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Sharifi G, Ansari M, Chalmiani EM, Javandoust Gharehbagh F, Darazam IA. An 11-month-old boy with tuberculous meningitis presenting as progressive limb weakness, fever, developmental retardation, and loss of consciousness: a case report. J Med Case Rep 2024; 18:210. [PMID: 38671477 PMCID: PMC11055343 DOI: 10.1186/s13256-024-04523-1] [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: 10/06/2023] [Accepted: 03/22/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Tuberculous meningitis (TBM) accounts for about 1% of all tuberculosis cases and about 5% of extrapulmonary tuberculosis cases. However, it poses major importance because approximately half of those affected die or become severely disabled. Herein, the successful treatment of an 11-month-old boy with progressive limb weakness, fever, developmental retardation, and loss of consciousness due to tuberculosis, was reported. CASE PRESENTATION An 11-month-old (Iranian Turk) boy was referred to Loghman Hakim hospital for progressive limb weakness and loss of previously attained developmental milestones for the past 2 months. He also had persistent fever and loss of consciousness for about 14 to 21 days. Before being referred to our center, the patient had been diagnosed with hydrocephalus at another center due to possible acute bacterial meningitis based on a CT scan and MRI imaging. On physical examination, anterior fontanel bulging and neck stiffness were observed on the admission. His body temperature and heart rate were 38.1 C and 86 beats per minute (bpm), respectively. He had left 6 cranial nerve palsy and spastic quadriparesis with a power of grade 3/5. Other systemic examinations were normal. Endoscopic third ventriculostomy (ETV) (and leptomeningeal biopsy) revealed diffuse thickening of the floor and lateral walls of the 3rd ventricle and also a cobblestone appearance in the form of multiple white patchy lesions was detected on the floor of the 3rd ventricle. CSF analysis and polymerase chain reaction confirmed the TB meningitis. During hospitalization, a temporary EVD (external ventricular drain) was initially inserted. Eventually, defervescence was denoted 5-6 days after initiation of anti-TB medications, and a permanent ventriculoperitoneal shunt was inserted due to hydrocephalus. Gradually his truncal and limb tone and motor function improved, as did his emotional responses to his parents and ability to eat. The patient can walk without help in the 15th month following the operation and resolved hydrocephalus demonstrated on follow-up imaging. CONCLUSION Over half of treated TB meningitis patients die or suffer severe neurological sequelae, mainly due to late diagnosis. Hence, early diagnosis and prompt initiation of TB treatment offer the best chance of a good neurological outcome.
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Affiliation(s)
- Guive Sharifi
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Ansari
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Elmira Mahmoudi Chalmiani
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Infectious Diseases and Tropical Medicine, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Makhsoos St, South Kargar Ave, Tehran, Iran
| | - Farid Javandoust Gharehbagh
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ilad Alavi Darazam
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
- Department of Infectious Diseases and Tropical Medicine, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Makhsoos St, South Kargar Ave, Tehran, Iran.
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Saifon W, Karaketklang K, Jitmuang A. Distinguishing clinical characteristics of central nervous system tuberculosis in immunodeficient and non-immunodeficient individuals: a 12-year retrospective study. Ann Clin Microbiol Antimicrob 2023; 22:69. [PMID: 37550721 PMCID: PMC10408106 DOI: 10.1186/s12941-023-00615-w] [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: 04/17/2023] [Accepted: 07/23/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Central nervous system tuberculosis (CNS TB) is a severe Mycobacterium tuberculosis (MTB) infection. It is unclear whether a patient's immune status alters the clinical manifestations and treatment outcomes of CNS TB. METHODS Between January 2007-December 2018, chart reviews of CNS TB, including tuberculous meningitis (TBM), tuberculoma/abscess, and TB myelitis, were made. Subjects were categorized as immunodeficient (ID) and non-immunodeficient (NID). RESULTS Of 310 subjects, 160 (51.6%) were in the ID group-132 (42.6%) had HIV and 28 (9.0%) had another ID, and 150 (48.4%) were in the NID group. The mean age was 43.64 ± 16.76 years, and 188 (60.6%) were male. There were 285 (91.9%) TBM, 16 (5.2%) tuberculoma/abscess, and 9 (2.9%) myelitis cases. The TBM characteristics in the ID group were younger age (p = 0.003), deep subcortical location of tuberculoma (p = 0.030), lower hemoglobin level (p < 0.001), and lower peripheral white blood cell count (p < 0.001). Only HIV individuals with TBM had an infection by multidrug-resistant MTB (p = 0.013). TBM mortality was varied by immune status -HIV 22.8%, other ID 29.6%, and NID 14.8% (p < 0.001). Factors significantly associated with unfavorable outcomes in TBM also differed between the HIV and NID groups. CONCLUSIONS TBM is the most significant proportion of CNS TB. Some of the clinical characteristics of TBM, such as age, radiographic findings, hematological derangement, and mortality, including factors associated with unfavorable outcomes, differed between ID and non-ID patients.
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Affiliation(s)
- Woraseth Saifon
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Khemajira Karaketklang
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Anupop Jitmuang
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand.
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Krishnakumariamma K, Ellappan K, Muthuraj M, Tamilarasu K, Kumar SV, Joseph NM. Diagnostic performance of real time PCR for the detection of Mycobacterium tuberculosis in cerebrospinal fluid samples. Indian J Med Microbiol 2023; 42:7-11. [PMID: 36967219 DOI: 10.1016/j.ijmmb.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 12/10/2022] [Accepted: 12/30/2022] [Indexed: 01/21/2023]
Abstract
PURPOSE We aimed this study to standardize real time - polymerase chain reaction (RT-PCR) for the detection of Mycobacterium tuberculosis (Mtb) in cerebrospinal fluid (CSF) samples and compare its diagnostic performance with GeneXpert (Xpert), Mycobacteria Growth Indicator Tube (MGIT) and Multiplex PCR (MPCR) for tuberculous meningitis (TBM). METHODOLOGY A total of 217 CSF samples were obtained from patients with suspected TBM during the study period between January 2019 and December 2021. The optimal cycle threshold (CT) of RT-PCR was determined by comparing different gene targets of Mtb (IS6110, 16SrRNA, HSP65 and Ag85B). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) was determined for RT-PCR, Xpert, MGIT960 and MPCR. Diagnostic accuracy of these assays was compared by using clinical diagnosis as reference standard. RESULTS IS6110RT-PCR was found to be highly sensitive as compared to other gene targets. Sensitivities of IS6110RT-PCR, MPCR, Xpert and MGIT against a reference standard of definite, probable and possible TBM were 36.7%, 21.1%, 16.7% and 6.7%, respectively; specificities were 97.6%, 100%, 100% and 100%, respectively. Xpert, RT-PCR, MPCR and MGIT960 detected 6.91% (n = 15), 5.99% (n = 13), 5.99% (n = 13) and 2.76% (n = 6) of definite TBM, respectively. RT-PCR detected 6.45% (n = 14) and 2.76% (n = 6) of possible TBM and probable TBM, respectively and MPCR detected 1.38% (n = 3) of possible and probable TBM each. CONCLUSION IS6110RT-PCR is highly sensitive for primary screening of suspected TB cases, which may help clinicians to start appropriate patient's treatment with clinical suspicion of TBM.
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Elusive tuberculous meningitis with rare neurological complication of longitudinally extensive transverse myelitis: a case report. Spinal Cord Ser Cases 2021; 7:82. [PMID: 34521808 PMCID: PMC8438549 DOI: 10.1038/s41394-021-00445-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 09/06/2021] [Accepted: 09/06/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Longitudinally extensive transverse myelitis (LETM) is inflammation of the spinal cord that spans three or more spinal segments. LETM is a rare occurrence on its own and has seldom been reported with tuberculous meningitis (TBM), the rarest and deadliest of tuberculous manifestations. TBM is usually seen in children, the immunocompromised, or those with a previous history of tuberculosis infection. CASE PRESENTATION A 24-year-old healthy male with no co-morbidities or history of tuberculosis presented with fever and headache for the past 3 months. The patient's Kernig's and Brudzinski's signs were both negative, with bilateral abnormal plantar reflexes. The neurological level of injury was T8 and the patient was classified as AIS grade A. His CSF analysis showed a lymphocytic picture. However, both GeneXpert and Ziehl-Neelsen staining came back negative for Mycobacterium tuberculosis. MRI scans of the brain and thoracic spine revealed enhancing nodules and ring lesions in the brain and spinal cord, along with the rare complication of LETM, extending from T2 to T9. DISCUSSION Although Mycobacterium tuberculosis was never isolated, the patient started recovering as soon as antituberculous therapy was initiated. Hence, more emphasis needs to be placed on radiological imaging in the management of rare medical emergencies like tuberculous meningitis, especially in areas where tuberculosis is rampant and endemic, rather than waiting for a positive culture. This case report also demonstrates the growing evidence that transverse myelitis and/or LETM is associated with TBM.
