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Sharma R, Vaibhav, Yadav D, Kaliraman V, Duhan A. Comprehensive Case Analysis of Tuberculous Meningitis in an Immunocompetent Patient: Diagnostic Challenges and Therapeutic Strategies. Cureus 2024; 16:e64332. [PMID: 39144857 PMCID: PMC11322630 DOI: 10.7759/cureus.64332] [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] [Accepted: 07/11/2024] [Indexed: 08/16/2024] Open
Abstract
Tuberculosis (TB) continues to be a significant global health concern, with India contributing substantially to the global burden. The management of TB is further complicated by HIV-associated immunodeficiency and the emergence of drug-resistant TB strains. Early diagnosis and treatment are critical, particularly for tubercular meningitis (TBM), which is among the most severe forms of extrapulmonary TB. We present the case of a 55-year-old male who arrived at our emergency department with a one-week history of fever, headache, incoherent speech, and slurred speech. The patient had no relevant medical history or known contact with TB patients. Neurological examination revealed ptosis of the right eye and a left extensor plantar response. Laboratory investigations revealed a miliary pattern on chest radiography, and cerebrospinal fluid analysis showed an adenosine deaminase (ADA) level of 14.4 U/L, a total cell count of 110/mm³, glucose of 6 mg/dL, and protein of 228.4 mg/dL, supporting the diagnosis of TBM. Magnetic resonance imaging (MRI) indicated brain lesions consistent with TBM. TBM represents the most devastating form of extrapulmonary TB if left untreated. Therefore, prompt initiation of antitubercular therapy and continued vigilance in endemic regions are essential for addressing this complex global health issue.
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Affiliation(s)
- Rohit Sharma
- Department of Medicine, Pandit Bhagwat Dayal Sharma University of Health Sciences, Rohtak, Rohtak, IND
| | - Vaibhav
- Department of Neurology, Pandit Bhagwat Dayal Sharma University of Health Sciences, Rohtak, Rohtak, IND
| | - Diksha Yadav
- Department of Medicine, Pandit Bhagwat Dayal Sharma University of Health Sciences, Rohtak, Rohtak, IND
| | - Vipul Kaliraman
- Department of Medicine, Maulana Azad Medical College, New Delhi, IND
| | - Aditya Duhan
- Department of Radiology, Pandit Bhagwat Dayal Sharma University of Health Sciences, Rohtak, Rohtak, IND
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Inbaraj LR, Manesh A, Ponnuraja C, Bhaskar A, Srinivasalu VA, Daniel BD. Comparative evaluation of intensified short course regimen and standard regimen for adults TB meningitis: a protocol for an open label, multi-center, parallel arms, randomized controlled superiority trial (INSHORT trial). Trials 2024; 25:294. [PMID: 38693583 PMCID: PMC11064413 DOI: 10.1186/s13063-024-08133-6] [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] [Received: 01/16/2024] [Accepted: 04/22/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Despite several incremental improvements in the management of tuberculous meningitis (TBM), the mortality rates remain high. In spite of national and international guidelines, variation in the choice, dose, and duration of drugs exist between countries and clinicians. We propose to evaluate a shorter and more effective regimen containing agents with augmented intracerebral drug exposure and anti-inflammatory approaches to improve disability-free survival among patients with TBM. Our strategy incorporates the various developments in the field of TBM over the last two decades and only few trials have evaluated a composite of these strategies in the overall outcomes of TBM. METHODS An open label, parallel arms, randomized controlled superiority trial will be conducted among 372 participants across 6 sites in India. Eligible participants will be randomly allocated in 1:1:1 ratio into one of the three arms. The intervention arm consists of 2 months of high-dose rifampicin (25 mg/kg), moxifloxacin (400 mg), pyrazinamide, isoniazid, aspirin (150 mg), and steroids followed by rifampicin, isoniazid, and pyrazinamide for 4 months. The second intervention arm includes all the drugs as per the first arm except aspirin and the patients in the control arm will receive treatment according to the National TB Elimination Program guidelines. All participants will be followed up for 1 year after the treatment. DISCUSSION: Current WHO regimens have agents with poor central nervous system drug exposure and is too long. It does not reflect the accumulating evidence in the field. We propose a comprehensive clinical trial incorporating the emerging evidence accrued over the last two decades to shorten the duration and improve the treatment outcomes. This multi-centric trial may generate crucial evidence with policy and practice implications in the treatment of TBM. TRIAL REGISTRATION Clinical Trial Registry India CTRI/2023/05/053314. Registered on 31 May 2023 ( https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=ODYzMzg=&Enc=&userName=CTRI/2023/05/053314 ). CLINICALTRIALS gov NCT05917340. Registered on 6 August 2023 ( https://classic. CLINICALTRIALS gov/ct2/show/NCT05917340 ). PROTOCOL VERSION Version 1.3 dated 12 July 2023.
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Affiliation(s)
- Leeberk Raja Inbaraj
- Department of Clinical Research, ICMR- National Institute for Research in Tuberculosis, Chethpet, Chennai, 600031, India.
| | - Abi Manesh
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | - C Ponnuraja
- Department of Statistics, ICMR- National Institute for Research in Tuberculosis, Chethpet, Chennai, 600031, India
| | - Adhin Bhaskar
- Department of Statistics, ICMR- National Institute for Research in Tuberculosis, Chethpet, Chennai, 600031, India
| | - Vignes Anand Srinivasalu
- Department of Clinical Research, ICMR- National Institute for Research in Tuberculosis, Chethpet, Chennai, 600031, India
| | - Bella Devaleenal Daniel
- Department of Statistics, ICMR- National Institute for Research in Tuberculosis, Chethpet, Chennai, 600031, India.
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Pinzon RT, Veronica V. Hydrocephalus Caused by Tuberculous Meningitis in an Immunocompetent Young Adult: A Case Report. Int Med Case Rep J 2023; 16:187-192. [PMID: 36968269 PMCID: PMC10038010 DOI: 10.2147/imcrj.s389204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 01/20/2023] [Indexed: 03/22/2023] Open
Abstract
Background Despite improved medical management, meningeal tuberculosis mortality and other outcomes have changed slightly over time due to a delay in diagnosis and treatment. This study reports a rare case of tuberculous meningitis in an immunocompetent host, calling into question the commonly held belief that tuberculous meningitis is a disease of immunocompromised individuals. Case Presentation A 26-year-old male with no significant past medical history, tuberculosis, or indications of immunological compromise, was admitted to our hospital with a fever and altered mental status. He was drowsy, febrile (temperature of 38°C), had a heart rate of 110 beats per minute, and showed mild neck stiffness but no meningeal sign. A lumbar puncture on the third day of admission suggested tuberculous meningitis. He was treated for tuberculosis meningitis, and his condition slightly improved. However, the patient's condition suddenly worsened, and a repeat contrast computed tomography (CT) of the brain showed the development of ventriculomegaly and basilar enhancement. Insertion of an emergency ventriculoperitoneal shunt was performed; however, the patient died ten days after hospital admission. Conclusion We report a fatal case of tuberculous meningitis in an immunocompetent patient. Healthcare practitioners must be trained to identify and diagnose tuberculous meningitis promptly. Early treatment of tuberculous meningitis based on clinical diagnosis and symptoms improves clinical outcomes.
