 114 patients with TBM and 47 with BM. Multivariate logistic regression analysis was performed on the characteristics of independently predicted TBM to develop a new diagnostic rule. Results Five characteristics were predictive of a diagnosis of TBM: duration of symptoms before admission; tuberculous symptoms; white blood cell (WBC) count, total cerebrospinal fluid WBC count, and cerebrospinal fluid chloride concentration. The sensitivity and specificity of the new scoring system developed in this study were 81.6 and 93.6%, respectively. Conclusion The new scoring system proposed in this study can help physicians empirically diagnose TBM and can be used in countries and regions with limited microbial and radiological resources.
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Affiliation(s)
- An Wen
- Department of Neurology, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
- Institution of Neurology, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
| | - Shi-Min Liu
- Department of Neurology, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
- Institution of Neurology, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
| | - Wen-Feng Cao
- Department of Neurology, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
- Institution of Neurology, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
| | - Yong-Liang Zhou
- Department of Neurology, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
- Institution of Neurology, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
| | - Chao-Qun Luo
- Department of Neurology, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
- Institution of Neurology, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
| | - Zheng-bing Xiang
- Department of Neurology, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
- Institution of Neurology, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
| | - Fan Hu
- Department of Neurology, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
- Institution of Neurology, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
| | - Ping Zhang
- Department of Neurology, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
- Institution of Neurology, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
| | - Er-Ling Leng
- Department of Pediatrics, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
- *Correspondence: Er-Ling Leng
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Sholeye AR, Williams AA, Loots DT, Tutu van Furth AM, van der Kuip M, Mason S. Tuberculous Granuloma: Emerging Insights From Proteomics and Metabolomics. Front Neurol 2022; 13:804838. [PMID: 35386409 PMCID: PMC8978302 DOI: 10.3389/fneur.2022.804838] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 02/24/2022] [Indexed: 12/24/2022] Open
Abstract
Mycobacterium tuberculosis infection, which claims hundreds of thousands of lives each year, is typically characterized by the formation of tuberculous granulomas — the histopathological hallmark of tuberculosis (TB). Our knowledge of granulomas, which comprise a biologically diverse body of pro- and anti-inflammatory cells from the host immune responses, is based mainly upon examination of lungs, in both human and animal studies, but little on their counterparts from other organs of the TB patient such as the brain. The biological heterogeneity of TB granulomas has led to their diverse, relatively uncoordinated, categorization, which is summarized here. However, there is a pressing need to elucidate more fully the phenotype of the granulomas from infected patients. Newly emerging studies at the protein (proteomics) and metabolite (metabolomics) levels have the potential to achieve this. In this review we summarize the diverse nature of TB granulomas based upon the literature, and amplify these accounts by reporting on the relatively few, emerging proteomics and metabolomics studies on TB granulomas. Metabolites (for example, trimethylamine-oxide) and proteins (such as the peptide PKAp) associated with TB granulomas, and knowledge of their localizations, help us to understand the resultant phenotype. Nevertheless, more multidisciplinary ‘omics studies, especially in human subjects, are required to contribute toward ushering in a new era of understanding of TB granulomas – both at the site of infection, and on a systemic level.
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Affiliation(s)
- Abisola Regina Sholeye
- Department of Biochemistry, Human Metabolomics, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom, South Africa
| | - Aurelia A. Williams
- Department of Biochemistry, Human Metabolomics, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom, South Africa
| | - Du Toit Loots
- Department of Biochemistry, Human Metabolomics, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom, South Africa
| | - A. Marceline Tutu van Furth
- Department of Pediatric Infectious Diseases and Immunology, Pediatric Infectious Diseases and Immunology, Amsterdam University Medical Center, Emma Children's Hospital, Amsterdam, Netherlands
| | - Martijn van der Kuip
- Department of Pediatric Infectious Diseases and Immunology, Pediatric Infectious Diseases and Immunology, Amsterdam University Medical Center, Emma Children's Hospital, Amsterdam, Netherlands
| | - Shayne Mason
- Department of Biochemistry, Human Metabolomics, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom, South Africa
- *Correspondence: Shayne Mason
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Saghazadeh A, Rezaei N. Central Inflammatory Cytokines in Tuberculous Meningitis: A Systematic Review and Meta-analysis. J Interferon Cytokine Res 2022; 42:95-107. [PMID: 35298290 DOI: 10.1089/jir.2021.0176] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
No formal agreement exists regarding central inflammatory cytokine aberrations in tuberculosis (TB). We undertook a systematic review and meta-analysis of studies comparing cytokine levels in cerebrospinal fluid (CSF) from patients with TB compared with controls. We searched PubMed, Scopus, and Web of Science for articles published up to June 22, 2021. Studies were included in the meta-analysis if they assessed unadjusted levels of cytokines in unstimulated CSF samples and drew the comparison(s) between any of the following pairs: patients with TB versus controls without central nervous system (CNS) infection and meningitis, patients with TB versus patients with meningitis of etiologies other than Mycobacterium tuberculosis, HIV-infected patients with TB versus HIV-uninfected patients with TB, and HIV-infected patients with TB versus HIV-infected patients without TB. The primary outcome was the difference in mean CSF inflammatory cytokine levels between each of the 2 groups mentioned. The standardized mean difference was chosen to measure effect using a restricted maximum-likelihood estimator random-effects model. Of 1170 records identified, 40 studies were included in the meta-analysis. We calculated effect sizes for 30 different cytokines. About half of the studies took place in South Africa and India (18 out of 40 studies). Studies were mostly (92.5%) on patients with tuberculous meningitis (TBM), with only 3 articles of patients with neurotuberculosis and spinal TB. The quality of studies was rated as low to moderate and high with a 1.2:1 ratio. Compared with controls without CNS infection and meningitis, interferon-gamma (IFNγ), interleukin (IL)-12p40, IL-17F, IL-1β, IL-2, IL-4, IL-6, IL-8, sIL-2R, transforming growth factor beta (TGFβ), TGFβ1, and tumor necrosis factor alpha (TNFα) were increased in patients with TBM. Compared with patients with meningitis of etiologies other than M. tuberculosis or combined meningitis and nonmeningitis patients, patients with TBM had higher CSF concentrations of IFNγ, IL-13, and sIL-2R, whereas levels of IL-12p70, IL-15, IL-1Ra, IL-5, IL-7, IL-9, and sTNFR55 were decreased. Compared with patients with meningitis of bacterial etiologies other than M. tuberculosis, CSF levels of IFNγ and sIL-2R were increased in patients with TBM, whereas levels of IL-1Ra, IL-13, IL-17, and TNF R55-BP were decreased. Patients with TBM were not different from patients with CM for most CSF cytokines assessed, but IFNγ and IL-1β were increased. TNFα, IL-1β, IL-1Ra, IL-8, IFNγ, sIL-2R, IL-13, and IL-17 were higher in patients with TBM than those with viral or aseptic meningitis. Compared with HIV-negative patients with TBM, IFNγ, IL-10, IL-12p70, and IL-5 were decreased in HIV-positive patients with TBM, whereas IL-1β, TNFα, and IL-2 were increased. Elevated TNFα, IL-1β, IFNγ, IL-6, IL-17, and IFNα2 were found in HIV-positive patients with TBM compared with their counterparts without TBM. This study should be considered an explorative meta-analytic review, leading us to offer the best TBM-associated central inflammatory cytokines. Our study could prepare a panel of central cytokines as a potential aid in diagnosing TBM and its differentiation from meningitis of other etiologies.