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de Almeida SM, Santana LB, Jr GG, Kussen GB, Nogueira K. Real-time Polymerase Chain Reaction for Mycobacterium tuberculosis Meningitis is More Sensitive in Patients with HIV Co-Infection. Curr HIV Res 2021; 18:267-276. [PMID: 32368978 DOI: 10.2174/1570162x18666200505083728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 04/14/2020] [Accepted: 04/16/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Tuberculous meningitis (TbM) is the most severe complication of extra pulmonary tuberculosis (Tb). There is a higher frequency of positive cerebrospinal fluid (CSF) cultures for Mycobacterium tuberculosis (MTb) in samples from human immunodeficiency virus (HIV) co-infected patients than in those from HIV-negative patients. We hypothesized that real time PCR assays for MTb (MTb qPCR) using CSF would be more sensitive in HIV co-infected patients owing to a greater MTb burden. The present study aimed to verify the diagnostic performance of MTb qPCR in CSF of TbM patients who either were co-infected with HIV or were HIVnegative. METHODS A total of 334 consecutive participants with suspected TbM were divided into two groups: HIV co-infected and HIV-negative; each group was categorized into definite TbM, probable TbM, possible TbM, and TbM-negative subgroups based on clinical, laboratory and imaging data. We evaluated the diagnostic characteristics of MTb qPCR analysis to detect TbM in CSF by comparing the results to those obtained for definite TbM (i.e., positive MTb culture) and/or probable TbM in CSF, as gold standard. RESULTS The sensitivity of MTb qPCR in the definite and probable subgroups of the HIV coinfected participants (n = 14) was 35.7%, with a specificity of 93.8%, negative predictive value (NPV) of 94.4%, and negative clinical utility index (CUI-) of 0.89. Results of the HIV-negative group (n = 7) showed lower sensitivity (14.3%) and similar specificity, NPV, and CUI-. CONCLUSION The findings confirmed our hypothesis, despite the low sensitivity. MTb qPCR may significantly contribute to diagnosis when associated with clinical criteria and complementary examinations.
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Affiliation(s)
- Sergio M de Almeida
- Neuroinfection Outclinic, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Lucas B Santana
- Neuroinfection Outclinic, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Gilberto Golin Jr
- Neuroinfection Outclinic, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Gislene B Kussen
- Bacteriology Laboratory, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Keite Nogueira
- Bacteriology Laboratory, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
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Purmohamad A, Azimi T, Nasiri MJ, Goudarzi M, Zangiabadian M, Sedighian H, Fooladi AAI. HIV-Tuberculous Meningitis Co-Infection: A Systematic Review and Meta-Analysis. Curr Pharm Biotechnol 2021; 22:960-968. [PMID: 32744963 DOI: 10.2174/1389201021666200730143906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/10/2020] [Accepted: 06/22/2020] [Indexed: 11/22/2022]
Abstract
Human Immunodeficiency Virus (HIV)-infected persons are at a higher risk of developing Tuberculous Meningitis (TBM). We aimed to estimate the prevalence of TBM-HIV co-infection. We systematically searched Pubmed/Medline, Embase and Cochrane library databases from January 1, 2000, to January 31, 2017, to find relevant studies. We employed the random-effects meta-analysis model to estimate the pooled prevalence of TBM-HIV co-infection. Twenty-six eligible studies showed the prevalence of HIV in TBM patients. In the pooled analyses, the prevalence of HIV was 30% (95% CI: 12-47) in patients with confirmed TBM, and 12.1% (95% CI: 7.3-19.2) in patients with suspected TBM. This study shows a high prevalence of TBM-HIV co-infection. Establishing proper diagnostic criteria and preventive measures for TBM infections could assist in the prevention and management of TBM infection, particularly TBM-HIV co-infection.
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Affiliation(s)
- Ali Purmohamad
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Taher Azimi
- Department of Pathobiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad J Nasiri
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehdi Goudarzi
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Moein Zangiabadian
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Sedighian
- Applied Microbiology Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Abbas A I Fooladi
- Applied Microbiology Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
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Development and validation of a new scoring system for the early diagnosis of tuberculous meningitis in adults. Diagn Microbiol Infect Dis 2021; 101:115393. [PMID: 34237646 DOI: 10.1016/j.diagmicrobio.2021.115393] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 03/24/2021] [Accepted: 04/08/2021] [Indexed: 11/21/2022]
Abstract
We developed and validated a new diagnostic scoring system by simultaneously comparing 28 factors (including clinical, laboratory, and imaging) of HIV uninfected adult tuberculous meningitis (TBM) with viral meningitis (VM), bacterial meningitis (BM), and cryptococcal meningitis (CM). Predictors of TBM diagnosis obtained by logistic regression. A total of 382 patients with intracranial infection participated, and eight factors were independently associated with TBM diagnosis: symptom duration, evidence of extracranial tuberculosis, cerebrospinal fluid (CSF) leukocyte, CSF neutrophil, CSF protein, low serum sodium, meningeal enhancement, and tuberculomas. Factors are assigned according to weight, a score of ≥ 5 was suggestive of TBM with a sensitivity of 85.8% and a specificity of 87.7%, and the area under the receiver operating characteristic curve was 0.923. When applied to a prospective validation cohort, this scoring model showed robust performance. Our study suggests that the application of this score can help diagnose TBM more efficiently.
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Tarulli A. Confusion. Neurology 2021. [DOI: 10.1007/978-3-030-55598-6_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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9
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Ahlawat S, Chaudhary R, Dangi M, Bala K, Singh M, Chhillar AK. Advances in tuberculous meningitis diagnosis. Expert Rev Mol Diagn 2020; 20:1229-1241. [PMID: 33259249 DOI: 10.1080/14737159.2020.1858805] [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: 10/22/2022]
Abstract
Introduction: Tuberculous meningitis (TBM) is the most devastating form of central nervous system tuberculosis (TB) and causes high mortality worldwide. Nonspecific clinical manifestations and limited sensitivity of existing laboratory methods make the diagnosis elusive due to the paucibacillary nature of the infection. Areas Covered: We reviewed current literature on the adequacy and limitations of globally existing laboratory methods for diagnosing TBM. Expert opinion: TBM is deadliest among all TB forms, as the outcome may lead to death in 50% of cases, and survivors undergo irreversible neurological disorders. Therefore, early diagnosis and prompt treatment are cornerstones of effective disease management. Conventional microscopy and culture are widely used modalities but remain inadequate in most TBM cases. Although expanded use of rapid molecular tests such as real-time PCR and Xpert Ultra, even in resource-limited settings, hold promising results for TB diagnosis but need optimization for early detection of TBM. Moreover, CSF IGRA is also used but unable to differentiate between active and latent TB. Overall no single test for diagnosing TBM has adequate accuracy so, there is an urgent need to devise a point-of-care test.
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Affiliation(s)
- Sonia Ahlawat
- Centre for Biotechnology, Maharshi Dayanand University (MDU) , Rohtak, India.,Amity Institute of Biotechnology, Amity University Haryana , Manesar, India
| | - Renu Chaudhary
- Council of Scientific & Industrial Research (CSIR)-institute of Genomics and Integrative Biology (IGIB) , New Delhi, India
| | - Mehak Dangi
- Department of Bioinformatics, Maharshi Dayanand University (MDU) , Rohtak, India
| | - Kiran Bala
- Department of Neurology, University of Health Sciences (UHS) , Rohtak, India
| | - Machiavelli Singh
- Amity Institute of Biotechnology, Amity University Haryana , Manesar, India
| | - Anil Kumar Chhillar
- Centre for Biotechnology, Maharshi Dayanand University (MDU) , Rohtak, India
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Garg RK. Microbiological diagnosis of tuberculous meningitis: Phenotype to genotype. Indian J Med Res 2019; 150:448-457. [PMID: 31939388 PMCID: PMC6977359 DOI: 10.4103/ijmr.ijmr_1145_19] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Indexed: 11/22/2022] Open
Abstract
Tuberculous meningitis (TBM) is a commonly encountered central nervous system infection. Characteristic clinical, imaging and cerebrospinal fluid parameters help clinicians to make a prompt presumptive diagnosis that enables them to start empirical anti-tuberculosis treatment. There are several close mimic to TBM, such as partially treated pyogenic meningitis, fungal meningitis, sarcoidosis, meningeal metastases and meningeal lymphomatosis. Microbiological confirmation instils a sense of confidence amongst treating physicians. With conventional phenotypic methods (cerebrospinal fluid microscopy and culture), in more than 50 per cent patients, microbiological confirmation is not achieved. Moreover, these methods take a long time before providing conclusive results. Negative result does not rule out Mycobacterium tuberculosis infection of the brain. Genotypic methods, such as IS 6110 polymerase chain reaction and automated Xpert M. tuberculosis/rifampicin (MTB/RIF) assay system improved the TBM diagnostics, as results are rapidly available. Xpert MTB/RIF assay, in addition, detects rifampicin resistance. Xpert MTB/RIF Ultra is advanced technology which has higher (60-70%) sensitivity and is being considered a game-changer in the diagnostics of TBM. A large number of TBM cases remain unconfirmed. The situation of TBM diagnostics will remain grim, if low-cost technologies are not widely available. Till then, physicians continue to rely on their clinical acumen to start empirical anti-tuberculosis treatment.