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Affiliation(s)
- Rizaldy Taslim Pinzon
- Faculty of Medicine, Duta Wacana Christian University, Yogyakarta, Indonesia
- Department of Neurology, Bethesda Hospital, Yogyakarta, Indonesia
- Correspondence: Rizaldy Taslim Pinzon, Duta Wacana Christian University School of Medicine, Doctor Wahidin Sudirohusodo St. 5-25, Yogyakarta, 55224, Indonesia, Email
| | - Vanessa Veronica
- Faculty of Medicine, Duta Wacana Christian University, Yogyakarta, Indonesia
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Maranchick NF, Alshaer MH, Smith AGC, Avaliani T, Gujabidze M, Bakuradze T, Sabanadze S, Avaliani Z, Kipiani M, Peloquin CA, Kempker RR. Cerebrospinal fluid concentrations of fluoroquinolones and carbapenems in tuberculosis meningitis. Front Pharmacol 2022; 13:1048653. [PMID: 36578553 PMCID: PMC9791083 DOI: 10.3389/fphar.2022.1048653] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/01/2022] [Indexed: 12/14/2022] Open
Abstract
Background: Tuberculosis meningitis (TBM) is the most lethal form of TB. It is difficult to treat in part due to poor or uncertain drug penetration into the central nervous system (CNS). To help fill this knowledge gap, we evaluated the cerebrospinal fluid (CSF) concentrations of fluoroquinolones and carbapenems in patients being treated for TBM. Methods: Serial serum and CSF samples were collected from hospitalized patients being treated for TBM. CSF was collected from routine lumbar punctures between alternating timepoints of 2 and 6 h after drug administration to capture early and late CSF penetration. Rich serum sampling was collected after drug administration on day 28 for non-compartmental analysis. Results: Among 22 patients treated for TBM (8 with confirmed disease), there was high use of fluoroquinolones (levofloxacin, 21; moxifloxacin, 10; ofloxacin, 6) and carbapenems (imipenem, 11; meropenem, 6). Median CSF total concentrations of levofloxacin at 2 and 6 h were 1.34 mg/L and 3.36 mg/L with adjusted CSF/serum ratios of 0.41 and 0.63, respectively. For moxifloxacin, the median CSF total concentrations at 2 and 6 h were 0.78 mg/L and 1.02 mg/L with adjusted CSF/serum ratios of 0.44 and 0.62. Serum and CSF concentrations of moxifloxacin were not affected by rifampin use. Among the 76 CSF samples measured for carbapenem concentrations, 79% were undetectable or below the limit of detection. Conclusion: Fluoroquinolones demonstrated high CSF penetration indicating their potential usefulness for the treatment of TBM. Carbapenems had lower than expected CSF concentrations.
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Affiliation(s)
- Nicole F. Maranchick
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Mohammad H. Alshaer
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Alison G. C. Smith
- Department of Medicine, Division of Internal Medicine, Duke University, Durham, NC, United States
| | - Teona Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Mariam Gujabidze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Tinatin Bakuradze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Shorena Sabanadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
- David Tvildiani Medical University, Tbilisi, Georgia
| | - Charles A. Peloquin
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Russell R. Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, GA, United States
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An Elusive Case of Tuberculous Meningitis in a Young Man With Altered Mental Status. J Emerg Med 2022; 63:551-556. [DOI: 10.1016/j.jemermed.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 06/08/2022] [Accepted: 07/09/2022] [Indexed: 12/05/2022]
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Donovan J, Khanh TDH, Thwaites GE, Geskus RB. A statistical analysis plan for the Adjunctive Corticosteroids for Tuberculous meningitis in HIV-positive adults (ACT HIV) clinical trial. Wellcome Open Res 2022; 6:280. [PMID: 34778571 PMCID: PMC8561610 DOI: 10.12688/wellcomeopenres.17154.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 11/20/2022] Open
Abstract
TBM is the most severe form of tuberculosis. Clinical trial data are required to provide an evidence base for adjunctive dexamethasone in HIV-positive individuals with TBM, and to guide clinical practice. This document details the planned analyses at 12 months post randomisation for the ACT HIV clinical trial (NCT03092817); ‘a randomised double-blind placebo-controlled trial of adjunctive dexamethasone for the treatment of HIV co-infected adults with tuberculous meningitis (TBM)’. The primary endpoint of the ACT HIV trial is death (from any cause) over the first 12 months after randomisation. This statistical analysis plan expands upon and updates the analysis plan outlined in the published study protocol.
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Affiliation(s)
- Joseph Donovan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- London School of Hygiene and Tropical Medicine, London, UK
| | - Trinh Dong Huu Khanh
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Guy E. Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ronald B. Geskus
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Rahman N, Pannu AK, Yadav R, Sethi S, Saroch A, Garg M, Kumar D, Bhalla A. Tuberculous meningitis in the elderly. QJM 2022; 115:381-387. [PMID: 34100953 DOI: 10.1093/qjmed/hcab162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 05/28/2021] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE Although the elderly population remains at high risk for tuberculosis, studies addressing tuberculous meningitis (TBM) in this age group are scarce. The present study aimed to evaluate the spectrum and outcome of geriatric TBM and document differences between older and young patients. METHODS A prospective cohort study was conducted in the adult TBM patients admitted at PGIMER, Chandigarh (India). Consecutive older patients aged 60 years and above were enrolled from January 2019 to December 2020, and young adults aged 18-59 years were enrolled from July 2019 to December 2019. RESULTS Fifty-five older patients with a mean age of 66.6 years and 73 young patients with a mean age of 35.1 years were enrolled. At admission, older patients were more likely to have altered mental status (96.4% vs. 78.1%, P = 0.003) and advanced disease with British medical research council staging 2 or 3 (98.2% vs. 89.0%, P = 0.043); however, headache (38.2% vs. 67.1%, P = 0.001), vomiting (18.2% vs. 35.6%, P = 0.030) and fever (80.0% vs. 91.8%, P = 0.052) were less common. Cerebrospinal fluid (CSF) abnormalities were less marked in older patients, with a significant difference in median total cells (70 vs. 110/µl, P = 0.013). Hydrocephalous and infarct were common neuroimaging abnormalities in both groups; however, tuberculomas were significantly less in the elderly (15.1% vs. 35.2%, P = 0.012). Older patients had a significantly low survival rate (56.4% vs. 76.7%, P = 0.021). CONCLUSION Significant differences in clinical, CSF and radiological characteristics exist between elderly and young TBM patients, with survival remains dismal in the elderly.