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Affiliation(s)
- Amene Saghazadeh
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Systematic Review and Meta-analysis Expert Group (SRMEG), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
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Zhang M, Wang M, He JQ. Intensified Antituberculosis Therapy Regimen Containing Higher Dose Rifampin for Tuberculous Meningitis: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:822201. [PMID: 35280900 PMCID: PMC8916538 DOI: 10.3389/fmed.2022.822201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 01/19/2022] [Indexed: 11/17/2022] Open
Abstract
Background Tuberculous meningitis is difficult to diagnose and is associated with high mortality. Recently, several studies evaluated the intensified regimen containing higher dose rifampin to treat tuberculous meningitis. However, this topic remains to be concluded. Therefore, this systematic review and meta-analysis was conducted to evaluate pharmacokinetics parameters, safety, and survival benefits of high-dose rifampin for tuberculous meningitis. Method Data were searched from PubMed, EMBASE, The Cochrane Library, and Web of Science for studies describing an antituberculosis regimen including a higher dose of rifampin for patients with tuberculous meningitis. The quality of eligible studies was evaluated via The Cochrane Risk of Bias Tool. The meta-analysis was performed by Review Manager 5.3 software, the synthesis of the data was shown in mean difference (MD) or relative risk (RR), and 95% confidence intervals (CIs). Results There were six randomized control trails included in this meta-analysis. The results showed that the concentration in plasma and cerebrospinal fluid (CSF) were significantly higher in the intervention group than the standard group [MD = 22.08, 95%CI (16.24, 27.92), p < 0.00001; MD = 0.74, 95%CI (0.42, 1.05), p < 0.00001], as well as the area under the time concentration curve between 0 and 24 h (AUC0−24) of rifampin [MD 203.56, 95%CI (153.07, 254.05), p < 0.00001] in plasma, but the overall survival did not improve [RR = 0.92, 95%CI (0.67, 1.26), p = 0.61]. For adverse events, the results showed a statistically significant lower incidence of hypersensitivity compared with the intervention group [RR = 1.72, 95%CI (1.13, 2.62), p = 0.01]. Fortunately, other common adverse drug reactions such as liver injury, neurological events, myelosuppression, and cardiotoxicity had no significant increase [RR = 0.98, 95%CI (0.77, 1.26), p = 0.90; RR = 1.10, 95%CI (0.94, 1.30), p = 0.23; RR = 0.82, 95%CI (0.59, 1.13), p = 0.22; RR = 1.11, 95%CI (0.66, 1.86), p = 0.70]. Conclusion This meta-analysis suggested that the intensified treatment regimen including a higher dose of rifampin significantly increased the rifampin concentration both in the plasma and CSF, and it was safe in patients with tuberculous meningitis, but resulted in no improvement in survival rates.
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Dasovic B, Ewa Borys, Schneck MJ. Granulomatous Diseases of the Central Nervous System. Curr Neurol Neurosci Rep 2022; 22:33-45. [PMID: 35138588 DOI: 10.1007/s11910-022-01173-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW To discuss the pathophysiology, key clinical features, necessary diagnostic evaluation, and current treatment regimens for granulomatous diseases of the central nervous system. RECENT FINDINGS The diagnosis and management of granulomatous disease of the central nervous system has been revolutionized by advances in diagnostic imaging. Nevertheless, tissue and/or cerebrospinal fluid (CSF) sampling remains necessary to establish the diagnosis in most cases. Establishing a specific diagnosis is critical because treatment selection needs to focus on the granulomatous process centering on either antibiotic or immunosuppressive agents. Particular for non-infectious granulomatous disease more aggressive immunotherapies may help in clinical outcome. There are multiple non-infectious and infectious etiologies for granulomatous disease of the central nervous system. Clinical manifestations result from local structural invasion of granulomas or granulomatous inflammation of the blood vessels and meninges. Rapid diagnosis and specific treatment is essential.
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Affiliation(s)
- Braden Dasovic
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, 2160 South First Avenue Maguire Building Suite 2700, Maywood, IL, 60153, USA
| | - Ewa Borys
- Department of Pathology, Stritch School of Medicine, Loyola University Chicago, 2160 South First Avenue Maguire Building Suite 2700, Maywood, IL, 60153, USA
| | - Michael J Schneck
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, 2160 South First Avenue Maguire Building Suite 2700, Maywood, IL, 60153, USA.
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Ali Y, Imam Y, Ahmedullah HS, Akhtar N, Kamran S, Al Maslmani M, Al Khal AL, Own A, Deleu D. Complicated Neurotuberculosis with sinus venous thrombosis: A case-report. IDCases 2022; 27:e01374. [PMID: 35079572 PMCID: PMC8777086 DOI: 10.1016/j.idcr.2022.e01374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 01/02/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Neurotuberculosis comprises around 6% of systemic tuberculosis. It targets a younger population, and it often leads to severe neurological complications or death. CASE REPORT We report a young gentleman with a clinically defined tuberculous meningitis (TBM) and multiple neurological complication associated with TBM occurring simultaneously. This includes hydrocephalus requiring a ventriculoperitoneal shunt, vasculitic infarcts, cranial nerve palsies, TB granuloma and cerebral venous thrombosis. The cerebrospinal fluid polymerase chain reaction for tuberculosis as well as cultures remained negative repeatedly. The patient was treated with anti-tuberculous medication in addition to steroids based on validated scoring systems suggestive of TBM and made a good recovery. CONCLUSION This report highlights the different complication seen with TBM and the importance of using clinical criteria to guide management plan particularly when cultures are negative.