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Affiliation(s)
- Ravindra Kumar Garg
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India
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11
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Wei Z, Zhang X, Wei C, Yao L, Li Y, Zhang X, Xu H, Jia Y, Guo R, Wu Y, Yang K, Gao X. Diagnostic accuracy of in-house real-time PCR assay for Mycobacterium tuberculosis: a systematic review and meta-analysis. BMC Infect Dis 2019; 19:701. [PMID: 31395014 PMCID: PMC6686366 DOI: 10.1186/s12879-019-4273-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 07/10/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In recent years, studies on the diagnostic accuracy of in-house real-time PCR (hRT-PCR) assay for the detection of Mycobacterium tuberculosis (Mtb) have been reported with unignorable discrepancies. To assess the overall accuracy of the hRT-PCR assay for Mtb diagnosis in different samples for individuals with active pulmonary and extra-pulmonary Mtb infection, a systematic review and meta-analysis were performed. METHODS The PUBMED, EMBASE, Web of Science, and Cochrane databases were searched up to June 2017 for eligible studies that estimated diagnostic sensitivity and specificity with the hRT-PCR assay in respiratory and non-respiratory samples in pulmonary and extra-pulmonary Mtb infection patients, with Mtb culture as the reference standard. Bivariate random effect models were used to provide pooled estimation of diagnostic accuracy. Further, subgroup and meta-regression analyses were performed to explore sources of heterogeneity. The risk of bias was assessed by the QUADAS-2 tool. RESULTS Of the 3589 candidate studies, 18 eligible studies met our inclusion criteria. Compared to Mtb culture data, the pooled sensitivity and specificity were 0.96 and 0.92, respectively. The diagnostic odds ratio (DOR) was 192.96 (95% CI 68.46, 543.90), and the area under the summary ROC curve (AUC) was 0.9791. There was significant heterogeneity in sensitivity and specificity among the enrolled studies (p < 0.001). The studies with high-quality assessment and application of respiratory specimen were associated with better accuracy. CONCLUSIONS In low-income/high-burden settings, our results suggested that the hRT-PCR assay could be a useful test for the diagnosis of TB with high sensitivity and specificity.
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Affiliation(s)
- Zhenhong Wei
- Blood Transfusion Department, Gansu Provincial Hospital, Lanzhou, 730000, Gansu, China
| | - Xiaoping Zhang
- Blood Transfusion Department, Gansu Provincial Hospital, Lanzhou, 730000, Gansu, China
| | - Chaojun Wei
- The Institute of Clinical Research and Translational Medicine, Gansu Provincial Hospital, No. 204, Donggang street, Chengguan district, Lanzhou, 730000, Gansu, China
| | - Liang Yao
- The Institute of Clinical Study and Evidence-Based Medicine, Gansu Provincial Hospital, Lanzhou, 730000, Gansu, China.,Evidence-Based Medicine Center and Key Laboratory of Evidence-Based Medicine and Knowledge Translation of Gansu Province, College of Basic Medicine, Lanzhou University, No. 199, Donggang street, Chengguan district, Lanzhou, 73000, Gansu, China
| | - Yonghong Li
- The Institute of Clinical Research and Translational Medicine, Gansu Provincial Hospital, No. 204, Donggang street, Chengguan district, Lanzhou, 730000, Gansu, China
| | - Xiaojing Zhang
- Blood Transfusion Department, Gansu Provincial Hospital, Lanzhou, 730000, Gansu, China
| | - Hui Xu
- The Institute of Clinical Research and Translational Medicine, Gansu Provincial Hospital, No. 204, Donggang street, Chengguan district, Lanzhou, 730000, Gansu, China
| | - Yanjuan Jia
- The Institute of Clinical Research and Translational Medicine, Gansu Provincial Hospital, No. 204, Donggang street, Chengguan district, Lanzhou, 730000, Gansu, China
| | - Rui Guo
- The Institute of Clinical Research and Translational Medicine, Gansu Provincial Hospital, No. 204, Donggang street, Chengguan district, Lanzhou, 730000, Gansu, China
| | - Yu Wu
- The Institute of Clinical Research and Translational Medicine, Gansu Provincial Hospital, No. 204, Donggang street, Chengguan district, Lanzhou, 730000, Gansu, China
| | - Kehu Yang
- The Institute of Clinical Study and Evidence-Based Medicine, Gansu Provincial Hospital, Lanzhou, 730000, Gansu, China. .,Evidence-Based Medicine Center and Key Laboratory of Evidence-Based Medicine and Knowledge Translation of Gansu Province, College of Basic Medicine, Lanzhou University, No. 199, Donggang street, Chengguan district, Lanzhou, 73000, Gansu, China.
| | - Xiaoling Gao
- The Institute of Clinical Research and Translational Medicine, Gansu Provincial Hospital, No. 204, Donggang street, Chengguan district, Lanzhou, 730000, Gansu, China.
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A Systematic Review and Meta-analysis of the Diagnostic Accuracy of Nucleic Acid Amplification Tests for Tuberculous Meningitis. J Clin Microbiol 2019; 57:JCM.01113-18. [PMID: 30944198 DOI: 10.1128/jcm.01113-18] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The diagnosis of tuberculous meningitis (TBM) is difficult and poses a significant challenge to physicians worldwide. Recently, nucleic acid amplification (NAA) tests have shown promise for the diagnosis of TBM, although their performance has been variable. We undertook a systematic review and meta-analysis to evaluate the diagnostic accuracy of NAA tests with cerebrospinal fluid (CSF) samples against that of culture as the reference standard or a combined reference standard (CRS) for TBM. We searched the Embase, PubMed, Web of Science, and Cochrane Library databases for the relevant records. The QUADAS-2 tool was used to assess the quality of the studies. Diagnostic accuracy measures (i.e., sensitivity and specificity) were pooled with a random-effects model. All statistical analyses were performed with STATA (version 14 IC; Stata Corporation, College Station, TX, USA), Meta-DiSc (version 1.4 for Windows; Cochrane Colloquium, Barcelona, Spain), and RevMan (version 5.3; The Nordic Cochrane Centre, the Cochrane Collaboration, Copenhagen, Denmark) software. Sixty-three studies comprising 1,381 cases of confirmed TBM and 5,712 non-TBM controls were included in the final analysis. These 63 studies were divided into two groups comprising 71 data sets (43 in-house tests and 28 commercial tests) that used culture as the reference standard and 24 data sets (21 in-house tests and 3 commercial tests) that used a CRS. Studies which used a culture reference standard had better pooled summary estimates than studies which used CRS. The overall pooled estimates of sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) of the NAA tests against culture were 82% (95% confidence interval [CI], 75 to 87%), 99% (95% CI, 98 to 99%), 58.6 (95% CI, 35.3 to 97.3), and 0.19 (95% CI, 0.14 to 0.25), respectively. The pooled sensitivity, specificity, PLR, and NLR of NAA tests against CRS were 68% (95% CI, 41 to 87%), 98% (95% CI, 95 to 99%), 36.5 (95% CI, 15.6 to 85.3), and 0.32 (95% CI, 0.15 to 0.70), respectively. The analysis has demonstrated that the diagnostic accuracy of NAA tests is currently insufficient for them to replace culture as a lone diagnostic test. NAA tests may be used in combination with culture due to the advantage of time to result and in scenarios where culture tests are not feasible. Further work to improve NAA tests would benefit from the availability of standardized reference standards and improvements to the methodology.