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Affiliation(s)
- N Rahman
- From the 1Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, 4th floor, F block, Sector 12, Chandigarh 160012, India
| | - A K Pannu
- From the 1Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, 4th floor, F block, Sector 12, Chandigarh 160012, India
| | - R Yadav
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Research Block A, Sector 12, Chandigarh 160012, India
| | - S Sethi
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Research Block A, Sector 12 , Chandigarh 160012, India
| | - A Saroch
- From the 1Department of Internal Medicine , Postgraduate Institute of Medical Education and Research, Nehru Hospital, 4th floor, F block, Sector 12, Chandigarh 160012, India
| | - M Garg
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh 160012, India
| | - D Kumar
- From the 1Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, 4th floor, F block, Sector 12, Chandigarh 160012, India
| | - A Bhalla
- From the 1Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, 4th floor, F block, Sector 12, Chandigarh 160012, India
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Donovan J, Tram TTB, Phu NH, Hiep NTT, Van VTT, Mui DTH, Ny NTH, Nghia HDT, Hanh NHH, Tan LV, Thuong NTT, Thwaites GE. Influence of Strongyloides stercoralis Coinfection on the Presentation, Pathogenesis, and Outcome of Tuberculous Meningitis. J Infect Dis 2022; 225:1653-1662. [PMID: 33104201 PMCID: PMC9071290 DOI: 10.1093/infdis/jiaa672] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 10/21/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Helminth infections may modulate the inflammatory response to Mycobacterium tuberculosis and influence disease presentation and outcome. Strongyloides stercoralis is common among populations with high tuberculosis prevalence. Our aim was to determine whether S. stercoralis coinfection influenced clinical presentation, cerebrospinal fluid (CSF) inflammation, and outcome from tuberculous meningitis (TBM). METHODS From June 2017 to December 2019, 668 Vietnamese adults with TBM, enrolled in the ACT HIV or LAST ACT trials (NCT03092817 and NCT03100786), underwent pretreatment S. stercoralis testing by serology, stool microscopy, and/or stool polymerase chain reaction. Comparisons of pretreatment TBM severity, CSF inflammation (including cytokines), and 3-month clinical end points were performed in groups with or without active S. stercoralis infection. RESULTS Overall, 9.4% participants (63 of 668) tested positive for S. stercoralis. Active S. stercoralis infection was significantly associated with reduced pretreatment CSF neutrophil counts (median [interquartile range], 3/μL [0-25/μL] vs 14 /μL [1-83/μL]; P = .04), and with reduced CSF interferon ɣ, interleukin 2, and tumor necrosis factor α concentrations (11.4 vs 56.0 pg/mL [P = .01], 33.1 vs 54.5 pg/mL [P = .03], and 4.5 vs 11.9 pg/mL [P = .02], respectively), compared with uninfected participants. Neurological complications by 3 months were significantly reduced in participants with active S. stercoralis infection compared with uninfected participants (3.8% [1 of 26] vs 30.0% [33 of 110], respectively; P = .01). CONCLUSIONS S. stercoralis coinfection may modulate the intracerebral inflammatory response to M. tuberculosis and improve TBM clinical outcomes.
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Affiliation(s)
- Joseph Donovan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Trinh Thi Bich Tram
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- School of Medicine, Vietnam National University of Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Nguyen Thi Thu Hiep
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Vu Thi Thu Van
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Nguyen Thi Han Ny
- Oxford University Clinical Research Unit, Centre for Tropical 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 Ho Hong Hanh
- School of Medicine, Vietnam National University of Ho Chi Minh City, Ho Chi Minh City, Vietnam
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Le Van Tan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nguyen Thuy Thuong Thuong
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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Tavares-Júnior JWL, Teles Júnior JN, Magalhães SC, Cavalcante TT, Coimbra PPDA, Luiz RDSS. Parinaud syndrome due to cofirmed neurotuberculosis in a lupus eritematosis systemic patient. Eur J Ophthalmol 2022:11206721221098284. [PMID: 35482349 DOI: 10.1177/11206721221098284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION This article aims to describe a patient with Parinaud syndrome due to neurotuberculosis confirmed by cerebrospinal fluid analysis. CASE REPORT Initially, patient sought medical care, performed a chest x-ray and later a chest CT scan, with a probable diagnosis of miliary tuberculosis. In addition, she presented binocular diplopia worse at right lateral gaze, paresis of vertical gaze, light near-dissociation and convergent retraction nystagmus and presence of mycobacterium tuberculosis on PCR Xpert MTB/RIF. The treatment of miliary tuberculosis was interrupted due to pharmacodermia, but after diagnosis of neurotuberculosis, it was restarted with isoniazid, pyrazinamide and ethambutol with partial visual symptoms improvement. DISCUSSION This case demonstrates the importance of pursuing diagnosis through more accurate techniques, especially in a patient with previous treatment pharmacoderma, whose absence of proper diagnosis and treatment would be extremely deleterious.
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Donovan J, Khanh TDH, Thwaites GE, Geskus RB. A statistical analysis plan for the Adjunctive Corticosteroids for Tuberculous meningitis in HIV-positive adults (ACT HIV) clinical trial. Wellcome Open Res 2021; 6:280. [PMID: 34778571 DOI: 10.12688/wellcomeopenres.17154.1] [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: 09/16/2021] [Indexed: 11/20/2022] Open
Abstract
TBM is the most severe form of tuberculosis. Clinical trial data are required to provide an evidence base for adjunctive dexamethasone in HIV-positive individuals with TBM, and to guide clinical practice. This document details the planned analyses at 12 months post randomisation for the ACT HIV clinical trial (NCT03092817); 'a randomised double-blind placebo-controlled trial of adjunctive dexamethasone for the treatment of HIV co-infected adults with tuberculous meningitis (TBM)'. The primary endpoint of the ACT HIV trial is death (from any cause) over the first 12 months after randomisation. This statistical analysis plan expands upon and updates the analysis plan outlined in the published study protocol.
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Affiliation(s)
- Joseph Donovan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,London School of Hygiene and Tropical Medicine, London, UK
| | - Trinh Dong Huu Khanh
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ronald B Geskus
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Donovan J, Oanh PKN, Dobbs N, Phu NH, Nghia HDT, Summers D, Thuong NTT, Thwaites GE. Optic Nerve Sheath Ultrasound for the Detection and Monitoring of Raised Intracranial Pressure in Tuberculous Meningitis. Clin Infect Dis 2021; 73:e3536-e3544. [PMID: 33283229 PMCID: PMC8563195 DOI: 10.1093/cid/ciaa1823] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Neurological complications of tuberculous meningitis (TBM) often lead to raised intracranial pressure (ICP) resulting in high morbidity and mortality. Measurement of optic nerve sheath diameter (ONSD) by point-of-care ultrasound may aid in the identification of raised ICP in TBM. METHODS From June 2017 to December 2019, 107 Vietnamese adults with TBM, enrolled in the ACT HIV or LAST ACT trials (NCT03092817, NCT03100786), underwent ONSD ultrasound at ≥1 of days 0, 3, 7, 14, 21, and day ±30 after enrollment. Demographic data, TBM severity grade, HIV coinfection status, and clinical endpoints by 3 months were recorded. ONSD values were correlated with disease severity, baseline brain imaging, cerebrospinal fluid parameters, and clinical endpoints. RESULTS 267 ONSD ultrasound scans were performed in 107 participants over the first 30 days of treatment, with measurements from 0.38-0.74 cm. Paired baseline ONSD and brain imaging were performed in 63 participants. Higher baseline ONSD was associated with more severe disease and abnormal brain imaging (abnormal imaging 0.55 cm vs 0.50 cm normal imaging, P = .01). Baseline median ONSD was significantly higher in participants who died by 3 months (0.56 cm [15/72]) versus participants who survived by 3 months (0.52 cm [57/72]) (P = .02). Median ONSD was higher at all follow-up times in participants who died by 3 months. CONCLUSIONS Higher ONSD was associated with increased disease severity, brain imaging abnormalities, and increased death by 3 months. ONSD ultrasound has a potential role as a noninvasive, affordable bedside tool for predicting brain pathology and death in TBM.