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Affiliation(s)
- Yousra Ali
- Department of Medicine, Hamad Medical Corporation Doha, Qatar
| | - Yahia Imam
- Neuroscience Institute, Hamad Medical Corporation Doha, Qatar
- Weil Cornell Medicine, Doha, Qatar
| | | | - Naveed Akhtar
- Neuroscience Institute, Hamad Medical Corporation Doha, Qatar
- Weil Cornell Medicine, Doha, Qatar
| | - Saadat Kamran
- Neuroscience Institute, Hamad Medical Corporation Doha, Qatar
- Weil Cornell Medicine, Doha, Qatar
| | - Muna Al Maslmani
- Weil Cornell Medicine, Doha, Qatar
- Center for Communicable Disease, Doha, Qatar
| | - A. Latif Al Khal
- Weil Cornell Medicine, Doha, Qatar
- Center for Communicable Disease, Doha, Qatar
| | - Ahmed Own
- Neuroscience Institute, Hamad Medical Corporation Doha, Qatar
| | - Dirk Deleu
- Neuroscience Institute, Hamad Medical Corporation Doha, Qatar
- Weil Cornell Medicine, Doha, Qatar
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Abo YN, Curtis N, Osowicki J, Haeusler G, Purcell R, Kadambari S, De Wachter M, Vanden Driessche K, Dekeyzer S, Coleman L, Crawford N, Graham S, Marais B, Gwee A. Infliximab for Paradoxical Reactions in Pediatric Central Nervous System Tuberculosis. J Pediatric Infect Dis Soc 2021; 10:1087-1091. [PMID: 34608937 DOI: 10.1093/jpids/piab094] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/28/2021] [Indexed: 12/29/2022]
Abstract
Paradoxical reactions in central nervous system tuberculosis (CNS-TB) are associated with significant morbidity and mortality. We describe 4 HIV-uninfected children treated for CNS-TB with severe paradoxical reactions unresponsive to corticosteroids. All made recovery after treatment with infliximab, highlighting the safety and effectiveness of infliximab for this complication, and need for prospective trials.
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Affiliation(s)
- Yara-Natalie Abo
- Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Nigel Curtis
- Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Joshua Osowicki
- Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Gabrielle Haeusler
- Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Rachael Purcell
- Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Seilesh Kadambari
- Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Matthias De Wachter
- Division of Paediatric Neurology, Department of Paediatrics, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Koen Vanden Driessche
- Division of Paediatric Pulmonology, Department of Paediatrics, University Hospital Antwerp, Edegem, Belgium.,Section of Paediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Nijmegen, The Netherlands.,DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research and SA/MRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Sven Dekeyzer
- Department of Radiology, Antwerp University Hospital (UZA), Edegem, Belgium
| | - Lee Coleman
- Department of Radiology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Nigel Crawford
- Department of Paediatrics, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Steve Graham
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Ben Marais
- The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Amanda Gwee
- Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
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Luo Y, Xue Y, Lin Q, Mao L, Tang G, Song H, Liu W, Wu S, Liu W, Zhou Y, Xu L, Xiong Z, Wang T, Yuan X, Gan Y, Sun Z, Wang F. Diagnostic Model for Discrimination Between Tuberculous Meningitis and Bacterial Meningitis. Front Immunol 2021; 12:731876. [PMID: 34867952 PMCID: PMC8632769 DOI: 10.3389/fimmu.2021.731876] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/07/2021] [Indexed: 11/15/2022] Open
Abstract
Background The differential diagnosis between tuberculous meningitis (TBM) and bacterial meningitis (BM) remains challenging in clinical practice. This study aimed to establish a diagnostic model that could accurately distinguish TBM from BM. Methods Patients with TBM or BM were recruited between January 2017 and January 2021 at Tongji Hospital (Qiaokou cohort) and Sino-French New City Hospital (Caidian cohort). The detection for indicators involved in cerebrospinal fluid (CSF) and T-SPOT assay were performed simultaneously. Multivariate logistic regression was used to create a diagnostic model. Results A total of 174 patients (76 TBM and 98 BM) and another 105 cases (39 TBM and 66 BM) were enrolled from Qiaokou cohort and Caidian cohort, respectively. Significantly higher level of CSF lymphocyte proportion while significantly lower levels of CSF chlorine, nucleated cell count, and neutrophil proportion were observed in TBM group when comparing with those in BM group. However, receiver operating characteristic (ROC) curve analysis showed that the areas under the ROC curve (AUCs) produced by these indicators were all under 0.8. Meanwhile, tuberculosis-specific antigen/phytohemagglutinin (TBAg/PHA) ratio yielded an AUC of 0.889 (95% CI, 0.840–0.938) in distinguishing TBM from BM, with a sensitivity of 68.42% (95% CI, 57.30%–77.77%) and a specificity of 92.86% (95% CI, 85.98%–96.50%) when a cutoff value of 0.163 was used. Consequently, we successfully established a diagnostic model based on the combination of TBAg/PHA ratio, CSF chlorine, CSF nucleated cell count, and CSF lymphocyte proportion for discrimination between TBM and BM. The established model showed good performance in differentiating TBM from BM (AUC: 0.949; 95% CI, 0.921–0.978), with 81.58% (95% CI, 71.42%–88.70%) sensitivity and 91.84% (95% CI, 84.71%–95.81%) specificity. The performance of the diagnostic model obtained in Qiaokou cohort was further validated in Caidian cohort. The diagnostic model in Caidian cohort produced an AUC of 0.923 (95% CI, 0.867–0.980) with 79.49% (95% CI, 64.47%–89.22%) sensitivity and 90.91% (95% CI, 81.55%–95.77%) specificity. Conclusions The diagnostic model established based on the combination of four indicators had excellent utility in the discrimination between TBM and BM.
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Affiliation(s)
- Ying Luo
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ying Xue
- Department of Immunology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qun Lin
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Laboratory Medicine Center, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Liyan Mao
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guoxing Tang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huijuan Song
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Liu
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shiji Wu
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Weiyong Liu
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Zhou
- Department of Laboratory Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Lingqing Xu
- Qingyuan People's Hospital, The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan, China
| | - Zhigang Xiong
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ting Wang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xu Yuan
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yong Gan
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ziyong Sun
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Feng Wang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Thee S, Basu Roy R, Blázquez-Gamero D, Falcón-Neyra L, Neth O, Noguera-Julian A, Lillo C, Galli L, Venturini E, Buonsenso D, Götzinger F, Martinez-Alier N, Velizarova S, Brinkmann F, Welch SB, Tsolia M, Santiago-Garcia B, Schilling R, Tebruegge M, Krüger R. Treatment and outcome in children with tuberculous meningitis - a multi-centre Paediatric Tuberculosis Network European Trials Group study. Clin Infect Dis 2021; 75:372-381. [PMID: 34849642 DOI: 10.1093/cid/ciab982] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Currently, data on treatment, outcome, and prognostic factors in children with tuberculous meningitis (TBM) in Europe are limited. To date, most existing data on TBM originate from adult studies, or studies conducted in low-resource settings. METHODS Multicentre, retrospective study involving 27 paediatric healthcare institutions in nine European countries via an established paediatric TB research network, before and after the 2014 revision of WHO dosing recommendations. RESULTS Of 118 children, 39 (33.1%) had TBM grade 1, 68 (57.6%) grade 2 and 11 (9.3%) grade 3. Fifty-eight (49.1%) children received a standard four-drug treatment regimen; other commonly used drugs included streptomycin, prothionamide, and amikacin. Almost half of the patients (48.3%; 56/116) were admitted to intensive care unit, with a median stay of 10 (IQR 4.5-21.0) days. Of 104 children with complete outcome data, 9.6% (10/104) died, and only 47.1% (49/104) recovered fully. Main long-term sequelae included spasticity of one or more limbs and developmental delay both in 19.2% (20/104), and seizure disorder in 17.3% (18/104). Multivariate regression analyses identified microbiological confirmation of TBM, the need for neurosurgical intervention and mechanical ventilation as risk factors for unfavourable outcome. DISCUSSION There was considerable heterogeneity in the use of TB drugs in this cohort. Despite few children presenting with advanced disease and the study being conducted in a high-resource setting, morbidity and mortality were high. Several risk factors for poor outcome were identified, which may aid prognostic predictions in children with TBM in the future.