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Application of Cerebrospinal Fluid Host Protein Biosignatures in the Diagnosis of Tuberculous Meningitis in Children from a High Burden Setting. Mediators Inflamm 2019; 2019:7582948. [PMID: 31148946 PMCID: PMC6501148 DOI: 10.1155/2019/7582948] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 01/14/2019] [Indexed: 02/07/2023] Open
Abstract
Background The diagnosis of tuberculous meningitis (TBM) especially in children is challenging. New tests are urgently needed for the diagnosis of the disease, especially in resource-limited settings. Methods We collected cerebrospinal fluid (CSF) samples from children presenting with symptoms requiring investigation for meningitis at a tertiary hospital in Cape Town, South Africa. Children were later classified as TBM or no TBM using published case definitions. Using a multiplex platform, we investigated the concentrations of biomarkers comprising a previously established 3-marker biosignature (VEGF, IL-13, and LL-37) and other potentially useful host biomarkers as diagnostic candidates for TBM. Findings Out of 47 children, age, 3 months to 13 years, 23 were diagnosed with TBM and six (16%) were HIV-infected. We validated the previously identified CSF biosignature (sensitivity of 95.7% (95% CI, 79.0-99.2%) and specificity of 37.5% (95% CI, 21.2-57.3%)). However, substitution of IL-13 and LL-37 with IFN-γ and MPO, respectively, resulted in improved accuracy (area under the ROC curve (AUC) = 0.97, 95% CI, 0.92-1.00, up to 91.3% (21/23) sensitivity and up to 100% (24/24) specificity). An alternative four-marker biosignature (sICAM-1, MPO, CXCL8, and IFN-γ) also showed potential, with an AUC of 0.97. Conclusion We validated a previously identified CSF biosignature and showed that refinement of this biosignature by incorporation of other biomarkers diagnosed TBM with high accuracy. Incorporation of these biomarkers into a point-of-care or bedside diagnostic test platform may result in the improved management of TBM in children.
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14
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Vera CA, Patron-Ordoñez G, Verastegui-Diaz A, Mejia CR. Factores sociodemográficos y fisiopatológicos asociados a la tuberculosis del sistema nervioso central en un Hospital Público de Lima-Perú, 2014-2017. INFECTIO 2019. [DOI: 10.22354/in.v23i2.772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objetivo: Determinar los factores sociodemográficos y fisiopatológicos de la neurotuberculosis (NTB) en los pacientes registrados en el Programa de Control de la Tuberculosis (PCT) del Hospital Nacional Dos de Mayo.Materiales y Métodos: Se realizó un estudio transversal analítico, desarrollado entre Julio del 2014 y Julio del 2017. Se diseñó una ficha que incluyó datos sociodemográficos, fisiopatológicos y las características al diagnóstico. Se obtuvieron las razones de prevalencia (RP) crudos y ajustados, con intervalos de confianza al 95%.Resultados: Participaron 1038 pacientes. El 16% de toda la población y de 34% de las tuberculosis extra pulmonares tenia NTB. La forma clínica más frecuente fue la meningoencefalitis tuberculosa (MEC TB) (96%). Dentro de las manifestaciones clínicas destacaron las convulsiones (22%), cefalea (20%), signos meníngeos (18%) y trastorno del sensorio (16%). La presencia de NTB estuvo asociada al diagnóstico de VIH (RPa: 2,06; IC95%: 1,53-2,76; Valor p<0,001), condición de alcoholismo (RPa: 1,53; IC95%: 1,04-2,25; Valor p=0,030) y género femenino (RPa: 1,40; IC95%: 1,06-1,84; Valor p=0,019).Conclusiones: El diagnóstico de VIH, condición de alcoholismo y el género femenino son factores asociados a mayor frecuencia de NTB en el Hospital Dos de Mayo.
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15
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Manyelo CM, Solomons RS, Snyders CI, Mutavhatsindi H, Manngo PM, Stanley K, Walzl G, Chegou NN. Potential of Host Serum Protein Biomarkers in the Diagnosis of Tuberculous Meningitis in Children. Front Pediatr 2019; 7:376. [PMID: 31612118 PMCID: PMC6773834 DOI: 10.3389/fped.2019.00376] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 09/02/2019] [Indexed: 01/22/2023] Open
Abstract
Background: Tuberculous meningitis (TBM) is the most severe form of tuberculosis and results in high morbidity and mortality in children. Diagnostic delay contributes to the poor outcome. There is an urgent need for new tools for the rapid diagnosis of TBM, especially in children. Methods: We collected serum samples from children in whom TBM was suspected at a tertiary hospital in Cape Town, South Africa. Children were subsequently classified as having TBM or no TBM using a published uniform research case-definition. Using a multiplex cytokine array platform, we investigated the concentrations of serum biomarkers comprising biomarkers that were previously found to be of value in the diagnosis of adult pulmonary TB (CRP, SAA, CFH, IFN-γ, IP-10, Apo-AI, and transthyretin) plus other potentially useful host biomarkers as diagnostic candidates for TBM. Findings: Out of 47 children included in the study, 23 (48.9%) had a final diagnosis of TBM and six were HIV infected. A modified version of the adult 7-marker biosignature in which transthyretin was replaced by NCAM1, diagnosed TBM in children with AUC of 0.80 (95% CI, 0.67-0.92), sensitivity of 73.9% (95% CI, 51.6-89.8%) and specificity of 66.7% (95% CI, 44.7-84.4%), with the other six proteins in the signature (CRP, IFN-γ, IP-10, CFH, Apo-A1, and SAA) only achieving and AUC of 0.75 (95% CI, 0.61-0.90) when used in combination. A new childhood TBM specific 3-marker biosignature (adipsin, Aβ42, and IL-10) showed potential in the diagnosis of TBM, with AUC of 0.84 (95% CI, 0.73-0.96), sensitivity of 82.6% (95 CI, 61.2-95.0%) and specificity of 75.0% (95% CI, 53.3-90.2%) after leave-one-out cross validation. Conclusion: A previously described adult 7-marker serum protein biosignature showed potential in the diagnosis of TBM in children. However, a smaller childhood TBM-specific 3-marker signature demonstrated improved performance characteristics. Our data indicates that blood-based biomarkers may be useful in the diagnosis of childhood TBM and requires further validation in larger cohort studies.
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Affiliation(s)
- Charles M Manyelo
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, 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
| | - Candice I Snyders
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Hygon Mutavhatsindi
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Portia M Manngo
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kim Stanley
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gerhard Walzl
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Novel N Chegou
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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16
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de Almeida SM, Borges CM, Santana LB, Golin G, Correa L, Kussen GB, Nogueira K. Validation of Mycobacterium tuberculosis real-time polymerase chain reaction for diagnosis of tuberculous meningitis using cerebrospinal fluid samples: a pilot study. ACTA ACUST UNITED AC 2018; 57:556-564. [DOI: 10.1515/cclm-2018-0524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 08/17/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Timely diagnosis of tuberculous meningitis (TBM) remains challenging. Molecular diagnostic tools are necessary, particularly in low- and middle-income countries. There is no approved commercial polymerase chain reaction (PCR) assay that can be used to detect Mycobacterium tuberculosis in non-respiratory samples, such as the cerebrospinal fluid (CSF). We aimed to validate the threshold cycle (Ct) cut-off points; calculate the operational characteristics of real-time PCR for detection of M. tuberculosis (MTb qPCR) in the CSF; and the inhibitory affect of CSF red blood cells (RBC) and total proteins on MTb qPCR.
Methods
A total of 334 consecutive participants were enrolled. Based on clinical, laboratory and imaging data, cases of suspected TBM were categorized as definite, probable, possible or not TBM cases. Receiver operating characteristic curve analysis was used to select the best discriminating Ct value.
Results
For TBM cases categorized as definite or probable (n=21), the Ct validated for CSF (≤39.5) improved the diagnostic performance of MTb qPCR on CSF samples. The sensitivity was 29%, specificity was 95%, positive predictive value was 26%, negative predictive value was 95%, efficiency was 90% and positive likelihood was 5.3. The CSF RBC and total protein did not affect the positivity of the MTb qPCR.
Conclusions
These data support the validation of a highly specific but low sensitive MTb qPCR assay for the TBM diagnosis using CSF samples. MTb qPCR contributes significantly to the diagnosis, mainly when associated with conventional microbiology tests and clinical algorithms.