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Affiliation(s)
- Joseph Donovan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Nicholas Dobbs
- Department of Clinical Neuroscience, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Nguyen Hoan Phu
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- 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
| | - David Summers
- Department of Clinical Neuroscience, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Nguyen Thuy Thuong Thuong
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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12
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Boonyagars L, Sangketchon C, Pholtawornkulchai K. Presentation, Clinical Characteristics, and Treatment Outcomes among Tuberculous Meningitis Patients with and Without HIV Infection at Vajira Hospital, Thailand: A Retrospective Cohort Study. J Int Assoc Provid AIDS Care 2021; 20:23259582211045551. [PMID: 34613826 PMCID: PMC8725209 DOI: 10.1177/23259582211045551] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
To compare the characteristics, presentation, investigations, and outcomes in tuberculous meningitis (TBM) patients with and without human immunodeficiency virus (HIV) coinfection. A retrospective cohort study was conducted on adult (age > 18 years) patients whose final diagnosis was TBM and who were treated at Vajira Hospital, Navamindradhiraj University, Thailand, between January 2005 and December 2016. A final total of 174 individuals were included in the study. Of these, 97 (55.75%) were HIV positive. Treatment was successful in 53 (30.5%) individuals. In HIV-infected TBM patients, there were higher proportions of patients who were younger in age (≤40 years), patients with a low body mass index, history of previous tuberculosis infection, or hepatitis C virus coinfection. A successful treatment outcome rate was lower in HIV-infected TBM patients than in HIV-uninfected TBM patients. Since HIV infection decreases the chance of successful treatment outcomes of TBM patients, future studies are needed to determine the clinical indicators for poorer survival outcomes in HIV-positive TBM patients.
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Affiliation(s)
- Lakkana Boonyagars
- Department of infectious diseases, Faculty of Medicine, Vajira Hospital, 292577Navamindradhiraj University, Bangkok, Thailand
| | - Chunlanee Sangketchon
- Department of Disaster and Emergency Medical Operations, Faculty of Science and Health Technology, Vajira Hospital, 292577Navamindradhiraj University, Bangkok, Thailand
| | - Kittisak Pholtawornkulchai
- Department of infectious diseases, Faculty of Medicine, Vajira Hospital, 292577Navamindradhiraj University, Bangkok, Thailand
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13
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Donovan J, Cresswell FV, Thuong NTT, Boulware DR, Thwaites GE, Bahr NC. Xpert MTB/RIF Ultra for the Diagnosis of Tuberculous Meningitis: A Small Step Forward. Clin Infect Dis 2020; 71:2002-2005. [PMID: 32543658 PMCID: PMC7643749 DOI: 10.1093/cid/ciaa473] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/22/2020] [Indexed: 11/30/2022] Open
Abstract
The delayed diagnosis of tuberculous meningitis (TBM) leads to poor outcomes, yet the current diagnostic methods for identifying Mycobacterium tuberculosis in cerebrospinal fluid (CSF) are inadequate. The first comparative study of the new GeneXpert MTB/RIF Ultra (Xpert Ultra) for TBM diagnosis suggested increased sensitivity of Xpert Ultra. Two subsequent studies have shown Xpert Ultra has improved sensitivity, but has insufficient negative predictive value to exclude TBM. Collecting and processing large volumes of CSF for mycobacterial testing are important for optimal diagnostic test performance. But clinical, radiological, and laboratory parameters remain essential for TBM diagnosis and empiric therapy is often needed. We therefore caution against the use of Xpert Ultra as a single diagnostic test for TBM; it cannot be used to "rule out" TBM.
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Affiliation(s)
- Joseph Donovan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Viet Nam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Fiona V Cresswell
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Nguyen Thuy Thuong Thuong
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Viet Nam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Viet Nam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, Kansas, USA
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14
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Holden IK, Lillebaek T, Andersen PH, Wejse C, Johansen IS. Characteristics and predictors for tuberculosis related mortality in Denmark from 2009 through 2014: A retrospective cohort study. PLoS One 2020; 15:e0231821. [PMID: 32497102 PMCID: PMC7272085 DOI: 10.1371/journal.pone.0231821] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 12/02/2019] [Indexed: 11/30/2022] Open
Abstract
Objectives Mortality from tuberculosis (TB) has been declining since 2000, nevertheless there is still a significant number of patients who die before or during TB treatment. The aims were to examine and describe predictors associated with TB related mortality. Methods Patients notified with TB from 2009 though 2014 in Denmark were included. Data were extracted from national registers and patient records were examined for clinical information and treatment outcome. Cox proportional hazards regression was used to examine TB related mortality. Results A total of 2131 cases were identified, 141 (6.6%) patients died before or during TB treatment. TB related mortality accounted for 104 cases (73.8%) and decreased significantly from 6.7% to 3.2% (p = .04) during the study period. Within 1 months of diagnosis, 49% of TB related deaths had occurred. The strongest risk factors present at time of diagnosis, associated with TB related mortality, were: age > 70 years, Charlson comorbidity index > 1, alcohol abuse, weight loss, anemia, and C-reactive protein > 100 mg/L (p < .05). Conclusion The majority of TB related deaths occurred soon after diagnosis, emphasizing that TB patients identified to have a high risk of mortality should be closely monitored before and during the intensive treatment period to improve their outcomes.