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Affiliation(s)
- Stephanie Thee
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Centre, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Robindra Basu Roy
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Daniel Blázquez-Gamero
- Paediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Instituto de Investigación Hospital Universitario 12 de Octubre (imas12), RITIP, Madrid, Spain
| | - Lola Falcón-Neyra
- Paediatric Infectious Diseases, Rheumatology and Immunology Unit, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Seville (IBIS), Sevilla, Spain
| | - Olaf Neth
- Paediatric Infectious Diseases, Rheumatology and Immunology Unit, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Seville (IBIS), Sevilla, Spain
| | - Antoni Noguera-Julian
- Malalties Infeccioses i Resposta Inflamatòria Sistèmica en Pediatria, Institut de Recerca Sant Joan de Déu, Barcelona, Spain.,Departament de Pediatria, Universitat de Barcelona, Barcelona, Spain.,CIBER de Epidemiología y Salud Pública, CIBERESP, Madrid, Spain.,Red de Investigación Translacional en Infectología Pediátrica, RITIP, Madrid, Spain
| | - Cristina Lillo
- Paediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Instituto de Investigación Hospital Universitario 12 de Octubre (imas12), RITIP, Madrid, Spain
| | - Luisa Galli
- Department of Health Sciences, University of Florence, Florence, Italy.,Paediatric Infectious Disease Unit, Meyer Children's University Hospital, Florence, Italy
| | - Elisabetta Venturini
- Department of Health Sciences, University of Florence, Florence, Italy.,Paediatric Infectious Disease Unit, Meyer Children's University Hospital, Florence, Italy
| | - Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Florian Götzinger
- Department of Paediatrics and Adolescent Medicine, National Reference Centre for Childhood Tuberculosis, Klinik Ottakring, Vienna, Austria
| | - Nuria Martinez-Alier
- Department of Paediatric Infectious Diseases & Immunology, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Svetlana Velizarova
- Department of Pulmonary Diseases, Medical University, Hospital for Lung Diseases 'St. Sofia', Sofia, Bulgaria
| | - Folke Brinkmann
- Department of Paediatric Pulmonology, Ruhr University Bochum, Bochum, Germany
| | - Steven B Welch
- Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Maria Tsolia
- Second Department or Paediatrics, National and Kapodistrian University of Athens, School of Medicine, P. and A. Kyriakou Children's Hospital, Athens, Greece
| | - Begoña Santiago-Garcia
- Department of Paediatric Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain. Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain. Red de Investigación Translacional en Infectología Pediátrica (RITIP)
| | - Ralph Schilling
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Germany.,Institute for Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, Germany
| | - Marc Tebruegge
- Department of Paediatric Infectious Diseases & Immunology, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK.,Department of Paediatrics, Royal Children's Hospital Melbourne, University of Melbourne, Melbourne, Australia.,Department of Infection, Immunity & Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Renate Krüger
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine and Cystic Fibrosis Centre, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Quinn CM, Kagimu E, Okirworth M, Bangdiwala AS, Mugumya G, Ramachandran PS, Wilson MR, Meya DB, Cresswell FV, Bahr NC, Boulware DR. Fujifilm SILVAMP TB LAM Assay on Cerebrospinal Fluid for the Detection of Tuberculous Meningitis in Adults With Human Immunodeficiency Virus. Clin Infect Dis 2021; 73:e3428-e3434. [PMID: 33388751 PMCID: PMC8563225 DOI: 10.1093/cid/ciaa1910] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Tuberculous meningitis (TBM) has a high fatality rate, with inadequate diagnostic tests being a major contributor. The rollout of Xpert MTB/Rif and Xpert MTB/RIF Ultra (Xpert Ultra) have improved time-to-diagnosis with sensitivities similar to culture, yet test availability and sensitivity are inadequate. The TB lipoarabinomannan lateral flow assay (AlereLAM) offers ease of use, but its low sensitivity in cerebrospinal fluid (CSF) limits clinical utility for TBM. The Fujifilm SILVAMP TB LAM (FujiLAM) assay has excellent sensitivity in urine, but performance on cerebrospinal fluid is uncertain. METHODS We conducted a prospective cohort study at Kiruddu National Referral Hospital in Kampala, Uganda, enrolling patients suspected to have TBM. CSF was tested using AlereLAM, Xpert Ultra, culture, and FujiLAM. Results were compared with 2 reference standards: probable and definite TBM or definite TBM alone by the uniform TBM case definition. RESULTS Of 101 patients enrolled (95/101 HIV-positive), 34 had definite TBM and 24 had probable TBM. FujiLAM sensitivity on CSF was 52% (30/58) for definite or probable TBM compared with 55% (32/58) for Xpert Ultra. AlereLAM had lower sensitivity than FujiLAM in the subgroup of patients tested with both assays (14% [4/28] vs 50% [14/28]; P < .01). FujiLAM specificity was 98% (42/43) for patients without probable or definite TBM. CONCLUSIONS FujiLAM showed higher sensitivity than AlereLAM, with sensitivity potentially approaching that of Xpert Ultra. FujiLAM could improve time-to-treatment-initiation, especially in settings where the more technical Xpert Ultra system might not be feasible. Large confirmatory studies are needed.
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Affiliation(s)
- Carson M Quinn
- School of Medicine, University of California, San Francisco, San Francisco, California, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Enock Kagimu
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Michael Okirworth
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Ananta S Bangdiwala
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Gerald Mugumya
- Microbiology Laboratory, Kiruddu National Referral Hospital, Kampala, Uganda
| | - Prashanth S Ramachandran
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Michael R Wilson
- Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - David B Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fiona V Cresswell
- Clinical Research Division, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, Kansas, USA
| | - David R Boulware
- Division of Infectious Diseases, Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Affiliation(s)
- H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa, .,Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Department of Infectious Diseases, Imperial College London, London, UK
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa, .,Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Department of Infectious Diseases, Imperial College London, London, UK
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38
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Mason S, Solomons R. CSF Metabolomics of Tuberculous Meningitis: A Review. Metabolites 2021; 11:661. [PMID: 34677376 PMCID: PMC8541251 DOI: 10.3390/metabo11100661] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/20/2021] [Accepted: 09/24/2021] [Indexed: 02/07/2023] Open
Abstract
From the World Health Organization's global TB report for 2020, it is estimated that in 2019 at least 80,000 children (a particularly vulnerable population) developed tuberculous meningitis (TBM)-an invariably fatal disease if untreated-although this is likely an underestimate. As our latest technologies have evolved-with the unprecedented development of the various "omics" disciplines-a mountain of new data on infectious diseases have been created. However, our knowledge and understanding of infectious diseases are still trying to keep pace. Metabolites offer much biological information, but the insights they permit can be difficult to derive. This review summarizes current metabolomics studies on cerebrospinal fluid (CSF) from TBM cases and collates the metabolic data reported. Collectively, CSF metabolomics studies have identified five classes of metabolites that characterize TBM: amino acids, organic acids, nucleotides, carbohydrates, and "other". Taken holistically, the information given in this review serves to promote the mechanistic action of hypothesis generation that will drive and direct future studies on TBM.