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Affiliation(s)
- Sérgio M. de Almeida
- Hospital de Clínicas-UFPR, Seção de Virologia, Setor Análises Clínicas , Rua Padre Camargo, 280 , Curitiba, PR, 80060-240 , Brazil
- Neuroinfection Outclinic, Hospital de Clinicas , Universidade Federal do Paraná , Curitiba, Paraná , Brazil
- Virology Laboratory, Hospital de Clinicas , Universidade Federal do Paraná , Curitiba, Paraná , Brazil
- Instituto de Pesquisa Pelé Pequeno Príncipe , Curitiba, Paraná , Brazil , Phone/Fax: +55 (41) 3360-7974
| | - Conrado M. Borges
- Neuroinfection Outclinic, Hospital de Clinicas , Universidade Federal do Paraná , Curitiba, Paraná , Brazil
| | - Lucas B. Santana
- Neuroinfection Outclinic, Hospital de Clinicas , Universidade Federal do Paraná , Curitiba, Paraná , Brazil
| | - Gilberto Golin
- Neuroinfection Outclinic, Hospital de Clinicas , Universidade Federal do Paraná , Curitiba, Paraná , Brazil
| | - Lísia Correa
- Bacteriology Laboratory, Hospital de Clinicas , Universidade Federal do Paraná , Curitiba, Paraná , Brazil
| | - Gislene B. Kussen
- Bacteriology Laboratory, Hospital de Clinicas , Universidade Federal do Paraná , Curitiba, Paraná , Brazil
| | - Keite Nogueira
- Bacteriology Laboratory, Hospital de Clinicas , Universidade Federal do Paraná , Curitiba, Paraná , Brazil
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17
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Sipos D, Ursu K, Dán Á, Herczeg D, Eszterbauer E. Susceptibility-related differences in the quantity of developmental stages of Myxobolus spp. (Myxozoa) in fish blood. PLoS One 2018; 13:e0204437. [PMID: 30240456 PMCID: PMC6150660 DOI: 10.1371/journal.pone.0204437] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 09/09/2018] [Indexed: 01/19/2023] Open
Abstract
Here, we investigated the early development of two closely related myxozoan parasites, the highly pathogenic Myxobolus cerebralis, the causative agent of the whirling disease in salmonids, and Myxobolus pseudodispar, a common, non-pathogenic parasite of cyprinids. The aim of our study was to examine under in vivo laboratory conditions whether fish blood is involved in the intrapiscine development of the two parasite species and investigate if there is dissimilarity between the parasite infection intensity in blood and if it varies in terms of host susceptibility and parasite pathogenicity. Highly susceptible, less susceptible and non-susceptible hosts were involved. Blood samples were taken 1 day, 1 week and 1 month post exposure to M. cerebralis and M. pseudodispar, respectively. The prevalence and infection intensity was estimated by parasite-specific quantitative real-time PCR. Although previous findings assumed that M. cerebralis might escape from host immune system by migrating via peripheral nerves, our experimental results demonstrated that M. cerebralis is present in blood during the early stage of intrapiscine development. For the non-pathogenic M. pseudodispar, the highest infection prevalence was found in the original host, common roach Rutilus rutilus, whereas the highest infection intensity was detected in rudd Scardinius erythrophthalmus, a “dead-end” host of the parasite. The presence of M. pseudodispar developmental stages in the blood of both susceptible and non-susceptible cyprinids suggests that the susceptibility differences remain hidden during the early stage of infection. Our findings supply further evidence that host specificity is not determined during the early, intrapiscine development involving the vascular system. Furthermore, we found remarkable differences in the infection dynamics of the two parasite species examined, possibly due to their distinct pathogenicity or variations in adaptive capabilities to immune components in host blood.
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Affiliation(s)
- Dóra Sipos
- Institute for Veterinary Medical Research, Centre for Agricultural Research, Hungarian Academy of Sciences, Budapest, Hungary
| | - Krisztina Ursu
- Veterinary Diagnostic Directorate, National Food Chain Safety Office (NFCSO), Budapest, Hungary
| | - Ádám Dán
- Veterinary Diagnostic Directorate, National Food Chain Safety Office (NFCSO), Budapest, Hungary
| | - Dávid Herczeg
- Institute for Veterinary Medical Research, Centre for Agricultural Research, Hungarian Academy of Sciences, Budapest, Hungary
| | - Edit Eszterbauer
- Institute for Veterinary Medical Research, Centre for Agricultural Research, Hungarian Academy of Sciences, Budapest, Hungary
- * E-mail:
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18
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Imran D, Estiasari R, Maharani K, Sucipto, Lestari DC, Yunus RE, Yunihastuti E, Karyadi TH, Oei D, Timan IS, Wulandari D, Wahyuningsih R, Adawiyah R, Kurniawan A, Mulyadi R, Karuniawati A, Jaya UA, Safari D, van Laarhoven A, Alisjahbana B, Dian S, Chaidir L, Ganiem AR, Lastri DN, Aye Myint KS, van Crevel R. Presentation, etiology, and outcome of brain infections in an Indonesian hospital: A cohort study. Neurol Clin Pract 2018; 8:379-388. [PMID: 30564491 DOI: 10.1212/cpj.0000000000000517] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 06/08/2018] [Indexed: 11/15/2022]
Abstract
Background Little detailed knowledge is available regarding the etiology and outcome of CNS infection, particularly in HIV-infected individuals, in low-resource settings. Methods From January 2015 to April 2016, we prospectively included all adults with suspected CNS infection in a referral hospital in Jakarta, Indonesia. Systematic screening included HIV testing, CSF examination, and neuroimaging. Results A total of 274 patients with suspected CNS infection (median age 26 years) presented after a median of 14 days with headache (77%), fever (78%), seizures (27%), or loss of consciousness (71%). HIV coinfection was common (54%), mostly newly diagnosed (30%) and advanced (median CD4 cell count 30/µL). Diagnosis was established in 167 participants (65%), including definite tuberculous meningitis (TBM) (n = 44), probable TBM (n = 48), cerebral toxoplasmosis (n = 48), cryptococcal meningitis (n = 14), herpes simplex virus/varicella-zoster virus/cytomegalovirus encephalitis (n = 10), cerebral lymphoma (n = 1), neurosyphilis (n = 1), and mucormycosis (n = 1). In-hospital mortality was 32%; 6-month mortality was 57%. The remaining survivors had either moderate or severe disability (36%) according to Glasgow Outcome Scale. Conclusion In this setting, patients with CNS infections present late with severe disease and often associated with advanced HIV infection. Tuberculosis, toxoplasmosis, and cryptococcosis are common. High mortality and long-term morbidity underline the need for service improvements and further study.
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Affiliation(s)
- Darma Imran
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Riwanti Estiasari
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Kartika Maharani
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Sucipto
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Delly Chipta Lestari
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Reyhan Eddy Yunus
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Evy Yunihastuti
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Teguh Haryono Karyadi
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Diana Oei
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Ina S Timan
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Dewi Wulandari
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Retno Wahyuningsih
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Robiatul Adawiyah
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Agnes Kurniawan
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Rahmad Mulyadi
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Anis Karuniawati
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Ungke Anton Jaya
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Dodi Safari
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Arjan van Laarhoven
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Bachti Alisjahbana
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Sofiati Dian
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Lidya Chaidir
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Ahmad Rizal Ganiem
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Diatri Nari Lastri
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Khin Saw Aye Myint
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Reinout van Crevel
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
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19
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Pormohammad A, Nasiri MJ, Riahi SM, Fallah F. Human immunodeficiency virus in patients with tuberculous meningitis: systematic review and meta-analysis. Trop Med Int Health 2018; 23:589-595. [PMID: 29660820 DOI: 10.1111/tmi.13059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Human immunodeficiency virus (HIV)-infected individuals are at increased risk for all forms of extrapulmonary tuberculosis (TB), including tuberculous meningitis (TBM). This study aimed to investigate the frequency of HIV in patients with TBM. METHODS PubMed, Embase, Web of Science and Cochrane Library were searched for articles including relevant data. Stata version 14.0 (StataCorp, College Station, Texas, USA) was used to analyse the data. RESULTS Twenty studies were identified. The pooled frequency of HIV among adult patients with TBM was 38.0% (95% CI: 21.0-57.0; I2 = 97%). In children (under the age of 15 years), 6.0% (95% CI: 1.0-13.0; I2 = 0.0%) had HIV infection. In patients with bacterial meningitis other than TBM, 36.0% (95% CI: 19.0-53.0; I2 = 100%) were HIV-infected. CONCLUSIONS A relatively high frequency of HIV in patients with TBM was indicated by our study. Establishment of diagnostic criteria and effective treatment strategies for TBM/HIV co-infection are recommended for better management of patients with TBM+HIV.