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Affiliation(s)
- Inge K. Holden
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
- Mycobacterial Centre for Research Southern Denmark–MyCRESD, Odense, Denmark
- * E-mail:
| | - Troels Lillebaek
- International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark
| | - Peter H. Andersen
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark
| | - Christian Wejse
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Isik S. Johansen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
- Mycobacterial Centre for Research Southern Denmark–MyCRESD, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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15
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Livesay S, Fried H, Gagnon D, Karanja N, Lele A, Moheet A, Olm-Shipman C, Taccone F, Tirschwell D, Wright W, Claude Hemphill Iii J. Clinical Performance Measures for Neurocritical Care: A Statement for Healthcare Professionals from the Neurocritical Care Society. Neurocrit Care 2020; 32:5-79. [PMID: 31758427 DOI: 10.1007/s12028-019-00846-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Performance measures are tools to measure the quality of clinical care. To date, there is no organized set of performance measures for neurocritical care. METHODS The Neurocritical Care Society convened a multidisciplinary writing committee to develop performance measures relevant to neurocritical care delivery in the inpatient setting. A formal methodology was used that included systematic review of the medical literature for 13 major neurocritical care conditions, extraction of high-level recommendations from clinical practice guidelines, and development of a measurement specification form. RESULTS A total of 50,257 citations were reviewed of which 150 contained strong recommendations deemed suitable for consideration as neurocritical care performance measures. Twenty-one measures were developed across nine different conditions and two neurocritical care processes of care. CONCLUSIONS This is the first organized Neurocritical Care Performance Measure Set. Next steps should focus on field testing to refine measure criteria and assess implementation.
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Affiliation(s)
- Sarah Livesay
- College of Nursing, Rush University, Chicago, IL, USA.
| | | | - David Gagnon
- Maine Medical Center Department of Pharmacy, Portland, ME, USA
| | - Navaz Karanja
- Departments of Neurosciences and Anesthesiology, University of California-San Diego, San Diego, CA, USA
| | - Abhijit Lele
- Department of Anesthesiology and Pain Medicine, Neurocritical Care Service, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Asma Moheet
- OhioHealth Riverside Methodist Hospital, Columbus, OH, USA
| | - Casey Olm-Shipman
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | - Fabio Taccone
- Department of Intensive Care of Hospital Erasme, Brussels, Belgium
| | - David Tirschwell
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Wendy Wright
- Departments of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
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16
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Geneviève LD, Martani A, Mallet MC, Wangmo T, Elger BS. Factors influencing harmonized health data collection, sharing and linkage in Denmark and Switzerland: A systematic review. PLoS One 2019; 14:e0226015. [PMID: 31830124 PMCID: PMC6907832 DOI: 10.1371/journal.pone.0226015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 11/18/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION The digitalization of medicine has led to a considerable growth of heterogeneous health datasets, which could improve healthcare research if integrated into the clinical life cycle. This process requires, amongst other things, the harmonization of these datasets, which is a prerequisite to improve their quality, re-usability and interoperability. However, there is a wide range of factors that either hinder or favor the harmonized collection, sharing and linkage of health data. OBJECTIVE This systematic review aims to identify barriers and facilitators to health data harmonization-including data sharing and linkage-by a comparative analysis of studies from Denmark and Switzerland. METHODS Publications from PubMed, Web of Science, EMBASE and CINAHL involving cross-institutional or cross-border collection, sharing or linkage of health data from Denmark or Switzerland were searched to identify the reported barriers and facilitators to data harmonization. RESULTS Of the 345 projects included, 240 were single-country and 105 were multinational studies. Regarding national projects, a Swiss study reported on average more barriers and facilitators than a Danish study. Barriers and facilitators of a technical nature were most frequently reported. CONCLUSION This systematic review gathered evidence from Denmark and Switzerland on barriers and facilitators concerning data harmonization, sharing and linkage. Barriers and facilitators were strictly interrelated with the national context where projects were carried out. Structural changes, such as legislation implemented at the national level, were mirrored in the projects. This underlines the impact of national strategies in the field of health data. Our findings also suggest that more openness and clarity in the reporting of both barriers and facilitators to data harmonization constitute a key element to promote the successful management of new projects using health data and the implementation of proper policies in this field. Our study findings are thus meaningful beyond these two countries.
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Affiliation(s)
| | - Andrea Martani
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | | | - Tenzin Wangmo
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Bernice Simone Elger
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
- University Center of Legal Medicine, University of Geneva, Geneva, Switzerland
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17
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Heemskerk AD, Nguyen MTH, Dang HTM, Vinh Nguyen CV, Nguyen LH, Do TDA, Nguyen TTT, Wolbers M, Day J, Le TTP, Nguyen BD, Caws M, Thwaites GE. Clinical Outcomes of Patients With Drug-Resistant Tuberculous Meningitis Treated With an Intensified Antituberculosis Regimen. Clin Infect Dis 2018; 65:20-28. [PMID: 28472255 PMCID: PMC5850451 DOI: 10.1093/cid/cix230] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 03/15/2017] [Indexed: 11/13/2022] Open
Abstract
Background Drug-resistant tuberculous meningitis (TBM) is difficult to diagnose and treat. Mortality is high and optimal treatment is unknown. We compared clinical outcomes of drug-resistant and -susceptible TBM treated with either standard or intensified antituberculosis treatment. Methods We analyzed the influence of Mycobacterium tuberculosis drug resistance on the outcomes of patients with TBM enrolled into a randomized controlled trial comparing a standard, 9-month antituberculosis regimen (containing rifampicin 10 mg/kg/day) with an intensified regimen with higher-dose rifampicin (15 mg/kg/day) and levofloxacin (20 mg/kg/day) for the first 8 weeks. The primary endpoint of the trial was 9-month survival. In this subgroup analysis, resistance categories were predefined as multidrug resistant (MDR), isoniazid resistant, rifampicin susceptible (INH-R), and susceptible to rifampicin and isoniazid (INH-S + RIF-S). Outcome by resistance categories and response to intensified treatment were compared and estimated by Cox regression. Results Of 817 randomized patients, 322 had a known drug resistance profile. INH-R was found in 86 (26.7%) patients, MDR in 15 (4.7%) patients, rifampicin monoresistance in 1 patient (0.3%), and INH-S + RIF-S in 220 (68.3%) patients. Multivariable regression showed that MDR (hazard ratio [HR], 5.91 [95% confidence interval {CI}, 3.00–11.6]), P < .001), was an independent predictor of death. INH-R had a significant association with the combined outcome of new neurological events or death (HR, 1.58 [95% CI, 1.11–2.23]). Adjusted Cox regression, corrected for treatment adjustments, showed that intensified treatment was significantly associated with improved survival (HR, 0.34 [95% CI, .15–.76], P = .01) in INH-R TBM. Conclusions Early intensified treatment improved survival in patients with INH-R TBM. Targeted regimens for drug-resistant TBM should be further explored. Clinical Trials Registration ISRCTN61649292.