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Affiliation(s)
- Shayne Mason
- Human Metabolomics, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom 2531, South Africa
| | - Regan Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg 7505, South Africa;
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Abstract
PURPOSE OF REVIEW Central nervous system (CNS) tuberculosis is the most devastating form of tuberculosis (TB), with mortality and or neurological sequelae in over half of individuals. We reviewed original research and systematic reviews published since 1 January 2019 for new developments in CNS TB pathophysiology, diagnosis, management and prognosis. RECENT FINDINGS Insight in the pathophysiology is increasing steadily since the landmark studies in 1933, focussing on granuloma type classification, the relevance of the M. tuberculosis bacterial burden and the wide range of immunological responses. Although Xpert/RIF has been recommended by the WHO for extrapulmonary TB diagnosis, culture is still needed to increase the sensitivity of TB meningitis diagnosis. Sequential MRIs can improve understanding of neurological deficits at baseline and during treatment. Pharmacokinetic/pharmacodynamic modelling suggests that higher doses of rifampicin and isoniazid in TB meningitis could improve survival. SUMMARY Recent studies in the field of CNS-TB have largely focussed on TB meningitis. The outcome may improve by optimizing treatment dosing. This needs to be confirmed in clinical trials. Due to the important role of inflammation, these trials should be used as the platform to study the inflammatory and metabolomic responses. This could improve understanding of the biology of this disease and improve patient outlook by enabling individualised host-directed therapy.
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Affiliation(s)
- Sofiati Dian
- Department of Neurology, Faculty of Medicine, Universitas Padjdjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
- Infectious Disease Research Center, Faculty of Medicine, Padjadjaran University/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Ahmad Rizal Ganiem
- Department of Neurology, Faculty of Medicine, Universitas Padjdjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
- Infectious Disease Research Center, Faculty of Medicine, Padjadjaran University/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Arjan van Laarhoven
- Department of Internal Medicine Radboud University Medical Center, Nijmegen, the Netherlands
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Manyelo CM, Chegou NN, Seddon JA, Snyders CI, Mutavhatsindi H, Manngo PM, Walzl G, Stanley K, Solomons RS. Serum and cerebrospinal fluid host proteins indicate stroke in children with tuberculous meningitis. PLoS One 2021; 16:e0250944. [PMID: 33930055 PMCID: PMC8087017 DOI: 10.1371/journal.pone.0250944] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/19/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Stroke is a common complication in children with tuberculous meningitis (TBM). Host proteins may give us insight into the mechanisms of stroke in TBM and serve as biomarkers for detection of stroke, however, they have not been widely explored. In this study, we compared the concentrations of cerebrospinal fluid (CSF) and serum proteins between children who had TBM-related stroke and children with TBM without stroke. Methods We collected CSF and serum from 47 children consecutively admitted to the Tygerberg Academic Hospital in Cape Town, South Africa between November 2016, and November 2017, on suspicion of having TBM. A multiplex platform was used to measure the concentrations of 69 host proteins in CSF and serum from all study participants. Results After classification of study participants, 23 (48.9%) out of the 47 study participants were diagnosed with TBM, of which 14 (60.9%) demonstrated radiological arterial ischemic infarction. The levels of lipocalin-2, sRAGE, IP-10/ CXCL10, sVCAM-1, MMP-1, and PDGF-AA in CSF samples and the levels of D-dimer, ADAMTS13, SAA, ferritin, MCP-1/ CCL2, GDF-15 and IL-13 in serum samples were statistically different between children who had TBM-related stroke and children with TBM without stroke. After correcting for multiple testing, only the levels of sVCAM-1, MMP-1, sRAGE, and IP-10/ CXCL10 in CSF were statistically different between the two groups. CSF and serum protein biosignatures indicated stroke in children diagnosed with TBM with up to 100% sensitivity and 88.9% specificity. Conclusion Serum and CSF proteins may serve as biomarkers for identifying individuals with stroke amongst children diagnosed with TBM at admission and may guide us to understand the biology of stroke in TBM. This was a pilot study, and thus further investigations in larger studies are needed.
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Affiliation(s)
- Charles M. Manyelo
- Division of Molecular Biology and Human Genetics, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Novel N. Chegou
- Division of Molecular Biology and Human Genetics, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - James A. Seddon
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
| | - Candice I. Snyders
- Division of Molecular Biology and Human Genetics, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Hygon Mutavhatsindi
- Division of Molecular Biology and Human Genetics, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Portia M. Manngo
- Division of Molecular Biology and Human Genetics, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gerhard Walzl
- Division of Molecular Biology and Human Genetics, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kim Stanley
- Division of Molecular Biology and Human Genetics, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Regan S. Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- * E-mail:
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Basu Roy R, Bakeera-Kitaka S, Chabala C, Gibb DM, Huynh J, Mujuru H, Sankhyan N, Seddon JA, Sharma S, Singh V, Wobudeya E, Anderson ST. Defeating Paediatric Tuberculous Meningitis: Applying the WHO "Defeating Meningitis by 2030: Global Roadmap". Microorganisms 2021; 9:microorganisms9040857. [PMID: 33923546 PMCID: PMC8073113 DOI: 10.3390/microorganisms9040857] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 04/11/2021] [Accepted: 04/13/2021] [Indexed: 01/05/2023] Open
Abstract
Children affected by tuberculous meningitis (TBM), as well as their families, have needs that lie at the intersections between the tuberculosis and meningitis clinical, research, and policy spheres. There is therefore a substantial risk that these needs are not fully met by either programme. In this narrative review article, we use the World Health Organization (WHO) “Defeating Meningitis by 2030: global roadmap” as a starting point to consider key goals and activities to specifically defeat TBM in children. We apply the five pillars outlined in the roadmap to describe how this approach can be adapted to serve children affected by TBM. The pillars are (i) prevention; (ii) diagnosis and treatment; (iii) surveillance; (iv) support and care for people affected by meningitis; and (v) advocacy and engagement. We conclude by calling for greater integration between meningitis and TB programmes at WHO and at national levels.