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Affiliation(s)
- Ali Pormohammad
- Student Research Committee, Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Javad Nasiri
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammad Riahi
- Department of Epidemiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Fallah
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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20
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Zhang P, Zhang W, Lang Y, Qu Y, Chu F, Chen J, Cui L. Mass spectrometry-based metabolomics for tuberculosis meningitis. Clin Chim Acta 2018; 483:57-63. [PMID: 29678632 DOI: 10.1016/j.cca.2018.04.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 04/14/2018] [Accepted: 04/16/2018] [Indexed: 02/07/2023]
Abstract
Tuberculosis meningitis (TBM) is a prevalent form of extra-pulmonary tuberculosis that causes substantial morbidity and mortality. Diagnosis of TBM is difficult because of the limited sensitivity of existing laboratory techniques. A metabolomics approach can be used to investigate the sets of metabolites of both bacteria and host, and has been used to clarify the mechanisms underlying disease development, and identify metabolic changes, leadings to improved methods for diagnosis, treatment, and prognostication. Mass spectrometry (MS) is a major analysis platform used in metabolomics, and MS-based metabolomics provides wide metabolite coverage, because of its high sensitivity, and is useful for the investigation of Mycobacterium tuberculosis (Mtb) and related diseases. It has been used to investigate TBM diagnosis; however, the processes involved in the MS-based metabolomics approach are complex and flexible, and often consist of several steps, and small changes in the methods used can have a huge impact on the final results. Here, the process of MS-based metabolomics is summarized and its applications in Mtb and Mtb-related diseases discussed. Moreover, the current status of TBM metabolomics is described.
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Affiliation(s)
- Peixu Zhang
- Department of Neurology, First Hospital, Jilin University, Changchun 130021, PR China
| | - Weiguanliu Zhang
- Department of Neurology, First Hospital, Jilin University, Changchun 130021, PR China
| | - Yue Lang
- Department of Neurology, First Hospital, Jilin University, Changchun 130021, PR China
| | - Yan Qu
- Blood Bank, Jilin Women and Children Health Hospital, Changchun 130021, PR China
| | - Fengna Chu
- Department of Neurology, First Hospital, Jilin University, Changchun 130021, PR China
| | - Jiafeng Chen
- Department of Neurology, First Hospital, Jilin University, Changchun 130021, PR China
| | - Li Cui
- Department of Neurology, First Hospital, Jilin University, Changchun 130021, PR China.
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21
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Chaidir L, Annisa J, Dian S, Parwati I, Alisjahbana A, Purnama F, van der Zanden A, Ganiem AR, van Crevel R. Microbiological diagnosis of adult tuberculous meningitis in a ten-year cohort in Indonesia. Diagn Microbiol Infect Dis 2018; 91:42-46. [PMID: 29444749 DOI: 10.1016/j.diagmicrobio.2018.01.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 12/29/2017] [Accepted: 01/04/2018] [Indexed: 10/18/2022]
Abstract
We evaluated microbiological diagnosis of tuberculous (TB) meningitis in a referral hospital in Indonesia. Over a ten-year period, we examined cerebrospinal fluid (CSF) samples of 1180 adult meningitis suspects. Sensitivity of different methods was compared, and results were stratified for HIV status, disease severity, and CSF volume. TB meningitis was bacteriologically confirmed in 501 patients. Using clinical diagnosis as reference standard (n = 713), sensitivity of different methods was 12.2% (86/703) for microscopy, 42% (73/174) for Xpert MTB/RIF, 46.0% (163/354) for solid culture, 48.8% (332/680) for liquid culture, and 64.0% (212/331) for in-house PCR. Head to head comparisons in 654 patients showed a higher yield of in-house PCR (32.3%) compared to culture (15.6%, P < 0.01). Microscopic observation of drug susceptibility (MODS) culture more rapidly became positive compared to other culture methods. Yield of culture was lower in HIV-infected (39/105) than in HIV-negative patients (N = 316/585; P < 0.01). Molecular and culture methods gave higher yields in patients with more severe disease (P < 0.01). CSF volume of ≥6 ml increased the yield of culture (42.8% versus 12.1% for CSF <6 ml, P < 0.01) and ZN-microscopy (18.3% versus 1.9% for CSF <6 ml, P < 0.01). CSF centrifugation had no clear effect on sensitivity of Xpert MTB/RIF. ZN-microscopy lacks sensitivity for diagnosis of TB meningitis. For molecular assays, in-house IS6110-PCR is more sensitive than Xpert MTB/RIF. MODS culture has a clear advantage in terms of speed. Large CSF volumes are necessary for all tests. The effect of CSF processing for Xpert MTB/RIF needs further study.
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Affiliation(s)
- Lidya Chaidir
- TB-HIV Research Center, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital, Eijkman 38, Bandung, Indonesia, 40161.
| | - Jessi Annisa
- TB-HIV Research Center, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital, Eijkman 38, Bandung, Indonesia, 40161
| | - Sofiati Dian
- TB-HIV Research Center, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital, Eijkman 38, Bandung, Indonesia, 40161; Department of Neurology, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital, Pasteur 38, Sukajadi, Bandung, Indonesia, 40161
| | - Ida Parwati
- Department of Clinical Pathology, Faculty of Medicine, Universitas Padjadjaran /Hasan Sadikin Hospital, Pasteur 38, Sukajadi, Bandung, Indonesia, 40161
| | - Arlisa Alisjahbana
- TB-HIV Research Center, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital, Eijkman 38, Bandung, Indonesia, 40161
| | - Feby Purnama
- TB-HIV Research Center, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital, Eijkman 38, Bandung, Indonesia, 40161
| | - Adri van der Zanden
- Laboratory for Microbiology, Twente Achterhoek, Boerhaavelaan 59, Hengelo, The Netherlands, 7555, BB
| | - Ahmad Rizal Ganiem
- TB-HIV Research Center, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital, Eijkman 38, Bandung, Indonesia, 40161; Department of Neurology, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin Hospital, Pasteur 38, Sukajadi, Bandung, Indonesia, 40161
| | - Reinout van Crevel
- Department of Medicine, Radboud University Medical Center, Geert Groteplein Zuid 8, Nijmegen, The Netherlands, 6500, HB
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22
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Abstract
Central nervous system (CNS) disease caused by Mycobacterium tuberculosis (MTB) is highly devastating. Tuberculous meningitis (TBM) is the most common form of CNS tuberculosis (TB). Rapid, sensitive, and affordable diagnostic tests are not available. Ziehl-Neelsen (ZN) stain has a very low sensitivity in cases of TBM, the sensitivity rates is of about 10-20%.The detection rate can be improved by taking large volume CSF samples (>6 ml) and prolonged slide examination (30 min). Culture of MTB from the CSF is slow and insufficiently sensitive. The sensitivity is different, which varies from 36% to 81.8%. The microscopic observation drug susceptibility (MODS) assay was recommended by the World Health Organization in 2011. The sensitivity is 65%, which is more sensitive and faster than CSF smear. Commercial PCR assays were found to be insensitive at detecting MTB in CSF samples. Many research provided the value of ADA on the TBM diagnosis. Interferon-gamma release assays (IGRAs) are not recommended for diagnosis of active TB disease. Imaging is essential in diagnosis and showing complications of CNS TB. Thwaites criteria and the Lancet consensus scoring system (LCSS) were developed to improve the diagnosis of TBM. Clinicians will continue to make judgment based on clinical examination, inflammatory CSF examinations, imaging studies, and scoring systems.
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Affiliation(s)
- Yi-Yi Wang
- Department of Neurology, Tianjin Haihe Hospital, Tianjin, P.R. China.
| | - Bing-di Xie
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, P.R. China
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23
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Sun Y, Chen J, Li J, Xu Y, Jin H, Xu N, Yin R, Hu G. Novel approach based on one-tube nested PCR and a lateral flow strip for highly sensitive diagnosis of tuberculous meningitis. PLoS One 2017; 12:e0186985. [PMID: 29084241 PMCID: PMC5662171 DOI: 10.1371/journal.pone.0186985] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 10/11/2017] [Indexed: 12/24/2022] Open
Abstract
Rapid and sensitive detection of Mycobacterium tuberculosis (M. Tb) in cerebrospinal fluid is crucial in the diagnosis of tuberculous meningitis (TBM), but conventional diagnostic technologies have limited sensitivity and specificity or are time-consuming. In this work, a novel, highly sensitive molecular diagnostic method, one-tube nested PCR-lateral flow strip test (OTNPCR-LFST), was developed for detecting M. tuberculosis. This one-tube nested PCR maintains the sensitivity of conventional two-step nested PCR and reduces both the chance of cross-contamination and the time required for analysis. The PCR product was detected by a lateral flow strip assay, which provided a basis for migration of the test to a point-of-care (POC) microfluidic format. The developed assay had an improved sensitivity compared with traditional PCR, and the limit of detection was up to 1 fg DNA isolated from M. tuberculosis. The assay was also specific for M. tuberculosis, and no cross-reactions were found in other non-target bacteria. The application of this technique to clinical samples was successfully evaluated, and OTNPCR-LFST showed 89% overall sensitivity and 100% specificity for TBM patients. This one-tube nested PCR-lateral flow strip assay is useful for detecting M. tuberculosis in TBM due to its rapidity, high sensitivity and simple manipulation.