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Affiliation(s)
- A Dorothee Heemskerk
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Nuffield Department of Medicine, University of Oxford, United Kingdom
| | | | - Ha Thi Minh Dang
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease, Vietnam
| | - Chau Van Vinh Nguyen
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Lan Huu Nguyen
- Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease, Vietnam
| | - Thu Dang Anh Do
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Marcel Wolbers
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Jeremy Day
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Nuffield Department of Medicine, University of Oxford, United Kingdom
| | | | - Bang Duc Nguyen
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease, Vietnam
| | - Maxine Caws
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Liverpool School of Tropical Medicine, United Kingdom
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Nuffield Department of Medicine, University of Oxford, United Kingdom
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18
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Ma Y, Zhang Y, Zhao Y, Wang X, Lin Y, Ma A. Expression of autophagy-related genes in cerebrospinal fluid of patients with tuberculous meningitis. Exp Ther Med 2018; 15:4671-4676. [PMID: 29805485 PMCID: PMC5952066 DOI: 10.3892/etm.2018.5999] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 12/11/2017] [Indexed: 12/21/2022] Open
Abstract
The expression of autophagy-related genes in cerebrospinal fluid of patients with tuberculous meningitis (TBM) and their clinical significance in patients with TBM was investigated. Sixty patients with TBM (observation group) and twenty healthy volunteers during the same period (control group) were selected and the cerebrospinal fluid was collected. The expression levels of p62, Beclin1 and LC3-II genes in cerebrospinal fluid were detected via semi-quantitative reverse transcription-polymerase chain reaction and patients in observation group were divided into high expression and normal or low expression group on the basis of LC3-II expression levels. On the other hand, the contents of inflammatory factors interleukin-6, −10 (IL-6, −10), and tumor necrosis factor-α (TNF-α) were detected using the enzyme-linked immunosorbent assay kit. The mRNA levels of p62, Beclin1 and LC3-II in cerebrospinal fluid of patients in observation were significantly higher than those in the control group (P<0.01). TUNEL assay showed that the apoptosis level of cerebro-spinal fluid in high expression was obviously lower than that in normal or low expression group (P<0.01); the content of IL-6 and TNF-α in cerebrospinal fluid in high expression was significantly lower than those in normal or low expression group (P<0.01); the content of IL-10 in cerebrospinal fluid in high expression was obviously higher than that in normal or low expression group (P<0.01). Correlation analysis revealed that LC3-II was positively correlated with IL-10, but negatively correlated with IL-6 and TNF-α. The mRNA levels of p62, Beclin1 and LC3-II in cerebrospinal fluid of patients with TBM are increased, there is a correlation between expression levels of autophagy-related genes and inflammatory factors, and the high expression of autophagy-related genes may have a protective effect on patients with TBM.
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Affiliation(s)
- Yunbo Ma
- Department of Preventive Medicine, Linyi People's Hospital, Linyi, Shandong 276034, P.R. China
| | - Yongxia Zhang
- Department of Emergency, Linyi People's Hospital, Linyi, Shandong 276034, P.R. China
| | - Yanyan Zhao
- Department of Clinical Laboratory, Linyi People's Hospital, Linyi, Shandong 276034, P.R. China
| | - Xianhua Wang
- School of Public Health, Qingdao University, Qingdao, Shandong 266021, P.R. China
| | - Yuefu Lin
- Department of Preventive Medicine, Linyi People's Hospital, Linyi, Shandong 276034, P.R. China
| | - Aiguo Ma
- School of Public Health, Qingdao University, Qingdao, Shandong 266021, P.R. China
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19
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Dunphy L, Shetty P, Randhawa R, Rani KA, Duodu Y. Tuberculous meningitis in an immunocompetent male complicated by hydrocephalus. BMJ Case Rep 2016; 2016:bcr-2015-213916. [PMID: 27758813 DOI: 10.1136/bcr-2015-213916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 39-year-old man, born in India but resident in the UK for 10 years, was travelling in America when he became feverish with an altered mentation. He reported a 10-day history of fever, photophobia, headache and fatigue. His medical history included hypothyroidism and migraine. He was a non-smoker, did not consume alcohol and denied a history of drug use. He was transferred to the emergency department. Laboratory investigations confirmed hyponatraemia (sodium 128 mmol/L). A chest radiograph confirmed no focal consolidation. Further investigation with a CT brain was unremarkable. A lumbar puncture was suggestive of viral meningitis, with a raised white cell count, lymphocytosis, high protein and low glucose. His PCR was negative for enterovirus and herpes simplex virus. Further investigation with a CT thorax, abdomen and pelvis demonstrated bilateral upper-lobe infiltrations. A bronchoalveolar lavage was negative for acid alcohol fast bacilli (AAFB). A diagnosis of tuberculous meningitis was rendered following a repeat lumbar puncture. Gram stain revealed AAFB and PCR was also positive. He started antitubercular treatment and corticosteroids. A repeat CT brain demonstrated ventriculomegaly, suggestive of hydrocephalus and an MRI head revealed likely communicating hydrocephalus with basilar enhancement. He was repatriated to the UK. Eleven days post transfer, he became acutely confused and required external ventricular drain insertion. After surgical management of his hydrocephalus, there was no further neurological deterioration. He remains committed to his neurorehabilitation.
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Affiliation(s)
- Louise Dunphy
- Department of Medicine, Milton Keynes University Hospital, Eaglestone, Milton Keynes, UK
| | - Prashanth Shetty
- Department of Respiratory Medicine, Milton Keynes University Hospital, Milton Keynes, UK
| | - Rabinder Randhawa
- Department of Respiratory Medicine, Milton Keynes University Hospital, Milton Keynes, UK
| | - Kharil Amir Rani
- Department of Stroke Medicine, Milton Keynes University Hospital, Milton Keynes, UK
| | - Yaw Duodu
- Department of Stroke Medicine, Milton Keynes University Hospital, Milton Keynes, UK
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20
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Analysis of extrapulmonary tuberculosis in Spain: 2007-2012 National Study. Enferm Infecc Microbiol Clin 2016; 35:82-87. [PMID: 27474212 DOI: 10.1016/j.eimc.2016.06.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 05/28/2016] [Accepted: 06/03/2016] [Indexed: 11/23/2022]
Abstract
INTRODUCTION This study sought to study the epidemiological characteristics of the extrapulmonary tuberculosis (EPTB) in relation to pulmonary tuberculosis (PTB) from 2007 to 2012 in Spain, and plot its trend across the same period. METHODS We conducted an analytical cross-sectional study in which the following variables were analysed: age; sex; disease site; history of antituberculosis treatment; country of birth; presence of HIV infection; and culture results. Age-related differences were ascertained using the test of comparison of proportions, and crude and adjusted ORs were calculated using linear regression models. RESULTS Of the total of 44,050 cases of tuberculosis reported in the period 2007-2012 and included in the study, 31,508 (71.53%) were pulmonary tuberculosis and 12,542 (28.47%) were EPTB. EPTB rates decreased across all age groups. The main EPTB risk factor was presence of HIV infection (OR 1.39). Persons aged under 65 years had a lower risk of EPTB. CONCLUSIONS Although persons aged over 65 years displayed the highest incidence, there was nevertheless a downward trend across all age groups. Whereas children showed a significant decrease in tuberculous meningitis, this was not so for all extrapulmonary forms. EPTB rates among persons born outside Spain were much higher than those among the Spanish population.