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Affiliation(s)
- Robindra Basu Roy
- Clinical Research Department, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK
- MRC Clinical Trials Unit at UCL, 90 High Holborn, Holborn, London WC1V 6LJ, UK; (D.M.G.); (S.T.A.)
- Correspondence:
| | | | - Chishala Chabala
- School of Medicine & University Teaching Hospital (UTH), University of Zambia, Lusaka, Zambia;
| | - Diana M Gibb
- MRC Clinical Trials Unit at UCL, 90 High Holborn, Holborn, London WC1V 6LJ, UK; (D.M.G.); (S.T.A.)
| | - Julie Huynh
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Hospital for Tropical Diseases, 764 Vo Van Kiet, District 5, Ho Chi Minh City, Vietnam;
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford OX3 7LG, UK
| | - Hilda Mujuru
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe;
| | - Naveen Sankhyan
- Post Graduate Institute of Education and Medical Research (PGI), Chandigarh 160017, India;
| | - James A Seddon
- Department of Infectious Diseases, Imperial College London, Norfolk Place, London W2 1PG, UK;
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town 8000, South Africa
| | - Suvasini Sharma
- Department of Pediatrics, Lady Hardinge Medical College and Assoc Kalawati Saran Children’s Hospital (Hospital-LHH), New Delhi 110001, India; (S.S.); (V.S.)
| | - Varinder Singh
- Department of Pediatrics, Lady Hardinge Medical College and Assoc Kalawati Saran Children’s Hospital (Hospital-LHH), New Delhi 110001, India; (S.S.); (V.S.)
| | - Eric Wobudeya
- MUJHU Research Collaboration, Kampala, Uganda; (S.B.-K.); (E.W.)
| | - Suzanne T Anderson
- MRC Clinical Trials Unit at UCL, 90 High Holborn, Holborn, London WC1V 6LJ, UK; (D.M.G.); (S.T.A.)
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Hammami F, Koubaa M, Chakroun A, Rekik K, Feki W, Marrakchi C, Smaoui F, Jemaa MB. Comparative analysis between tuberculous meningitis and other forms of extrapulmonary tuberculosis. Germs 2021; 11:23-31. [PMID: 33898338 DOI: 10.18683/germs.2021.1237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/17/2020] [Accepted: 12/30/2020] [Indexed: 11/08/2022]
Abstract
Introduction Tuberculosis is a multisystem disease that may affect any organ or tissue. Tuberculous meningitis (TBM) is the most severe form of tuberculosis and commonly affects the brain. We aimed to study the epidemiological, clinical, therapeutic and evolutionary features of TBM among adults and to compare them with other forms of extrapulmonary tuberculosis. Methods We conducted a retrospective study including all patients hospitalized for extrapulmonary tuberculosis in the infectious disease department in Sfax, Tunisia between 1993 and 2018. We specified the particularities of TBM cases, and we compared them with other extrapulmonary tuberculosis cases. Results We encountered 78 patients diagnosed with TBM, among 519 patients with extrapulmonary tuberculosis (15%). The median age was 36 years (23-50) years. There were 44 females (56.4%). In comparison with other forms of extrapulmonary tuberculosis, fever [odds ratio (OR)=4.4; p<0.001], asthenia (OR=3.4; p<0.001) and anorexia (OR=2.3; p=0.001) were significantly more frequent in TBM patients. Adverse effects of antitubercular therapy were more frequent among TBM patients (OR=3.1; p<0.001). The mean duration of antitubercular therapy was 15 (12-20) months. Recovery occurred in 66 cases (84.6%), complications in 44 cases (56.4%) and death in 7 cases (9%). Comparison of the disease evolution showed that complications (OR=7.4; p<0.001) and mortality rates (OR=10.7; p<0.001) were significantly more frequent in TBM patients, while recovery was significantly more frequent in other sites of extrapulmonary tuberculosis patients (OR=0.5; p=0.02). Conclusions In our country, TBM remains a disabling disease. Despite antitubercular therapy, the prognosis was more severe with the occurrence of not only complications but also a high mortality rate in comparison with other forms of extrapulmonary tuberculosis. When clinical and laboratory features suggest the diagnosis of TBM, clinicians should look for tuberculosis elsewhere in the body.
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Affiliation(s)
- Fatma Hammami
- MD, Infectious Diseases Department and Extra-pulmonary Research Unity, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Makram Koubaa
- MD, Infectious Diseases Department and Extra-pulmonary Research Unity, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Amal Chakroun
- MD, Infectious Diseases Department and Extra-pulmonary Research Unity, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Khaoula Rekik
- MD, Infectious Diseases Department and Extra-pulmonary Research Unity, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Wiem Feki
- MD, Radiology Department, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Chakib Marrakchi
- MD, Infectious Diseases Department and Extra-pulmonary Research Unity, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Fatma Smaoui
- MD, Infectious Diseases Department and Extra-pulmonary Research Unity, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
| | - Mounir Ben Jemaa
- MD, Infectious Diseases Department and Extra-pulmonary Research Unity, Hedi Chaker University Hospital, University of Sfax, 3029, Tunisia
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Tuberculous Meningitis: Pathogenesis, Immune Responses, Diagnostic Challenges, and the Potential of Biomarker-Based Approaches. J Clin Microbiol 2021; 59:JCM.01771-20. [PMID: 33087432 PMCID: PMC8106718 DOI: 10.1128/jcm.01771-20] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Tuberculous meningitis (TBM) is the most devastating form of tuberculosis (TB), causing high mortality or disability. Clinical management of the disease is challenging due to limitations of the existing diagnostic approaches. Our knowledge on the immunology and pathogenesis of the disease is currently limited. More research is urgently needed to enhance our understanding of the immunopathogenesis of the disease and guide us toward the identification of targets that may be useful for vaccines or host-directed therapeutics. Tuberculous meningitis (TBM) is the most devastating form of tuberculosis (TB), causing high mortality or disability. Clinical management of the disease is challenging due to limitations of the existing diagnostic approaches. Our knowledge on the immunology and pathogenesis of the disease is currently limited. More research is urgently needed to enhance our understanding of the immunopathogenesis of the disease and guide us toward the identification of targets that may be useful for vaccines or host-directed therapeutics. In this review, we summarize the current knowledge about the immunology and pathogenesis of TBM and summarize the literature on existing and new, especially biomarker-based, approaches that may be useful in the management of TBM. We identify research gaps and provide directions for research which may lead to the development of new tools for the control of the disease in the near future.