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Affiliation(s)
- Yajuan Sun
- Department of Neurology, the Second Hospital of Jilin University, Changchun, Jilin, China
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Jiajun Chen
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Jia Li
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Yawei Xu
- College of Life Science, Jilin Agricultural University, Changchun, Jilin, China
| | - Hui Jin
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Na Xu
- College of Life Science, Jilin Agricultural University, Changchun, Jilin, China
| | - Rui Yin
- College of Life Science, Jilin Agricultural University, Changchun, Jilin, China
- College of Biological Engineering, Jilin College of Agricultural Science and Technology, Jilin, Jilin, China
- * E-mail: (GHH); (RY)
| | - Guohua Hu
- Department of Neurology, the Second Hospital of Jilin University, Changchun, Jilin, China
- * E-mail: (GHH); (RY)
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24
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Babafemi EO, Cherian BP, Banting L, Mills GA, Ngianga K. Effectiveness of real-time polymerase chain reaction assay for the detection of Mycobacterium tuberculosis in pathological samples: a systematic review and meta-analysis. Syst Rev 2017; 6:215. [PMID: 29070061 PMCID: PMC5657121 DOI: 10.1186/s13643-017-0608-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 10/12/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Rapid and accurate diagnosis of tuberculosis (TB) is key to manage the disease and to control and prevent its transmission. Many established diagnostic methods suffer from low sensitivity or delay of timely results and are inadequate for rapid detection of Mycobacterium tuberculosis (MTB) in pulmonary and extra-pulmonary clinical samples. This study examined whether a real-time polymerase chain reaction (RT-PCR) assay, with a turn-a-round time of 2 h, would prove effective for routine detection of MTB by clinical microbiology laboratories. METHODS A systematic literature search was performed for publications in any language on the detection of MTB in pathological samples by RT-PCR assay. The following sources were used MEDLINE via PubMed, EMBASE, BIOSIS Citation Index, Web of Science, SCOPUS, ISI Web of Knowledge and Cochrane Infectious Diseases Group Specialised Register, grey literature, World Health Organization and Centres for Disease Control and Prevention websites. Forty-six studies met set inclusion criteria. Generated pooled summary estimates (95% CIs) were calculated for overall accuracy and bivariate meta-regression model was used for meta-analysis. RESULTS Summary estimates for pulmonary TB (31 studies) were as follows: sensitivity 0.82 (95% CI 0.81-0.83), specificity 0.99 (95% CI 0.99-0.99), positive likelihood ratio 43.00 (28.23-64.81), negative likelihood ratio 0.16 (0.12-0.20), diagnostic odds ratio 324.26 (95% CI 189.08-556.09) and area under curve 0.99. Summary estimates for extra-pulmonary TB (25 studies) were as follows: sensitivity 0.70 (95% CI 0.67-0.72), specificity 0.99 (95% CI 0.99-0.99), positive likelihood ratio 29.82 (17.86-49.78), negative likelihood ratio 0.33 (0.26-0.42), diagnostic odds ratio 125.20 (95% CI 65.75-238.36) and area under curve 0.96. CONCLUSIONS RT-PCR assay demonstrated a high degree of sensitivity for pulmonary TB and good sensitivity for extra-pulmonary TB. It indicated a high degree of specificity for ruling in TB infection from sampling regimes. This was acceptable, but may better as a rule out add-on diagnostic test. RT-PCR assays demonstrate both a high degree of sensitivity in pulmonary samples and rapidity of detection of TB which is an important factor in achieving effective global control and for patient management in terms of initiating early and appropriate anti-tubercular therapy. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015027534 .
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Affiliation(s)
- Emmanuel O. Babafemi
- Microbiology Department, Pathology Division, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | - Lee Banting
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - Graham A. Mills
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - Kandala Ngianga
- School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, UK
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25
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van Laarhoven A, Dian S, Ruesen C, Hayati E, Damen MSMA, Annisa J, Chaidir L, Ruslami R, Achmad TH, Netea MG, Alisjahbana B, Rizal Ganiem A, van Crevel R. Clinical Parameters, Routine Inflammatory Markers, and LTA4H Genotype as Predictors of Mortality Among 608 Patients With Tuberculous Meningitis in Indonesia. J Infect Dis 2017; 215:1029-1039. [PMID: 28419315 DOI: 10.1093/infdis/jix051] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 01/19/2017] [Indexed: 01/12/2023] Open
Abstract
Background Damaging inflammation is thought to contribute to the high morbidity and mortality of tuberculous meningitis (TBM), but the link between inflammation and outcome remains unclear. Methods We performed prospective clinical and routine laboratory analyses of a cohort of adult patients with TBM in Indonesia. We also examined the LTA4H promoter polymorphism, which predicted cerebrospinal fluid (CSF) leukocyte count and survival of Vietnamese patients with TBM. Patients were followed for >1 year. Results We included 608 patients with TBM, of whom 67.1% had bacteriological confirmation of disease and 88.2% had severe (ie, grade II or III) disease. One-year mortality was 43.7% and strongly associated with decreased consciousness, fever, and focal neurological signs. Human immunodeficiency virus (HIV) infection, present in 15.3% of patients, was associated with higher mortality and different CSF characteristics, compared with absence of HIV infection. Among HIV-uninfected patients, mortality was associated with higher CSF neutrophil counts (hazard ratio [HR], 1.10 per 10% increase; 95% confidence interval [CI], 1.04-1.16), low CSF to blood glucose ratio (HR, 1.16 per 0.10 decrease; 95% CI, 1.04-1.30), CSF culture positivity (HR, 1.37; 95% CI, 1.02-1.84), and blood neutrophilia (HR, 1.06 per 109 neutrophils/L increase; 95% CI, 1.03-1.10). The LTA4H promoter polymorphism correlated with CSF mononuclear cell count but not with mortality (P = .915). Conclusions A strong neutrophil response and fever may contribute to or be a result of (immuno)pathology in TBM. Aggressive fever control might improve outcome, and more-precise characterization of CSF leukocytes could guide possible host-directed therapeutic strategies in TBM.
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Affiliation(s)
- Arjan van Laarhoven
- Department of Internal Medicine and.,Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands ; and.,TB/HIV Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Sofiati Dian
- Department of Internal Medicine and.,Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands ; and.,TB/HIV Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Carolien Ruesen
- Department of Internal Medicine and.,Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands ; and
| | - Ela Hayati
- TB/HIV Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Michelle S M A Damen
- Department of Internal Medicine and.,Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands ; and
| | - Jessi Annisa
- TB/HIV Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Lidya Chaidir
- Department of Internal Medicine and.,Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands ; and.,TB/HIV Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Rovina Ruslami
- TB/HIV Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Tri Hanggono Achmad
- TB/HIV Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Mihai G Netea
- Department of Internal Medicine and.,Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands ; and
| | - Bachti Alisjahbana
- TB/HIV Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Ahmad Rizal Ganiem
- TB/HIV Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Reinout van Crevel
- Department of Internal Medicine and.,Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands ; and
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Palomo FS, Rivero MGC, Quiles MG, Pinto FP, Machado AMDO, Carlos Campos Pignatari A. Comparison of DNA Extraction Protocols and Molecular Targets to Diagnose Tuberculous Meningitis. Tuberc Res Treat 2017; 2017:5089046. [PMID: 28638662 PMCID: PMC5468578 DOI: 10.1155/2017/5089046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/22/2017] [Accepted: 04/27/2017] [Indexed: 11/18/2022] Open
Abstract
Tuberculous meningitis (TBM) is a severe form of extrapulmonary tuberculosis. The aims of this study were to evaluate in-house molecular diagnostic protocols of DNA extraction directly from CSF samples and the targets amplified by qPCR as an accurate and fast diagnosis of TBM. One hundred CSF samples from 68 patients suspected of TBM were studied. Four DNA extraction techniques (phenol-chloroform-thiocyanate guanidine, silica thiocyanate guanidine, resin, and resin with ethanol) were compared and CSF samples were used to determine the best target (IS6110, MPB64, and hsp65 KDa) by qPCR. The extraction protocol using the phenol-chloroform-thiocyanate guanidine showed the best results in terms of quantification and sensitivity of PCR amplification, presenting up to 10 times more DNA than the second best protocol, the silica guanidine thiocyanate. The target that showed the best result for TBM diagnosis was the IS6110. This target showed 91% sensitivity and 97% specificity when we analyzed the results by sample and showed 100% sensitivity and 98% specificity when we analyzed the results by patient. The DNA extraction with phenol-chloroform-thiocyanate guanidine followed by IS6110 target amplification has been shown to be suitable for diagnosis of TBM in our clinical setting.