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Majeed S, Radotra BD, Sharma S. Adjunctive role of MMP-9 inhibition along with conventional anti-tubercular drugs against experimental tuberculous meningitis. Int J Exp Pathol 2016; 97:230-7. [PMID: 27385155 DOI: 10.1111/iep.12191] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 03/20/2016] [Indexed: 12/25/2022] Open
Abstract
Tuberculous meningitis (TBM) is an outcome of neuroinflammatory degeneration caused due to Mycobacterium tuberculosis infection and leads to death or neurological disabilities in the affected individuals. It causes the highest morbidity and mortality amongst all forms of tuberculosis. Matrix metalloproteinase-9 levels increase and cause inflammatory destruction during progression of the disease. Although corticosteroids are usually given as an adjuvant therapy to overcome these complications, treatment outcome is contradictory. This study was designed to evaluate whether specific inhibition of MMP-9 can be beneficial in management of the disease. MMP-9 levels were inhibited using SB-3CT or dexamethasone along with conventional drugs for treatment of tuberculous meningitis. Both SB-3CT and dexamethasone decreased the elevated levels of MMP-9 in sera and tissues of the infected mice. However, dexamethasone administration had an inhibitory effect on bacillary clearance, while SB-3CT potentiated the bacillary clearance, suggesting that MMP-9, if specifically inhibited, can be beneficial in the management of TBM.
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Affiliation(s)
- Shahnawaz Majeed
- Department of Biochemistry, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Bishan D Radotra
- Department of Histopathology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Sadhna Sharma
- Department of Biochemistry, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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22
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Erdem H, Senbayrak S, Gencer S, Hasbun R, Karahocagil MK, Sengoz G, Karsen H, Kaya S, Civljak R, Inal AS, Pekok AU, Celen MK, Deniz S, Ulug M, Demirdal T, Namiduru M, Tekin R, Guven T, Parlak E, Bolukcu S, Avci M, Sipahi OR, Nayman-Alpat S, Yaşar K, Pehlivanoğlu F, Yilmaz E, Ates-Guler S, Mutlu-Yilmaz E, Tosun S, Sirmatel F, Şahin-Horasan E, Akbulut A, Johansen IS, Simeon S, Batirel A, Öztoprak N, Cag Y, Catroux M, Hansmann Y, Kadanali A, Turgut H, Baran AI, Gul HC, Karaahmetoglu G, Sunnetcioglu M, Haykir-Solay A, Denk A, Ayaz C, Kose S, Gorenek L. Tuberculous and brucellosis meningitis differential diagnosis. Travel Med Infect Dis 2015; 13:185-91. [PMID: 25801665 DOI: 10.1016/j.tmaid.2015.02.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 02/18/2015] [Accepted: 02/27/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Thwaites and Lancet scoring systems have been used in the rapid diagnosis of tuberculous meningitis (TBM). However, brucellar meningoencephalitis (BME) has similar characteristics with TBM. The ultimate aim of this study is to infer data to see if BME should be included in the differential diagnosis of TBM when these two systems suggest the presence of TBM. METHOD BME and TBM patients from 35 tertiary hospitals were included in this study. Overall 294 adult patients with BME and 190 patients with TBM were enrolled. All patients involved in the study had microbiological confirmation for either TBM or BME. Finally, the Thwaites and Lancet scoring systems were assessed in both groups. RESULTS The Thwaites scoring system more frequently predicted BME cases (n = 292, 99.3%) compared to the TBM group (n = 182, 95.8%) (P = 0.017). According to the Lancet scoring system, the mean scores for BME and TBM were 9.43 ± 1.71 and 11.45 ± 3.01, respectively (P < 0.001). In addition, TBM cases were classified into "probable" category more significantly compared to BME cases, and BME cases were categorized into the "possible" category more frequently. CONCLUSIONS When the Thwaites or Lancet scoring systems indicate TBM, brucellar etiology should also be taken into consideration particularly in endemic countries.
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Affiliation(s)
- Hakan Erdem
- GATA Haydarpasa Training Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey.
| | - Seniha Senbayrak
- Haydarpasa Numune Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Serap Gencer
- Lutfi Kirdar Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Rodrigo Hasbun
- The University of Texas Health Science Center at Houston, Medical School, Department of Infectious Diseases, USA
| | - Mustafa Kasim Karahocagil
- Yuzuncuyil University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Van, Turkey
| | - Gonul Sengoz
- Haseki Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Hasan Karsen
- Harran University, School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Sanliurfa, Turkey
| | - Selçuk Kaya
- Karadeniz Technical University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Trabzon, Turkey
| | - Rok Civljak
- Dr. Fran Mihaljevic University Hospital for Infectious Diseases, Department of Infectious Diseases, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Ayşe Seza Inal
- Cukurova University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Adana, Turkey
| | - Abdullah Umut Pekok
- Private Erzurum Sifa Hospital, Department of Infectious Diseases and Clinical Microbiology, Erzurum, Turkey
| | - Mustafa Kemal Celen
- Dicle University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Diyarbakir, Turkey
| | - Secil Deniz
- Haydarpasa Numune Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Mehmet Ulug
- Private Umit Hospital, Department of Infectious Diseases and Clinical Microbiology, Eskisehir, Turkey
| | - Tuna Demirdal
- Katip Celebi University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Izmir, Turkey
| | - Mustafa Namiduru
- Gaziantep University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Gaziantep, Turkey
| | - Recep Tekin
- Dicle University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Diyarbakir, Turkey
| | - Tumer Guven
- Ankara Atatürk Training & Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Ankara, Turkey
| | - Emine Parlak
- Ataturk University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Erzurum, Turkey
| | - Sibel Bolukcu
- Bezmi Alem Vakif University, School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Meltem Avci
- Izmir Bozyaka Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Izmir, Turkey
| | - Oğuz Reşat Sipahi
- Bezmi Alem Vakif University, School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Saygin Nayman-Alpat
- Osmangazi University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Eskisehir, Turkey
| | - Kadriye Yaşar
- Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Filiz Pehlivanoğlu
- Haseki Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Emel Yilmaz
- Uludag University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Bursa, Turkey
| | - Selma Ates-Guler
- Sutcu Imam University, School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Kahramanmaras, Turkey
| | - Esmeray Mutlu-Yilmaz
- Samsun Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Samsun, Turkey
| | - Selma Tosun
- Izmir Bozyaka Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Izmir, Turkey
| | - Fatma Sirmatel
- Izzet Baysal University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Bolu, Turkey
| | - Elif Şahin-Horasan
- Mersin University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Mersin, Turkey
| | - Ayhan Akbulut
- Firat University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Elazig, Turkey
| | | | - Soline Simeon
- University Hospital of Pontchaillou, Department of Infectious and Tropical Diseases, Rennes, France
| | - Ayşe Batirel
- Lutfi Kirdar Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Nefise Öztoprak