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Broger T, Nicol MP. A novel bedside rule-in test for tuberculous meningitis in HIV-infected adults. Clin Infect Dis 2021; 73:e3435-e3437. [PMID: 33403391 DOI: 10.1093/cid/ciaa1915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Tobias Broger
- Division of Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Mark P Nicol
- Division of Infection and Immunity, School of Biomedical Sciences, University of Western Australia
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Dodd PJ, Osman M, Cresswell FV, Stadelman AM, Lan NH, Thuong NTT, Muzyamba M, Glaser L, Dlamini SS, Seddon JA. The global burden of tuberculous meningitis in adults: A modelling study. PLOS GLOBAL PUBLIC HEALTH 2021; 1:e0000069. [PMID: 36962116 PMCID: PMC10021871 DOI: 10.1371/journal.pgph.0000069] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/15/2021] [Indexed: 11/19/2022]
Abstract
Tuberculous meningitis (TBM) is the most lethal form of tuberculosis. The incidence and mortality of TBM is unknown due to diagnostic challenges and limited disaggregated reporting of treated TBM by existing surveillance systems. We aimed to estimate the incidence and mortality of TBM in adults (15+ years) globally. Using national surveillance data from Brazil, South Africa, the United Kingdom, the United States of America, and Vietnam, we estimated the fraction of reported tuberculosis that is TBM, and the case fatality ratios for treated TBM in each of these countries. We adjusted these estimates according to findings from a systematic review and meta-analysis and applied them to World Health Organization tuberculosis notifications and estimates to model the global TBM incidence and mortality. Assuming the case detection ratio (CDR) for TBM was the same as all TB, we estimated that in 2019, 164,000 (95% UI; 129,000-199,000) adults developed TBM globally; 23% were among people living with HIV. Almost 60% of incident TBM occurred in males and 20% were in adults 25-34 years old. 70% of global TBM incidence occurred in Southeast Asia and Africa. We estimated that 78,200 (95% UI; 52,300-104,000) adults died of TBM in 2019, representing 48% of incident TBM. TBM case fatality in those treated was on average 27%. Sensitivity analysis assuming improved detection of TBM compared to other forms of TB (CDR odds ratio of 2) reduced estimated global mortality to 54,900 (95% UI; 32,200-77,700); assuming instead worse detection for TBM (CDR odds ratio of 0.5) increased estimated mortality to 125,000 (95% UI; 88,800-161,000). Our results highlight the need for improved routine TBM monitoring, especially in high burden countries. Reducing TBM incidence and mortality will be necessary to achieve the End TB Strategy targets.
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Affiliation(s)
- Peter J Dodd
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Fiona V Cresswell
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Infectious Diseases Institute, Kampala, Uganda
- MRC-UVRI-LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Anna M Stadelman
- School of Public Health, University of Minnesota, Minneapolis, MN, United States of America
| | | | - Nguyen Thuy Thuong Thuong
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Morris Muzyamba
- Tuberculosis Section, National Infection Service, Public Health England, London, United Kingdom
| | - Lisa Glaser
- Tuberculosis Section, National Infection Service, Public Health England, London, United Kingdom
| | - Sicelo S Dlamini
- Research Information Monitoring, Evaluation, and Surveillance, National Tuberculosis Control and Management Cluster, National Department of Health, Pretoria, South Africa
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
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Quinn CM, Poplin V, Kasibante J, Yuquimpo K, Gakuru J, Cresswell FV, Bahr NC. Tuberculosis IRIS: Pathogenesis, Presentation, and Management across the Spectrum of Disease. Life (Basel) 2020; 10:E262. [PMID: 33138069 PMCID: PMC7693460 DOI: 10.3390/life10110262] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/13/2020] [Accepted: 10/21/2020] [Indexed: 12/14/2022] Open
Abstract
Antiretroviral therapy (ART), while essential in combatting tuberculosis (TB) and HIV coinfection, is often complicated by the TB-associated immune reconstitution inflammatory syndrome (TB-IRIS). Depending on the TB disease site and treatment status at ART initiation, this immune-mediated worsening of TB pathology can take the form of paradoxical TB-IRIS, unmasking TB-IRIS, or CNS TB-IRIS. Each form of TB-IRIS has unique implications for diagnosis and treatment. Recently published studies have emphasized the importance of neutrophils and T cell subtypes in TB-IRIS pathogenesis, alongside the recognized role of CD4 T cells and macrophages. Research has also refined our prognostic understanding, revealing how the disease can impact lung function. While corticosteroids remain the only trial-supported therapy for prevention and management of TB-IRIS, increasing interest has been given to biologic therapies directly targeting the immune pathology. TB-IRIS, especially its unmasking form, remains incompletely described and more data is needed to validate biomarkers for diagnosis. Management strategies remain suboptimal, especially in the highly morbid central nervous system (CNS) form of the disease, and further trials are necessary to refine treatment. In this review we will summarize the current understanding of the immunopathogenesis, the presentation of TB-IRIS and the evidence for management recommendations.
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Affiliation(s)
- Carson M. Quinn
- School of Medicine, University of California, San Francisco, CA 94143, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
| | - Victoria Poplin
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, KS 66045, USA; (V.P.); (N.C.B.)
| | - John Kasibante
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
| | - Kyle Yuquimpo
- Department of Medicine, University of Kansas, Kansas City, KS 66045, USA;
| | - Jane Gakuru
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
| | - Fiona V. Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Medical Research Council, Uganda Virus Research Unit, London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Nathan C. Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, KS 66045, USA; (V.P.); (N.C.B.)
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Ancient foe, serious weapon: Subarachnoid hemorrhage secondary to TB meningitis. IDCases 2020; 22:e00941. [PMID: 32983890 PMCID: PMC7494791 DOI: 10.1016/j.idcr.2020.e00941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/22/2020] [Accepted: 08/25/2020] [Indexed: 12/14/2022] Open
Abstract
Tuberculosis is an ancient infectious disease with global distribution and a multitude of multisystem presentations. Infection of the central nervous system (CNS) is the most serious presentation manifested as tuberculous meningitis (TBM), intracranial tuberculoma, and tuberculous arachnoiditis all associated with significant morbidity and mortality. TBM is the commonest form of CNS manifestations capable of causing secondary arteritis leading to vascular complications. We report a case of a 22-year-old Indian patient diagnosed with TBM who subsequently presented with sudden onset severe headache, which was eventually diagnosed as subarachnoid hemorrhage. Radiological assessment confirmed secondary complications with cerebral aneurysmal dilatation attributed to TBM. The patient was safely managed with combined radiological and surgical interventions with uneventful outcomes. Review of the literature revealed that such complication of TBM is rare usually with serious implications. We aim to highlight to infection specialists to be aware of such association.