- Antalya Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Antalya, Turkey
| | - Yasemin Cag
- Lutfi Kirdar Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Melanie Catroux
- Poitiers University Hospital, Department of Infectious Diseases, France
| | - Yves Hansmann
- University Hospital, Department of Infectious Diseases, Strasbourg, France
| | - Ayten Kadanali
- Umraniye Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Huseyin Turgut
- Pamukkale University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Denizli, Turkey
| | - Ali Irfan Baran
- Yuzuncuyil University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Van, Turkey
| | - Hanefi Cem Gul
- Gulhane Medical Academy, Department of Infectious Diseases and Clinical Microbiology, Ankara, Turkey
| | - Gokhan Karaahmetoglu
- GATA Haydarpasa Training Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Mahmut Sunnetcioglu
- Yuzuncuyil University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Van, Turkey
| | - Asli Haykir-Solay
- Igdir State Hospital, Department of Infectious Diseases and Clinical Microbiology, Igdir, Turkey
| | - Affan Denk
- Firat University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Elazig, Turkey
| | - Celal Ayaz
- Dicle University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Diyarbakir, Turkey
| | - Sukran Kose
- Tepecik Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Izmir, Turkey
| | - Levent Gorenek
- GATA Haydarpasa Training Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
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23
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Hamsi scoring in the prediction of unfavorable outcomes from tuberculous meningitis: results of Haydarpasa-II study. J Neurol 2015; 262:890-8. [PMID: 25634680 DOI: 10.1007/s00415-015-7651-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 12/14/2014] [Accepted: 12/27/2014] [Indexed: 10/24/2022]
Abstract
Predicting unfavorable outcome is of paramount importance in clinical decision making. Accordingly, we designed this multinational study, which provided the largest case series of tuberculous meningitis (TBM). 43 centers from 14 countries (Albania, Croatia, Denmark, Egypt, France, Hungary, Iraq, Italy, Macedonia, Romania, Serbia, Slovenia, Syria, Turkey) submitted data of microbiologically confirmed TBM patients hospitalized between 2000 and 2012. Unfavorable outcome was defined as survival with significant sequela or death. In developing our index, binary logistic regression models were constructed via 200 replicates of database by bootstrap resampling methodology. The final model was built according to the selection frequencies of variables. The severity scale included variables with arbitrary scores proportional to predictive powers of terms in the final model. The final model was internally validated by bootstrap resampling. A total of 507 patients' data were submitted among which 165 had unfavorable outcome. Eighty-six patients died while 119 had different neurological sequelae in 79 (16%) patients. The full model included 13 variables. Age, nausea, vomiting, altered consciousness, hydrocephalus, vasculitis, immunosuppression, diabetes mellitus and neurological deficit remained in the final model. Scores 1-3 were assigned to the variables in the severity scale, which included scores of 1-6. The distribution of mortality for the scores 1-6 was 3.4, 8.2, 20.6, 31, 30 and 40.1%, respectively. Altered consciousness, diabetes mellitus, immunosuppression, neurological deficits, hydrocephalus, and vasculitis predicted the unfavorable outcome in the scoring and the cumulative score provided a linear estimation of prognosis.
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24
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Christensen ASH, Roed C, Andersen PH, Andersen AB, Obel N. Long-term mortality in patients with pulmonary and extrapulmonary tuberculosis: a Danish nationwide cohort study. Clin Epidemiol 2014; 6:405-21. [PMID: 25419160 PMCID: PMC4235508 DOI: 10.2147/clep.s65331] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Long-term mortality and causes of death in patients with pulmonary tuberculosis (PTB) and extrapulmonary tuberculosis (EPTB) are poorly documented. In this study, long-term mortality and causes of death in PTB and EPTB patients were compared with the background population and it was investigated whether mortality was associated with family-related risk factors. METHODS A NATIONWIDE COHORT STUDY WAS CONDUCTED INCLUDING: all adult Danes notified with PTB or EPTB from 1977 to 2008 and alive 1 year after diagnosis; a randomly selected comparison cohort matched on birth date and sex; adult siblings of PTB patients; and population controls. Data were extracted from national registries. All-cause and cause-specific mortality rate ratios were calculated for patients and siblings and compared with their respective control cohorts. A total of 8,291 patients (6,402 PTB and 1,889 EPTB), 24,873 population controls, 1,990 siblings of PTB patients and 11,679 siblings of PTB population controls were included. RESULTS Overall, the mortality rate ratio was 1.86 (95% confidence interval [CI] 1.77-1.96) for PTB patients and 1.24 (95% CI 1.12-1.37) for EPTB patients. Both patient cohorts had significantly increased risk of death due to infectious diseases and diabetes. Further, the PTB patients had increased mortality due to cancers (mainly respiratory and gastrointestinal tract), liver and respiratory system diseases, and alcohol and drug abuse. The PTB patients had increased mortality compared with their siblings (mortality rate ratio 3.55; 95% CI 2.57-4.91) as did the siblings of the PTB patients compared with the siblings of population controls (mortality rate ratio 2.16; 95% CI 1.62-2.87). CONCLUSION We conclude that adult PTB patients have an almost two-fold increased long-term mortality whereas EPTB patients have a slightly increased long-term mortality compared with the background population. The increased long-term mortality in PTB patients stems from diseases associated with alcohol, tobacco, and drug abuse as well as immune suppression, and family-related factors.
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Affiliation(s)
| | - Casper Roed
- Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peter H Andersen
- Department of Infectious Disease Epidemiology, Statens Serum Institut, Copenhagen, Denmark
| | | | - Niels Obel
- Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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25
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Erdem H, Ozturk-Engin D, Elaldi N, Gulsun S, Sengoz G, Crisan A, Johansen I, Inan A, Nechifor M, Al-Mahdawi A, Civljak R, Ozguler M, Savic B, Ceran N, Cacopardo B, Inal A, Namiduru M, Dayan S, Kayabas U, Parlak E, Khalifa A, Kursun E, Sipahi O, Yemisen M, Akbulut A, Bitirgen M, Dulovic O, Kandemir B, Luca C, Parlak M, Stahl J, Pehlivanoglu F, Simeon S, Ulu-Kilic A, Yasar K, Yilmaz G, Yilmaz E, Beovic B, Catroux M, Lakatos B, Sunbul M, Oncul O, Alabay S, Sahin-Horasan E, Kose S, Shehata G, Andre K, Alp A, Ćosic G, Gul HC, Karakas A, Chadapaud S, Hansmann Y, Harxhi A, Kirova V, Masse-Chabredier I, Oncu S, Sener A, Tekin R, Deveci O, Karabay O, Agalar C. The microbiological diagnosis of tuberculous meningitis of Haydarpasa-1 study. Clin Microbiol Infect 2014; 20:O600-8. [DOI: 10.1111/1469-0691.12478] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 11/21/2013] [Accepted: 11/22/2013] [Indexed: 12/17/2022]
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26
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Tuberculous meningitis and hydrocephalus. J Infect 2013; 66:541. [DOI: 10.1016/j.jinf.2013.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 03/08/2013] [Indexed: 11/22/2022]
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