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Legaspi GD, Espiritu AI, Omar AT. Success and complication rates of endoscopic third ventriculostomy for tuberculous meningitis: a systematic review and meta-analysis. Neurosurg Rev 2020; 44:2201-2209. [PMID: 32974813 DOI: 10.1007/s10143-020-01396-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 09/03/2020] [Accepted: 09/17/2020] [Indexed: 10/23/2022]
Abstract
Because ventriculoperitoneal shunt (VPS) insertion for patients with hydrocephalus from tuberculous meningitis (TBM) can be complicated by shunt infection and malfunction, endoscopic third ventriculostomy (ETV) has been proposed as an alternative. The aim of this review was to determine the success, technical failure, and complication rates of ETV in TBM in a meta-analysis and determine which factors are predictive of outcome. The PubMed, Scopus, and CENTRAL databases were searched from inception to April 2020 for case series, cohort studies, or randomized controlled trials reporting success, technical failure, or complication rates. For studies with individual patient data available, logistic regression analysis was done to determine whether age, sex, clinical grade, and type of hydrocephalus on imaging was predictive of outcome. Eight studies with a total of 174 patients were included in the review. Using random-effects modeling, the pooled estimate of success rate was 59% (95% CI 50-68%), with low heterogeneity (I2 = 30%). The technical failure and complication rates were 5% and 15%, respectively, but these variables had moderate heterogeneity. In 36 patients with individual patient data, a non-communicating type of hydrocephalus on imaging was associated with an odds ratio of 5.90 (95% CI 1.1-32.9, p = 0.043) for success. In summary, ETV for TBM had a pooled success rate of 59%, technical failure rate of 5%, and complication rate of 15%. An imaging finding of non-communicating hydrocephalus was associated with increased success. High-quality randomized, prospective studies using VPS insertion as control are needed to further define the role of ETV in TBM.
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Affiliation(s)
- Gerardo D Legaspi
- Division of Neurosurgery, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Taft Avenue, Ermita, 1000, Manila, Philippines
| | - Adrian I Espiritu
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Taft Avenue, Ermita, 1000, Manila, Philippines.,Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Taft Avenue, Ermita, 1000, Manila, Philippines
| | - Abdelsimar T Omar
- Division of Neurosurgery, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Taft Avenue, Ermita, 1000, Manila, Philippines.
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Luo Y, Xue Y, Guo X, Lin Q, Mao L, Tang G, Song H, Wang F, Sun Z. Diagnostic Accuracy of T-SPOT.TB Assay for Tuberculous Meningitis: An Updated Meta-Analysis. Front Neurol 2020; 11:866. [PMID: 33013621 PMCID: PMC7494808 DOI: 10.3389/fneur.2020.00866] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/07/2020] [Indexed: 12/12/2022] Open
Abstract
Background: The role of T-SPOT.TB (T-SPOT) assay for tuberculous meningitis (TBM) diagnosis has not been fully assessed. Here, we conducted an updated meta-analysis to evaluate the diagnostic accuracy of peripheral blood (PB) T-SPOT and cerebrospinal fluid (CSF) T-SPOT for diagnosing TBM. Methods: Relevant studies in the PubMed database, EmBase database, Cochrane database, Scopus database, Google Scholar, China National Knowledge Internet, and Wan-Fang database were retrieved from August 1, 2005, to June 22, 2020. Statistical analysis was performed using Stata, Revman, and Meta-Disc software. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), summary receiver operating characteristic curves, and the area under the curve were determined and analyzed. Results: A total of 27 studies were eligible for inclusion within the meta-analysis. The pooled sensitivity and specificity of PB T-SPOT for TBM diagnosis were 0.78 (95% CI, 0.76-0.81) and 0.68 (95% CI, 0.66-0.71), respectively, whereas the pooled PLR, NLR, and DOR were 2.80 (95% CI, 2.29-3.42), 0.32 (95% CI, 0.27-0.38), and 10.08 (95% CI, 7.21-14.08), respectively. On the other hand, the pooled sensitivity and specificity of CSF T-SPOT on diagnosing TBM were 0.76 (95% CI, 0.72-0.80) and 0.88 (95% CI, 0.85-0.90), respectively, whereas the pooled PLR, NLR, and DOR were 5.92 (95% CI, 4.25-8.25), 0.28 (95% CI, 0.21-0.39), and 29.05 (95% CI, 16.40-51.45), respectively. The area under the summary receiver operating characteristic curve values of PB T-SPOT and CSF T-SPOT for TBM diagnosis were 0.83 (95% CI, 0.80-0.86) and 0.92 (95% CI, 0.89-0.94), respectively. Conclusions: CSF T-SPOT showed a higher specificity compared with PB T-SPOT for diagnosing TBM. Both two T-SPOT assays have considerable potential in improving the diagnosis of TBM. Furthermore, the standardization of the operating procedure is further needed when performing CSF T-SPOT.
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Affiliation(s)
- Ying Luo
- Department of Laboratory Medicine, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Ying Xue
- Department of Clinical Immunology, Tongji Medical College, Tongji Hospital, Huazhong University of Sciences and Technology, Wuhan, China
| | - Xueyun Guo
- Department of Dermatology, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Qun Lin
- Department of Laboratory Medicine, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Liyan Mao
- Department of Laboratory Medicine, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Guoxing Tang
- Department of Laboratory Medicine, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Huijuan Song
- Department of Laboratory Medicine, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Feng Wang
- Department of Laboratory Medicine, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Ziyong Sun
- Department of Laboratory Medicine, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
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Foppiano Palacios C, Saleeb PG. Challenges in the diagnosis of tuberculous meningitis. J Clin Tuberc Other Mycobact Dis 2020; 20:100164. [PMID: 32462082 PMCID: PMC7240715 DOI: 10.1016/j.jctube.2020.100164] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Tuberculosis (TB) continues to pose a significant public health problem. Tuberculous meningitis (TBM) is the most severe form of extra-pulmonary TB. TBM carries a high mortality rate, including for those receiving treatment for TB. Diagnosis of TBM is difficult for clinicians as it can clinically present similarly to other forms of meningitis. The difficulty in diagnosis often leads to a delay in treatment and subsequent mortality. Those who survive are left with long-term sequelae leading to lifelong disability. The microbiologic diagnosis of TBM requires the isolation of Mycobacterium tuberculosis from the cerebrospinal fluid (CSF) of an infected patient. The diagnosis of tuberculous meningitis continues to be challenging for clinicians. Unfortunately, many cases of TBM cannot be confirmed based on clinical and imaging findings as the clinical findings are nonspecific, while laboratory techniques are largely insensitive or slow. Until recently, the lack of accessible and timely tests has contributed to a delay in diagnosis and subsequent morbidity and mortality for many patients, particularly those in resourcelimited settings. The availability of Xpert Ultra and point-of-care lipoarabinomannan (LAM) testing could represent a new era of prompt diagnosis and early treatment of tuberculous meningitis. However, clinicians must be cautious when ruling out TBM with Xpert Ultra due to its low negative predictive value. Due to the limitations of current diagnostics, clinicians should utilize a combination of diagnostic modalities in order to prevent morbidity in patients with TBM.
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Affiliation(s)
- Carlo Foppiano Palacios
- Departments of Internal Medicine and Pediatrics, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201, United States
| | - Paul G. Saleeb
- Institute of Human Virology, University of Maryland School of Medicine, 725 W Lombard St, Baltimore, MD 21201, United States
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