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Affiliation(s)
- Flavia Silva Palomo
- Special Clinical Microbiology Laboratory (LEMC), Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
- Central Laboratory of São Paulo Hospital, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Martha Gabriela Celle Rivero
- Special Clinical Microbiology Laboratory (LEMC), Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Milene Gonçalves Quiles
- Special Clinical Microbiology Laboratory (LEMC), Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Fernando Pereira Pinto
- Central Laboratory of São Paulo Hospital, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
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Thind GS, Roach R. A case of acyclovir neurotoxicity presenting with atypical cerebrospinal fluid findings. BMJ Case Rep 2017; 2017:bcr-2017-220372. [PMID: 28536235 DOI: 10.1136/bcr-2017-220372] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
An 82-year-old man with a history of end-stage renal disease presented with progressively worsening confusion and somnolence for the past 4-5 days. The patient was diagnosed with herpes zoster by his primary care physician 5 days ago and was started on a course of valacyclovir 1 g three times a day (dose not adjusted for renal impairment).A lumbar puncture was performed and cerebrospinal fluid (CSF) studies revealed 37 white blood cells (WBCs)/hpf (100% monocytes), protein 64 mg/dL and glucose 52 mg/dL. He was started on ceftriaxone, ampicillin and acyclovir. MRI of the brain was done and was unremarkable. Acyclovir-induced encephalopathy was high on differential, but his CSF findings were concerning for viral encephalitis. Nonetheless, all antimicrobials were discontinued and he was scheduled for a 5-hour dialysis session. The very next day, he showed immense improvement and eventually recovered completely. CSF PCR tests for both herpes simplex virus and varicella zoster virus came back negative.
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Affiliation(s)
| | - Richard Roach
- Internal Medicine, Western Michigan University School of Medicine, Kalamazoo, Michigan, USA
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28
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Sun WW, Sun Q, Yan LP, Zhang Q. The application of IS6110-baced loop-mediated isothermal amplification (LAMP) in the early diagnosis of tuberculous meningitis. Oncotarget 2017; 8:57537-57542. [PMID: 28915693 PMCID: PMC5593665 DOI: 10.18632/oncotarget.15734] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 02/08/2017] [Indexed: 01/22/2023] Open
Abstract
Here, we evaluated the potential activity of rapid Mycobacterium tuberculosis detection with loop-mediated isothermal amplification (LAMP), for the early diagnosis of tuberculous meningitis (TBM). Patients with suspected TBM from January 2014 to December 2015 were reviewed retrospectively. The cerebrospinalfluid(CSF) was collected. Acid-fast bacillus (AFB) staining, MGIT 960 culture, real-time fluorescent quantitative polymerase chain reaction (RTFQ PCR) and LAMP were performed. A total of 200 patients were included in the study. Of which, 172 of them were diagnosed with TBM (86.00%). The sensitivities of AFB staining, MGIT 960 culture, LAMP and RTFQ PCR for TBM diagnosis were 2.91% (5/172), 12.79% (22/172), 43.02% (74/172), and 34.30% (59/172), respectively. The sensitivity of LAMP for TBM was significantly higher than those of AFB staining and MGIT960 culture (χ2 = 75.11, P < 0.001; χ2 = 43.88, P = 0.002). LAMP's sensitivity was however comparable to RTFQ PCR assay (χ2 = 2.08, P = 0.130). The specificity, positive predictive value and negative predictive value of LAMP in the diagnosis of TBM were 92.86% (26/28), 97.37% (74/76) and 20.97 % (26/124), respectively. The overall consistency between LAMP and RTFQ PCR in the diagnosis of TBM was 88.5% (177/200), with Kappa value of 0.870. The consistency between LAMP and MGIT960 culture was 71% (142/200), with Kappa value of 0.730. Among all the methods, LAMP had high sensitivity, specificity and positive predictive value, showing high consistency with MGIT960 culture and RTFQ PCR.
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Affiliation(s)
- Wen-Wen Sun
- Clinic and Research Center of Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qin Sun
- Clinic and Research Center of Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Li-Ping Yan
- Clinic and Research Center of Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qing Zhang
- Clinic and Research Center of Tuberculosis, Shanghai Key Laboratory of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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30
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Wang T, Feng GD, Pang Y, Liu JY, Zhou Y, Yang YN, Dai W, Zhang L, Li Q, Gao Y, Chen P, Zhan LP, Marais BJ, Zhao YL, Zhao G. High rate of drug resistance among tuberculous meningitis cases in Shaanxi province, China. Sci Rep 2016; 6:25251. [PMID: 27143630 PMCID: PMC4855176 DOI: 10.1038/srep25251] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 04/12/2016] [Indexed: 11/18/2022] Open
Abstract
The clinical and mycobacterial features of tuberculous meningitis (TBM) cases in China are not well described; especially in western provinces with poor tuberculosis control. We prospectively enrolled patients in whom TBM was considered in Shaanxi Province, northwestern China, over a 2-year period (September 2010 to December 2012). Cerebrospinal fluid specimens were cultured for Mycobacterium tuberculosis; with phenotypic and genotypic drug susceptibility testing (DST), as well as genotyping of all positive cultures. Among 350 patients included in the study, 27 (7.7%) had culture-confirmed TBM; 84 (24.0%) had probable and 239 (68.3%) had possible TBM. DST was performed on 25/27 (92.3%) culture positive specimens; 12/25 (48.0%) had "any resistance" detected and 3 (12.0%) were multi-drug resistant (MDR). Demographic and clinical features of drug resistant and drug susceptible TBM cases were similar. Beijing was the most common genotype (20/25; 80.0%) with 9/20 (45%) of the Beijing strains exhibiting drug resistance; including all 3 MDR strains. All (4/4) isoniazid resistant strains had mutations in the katG gene; 75% (3/4) of strains with phenotypic rifampicin resistance had mutations in the rpoB gene detected by Xpert MTB/RIF®. High rates of drug resistance were found among culture-confirmed TBM cases; most were Beijing strains.
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Affiliation(s)
- Ting Wang
- Department of Neurology, Xijing Hospital, the Fourth Military Medical University, no.169 Changle West Road, Xi’an, Shaanxi, 710032, P.R.China
- Department of Neurology, Kunming Medical University affiliated Yan’an Hospital, 245 Renming East Road, Kunming, Yunnan, 650200, P.R.China
| | - Guo-Dong Feng
- Department of Neurology, Xijing Hospital, the Fourth Military Medical University, no.169 Changle West Road, Xi’an, Shaanxi, 710032, P.R.China
| | - Yu Pang
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, no.155 Changbai Road, Beijing, 102206, P.R.China
| | - Jia-Yun Liu
- Department of Inspection, Xijing Hospital, Fourth Military Medical University, no.169 Changle West Road, Xi’an, Shaanxi, 710032, P.R.China
| | - Yang Zhou
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, no.155 Changbai Road, Beijing, 102206, P.R.China
| | - Yi-Ning Yang
- Department of Neurology, Xijing Hospital, the Fourth Military Medical University, no.169 Changle West Road, Xi’an, Shaanxi, 710032, P.R.China
| | - Wen Dai
- Department of Neurology, Xijing Hospital, the Fourth Military Medical University, no.169 Changle West Road, Xi’an, Shaanxi, 710032, P.R.China
| | - Lin Zhang
- Department of Neurology, Xijing Hospital, the Fourth Military Medical University, no.169 Changle West Road, Xi’an, Shaanxi, 710032, P.R.China
| | - Qiao Li
- Department of Neurology, Xijing Hospital, the Fourth Military Medical University, no.169 Changle West Road, Xi’an, Shaanxi, 710032, P.R.China
| | - Yu Gao
- Department of Neurology, Xijing Hospital, the Fourth Military Medical University, no.169 Changle West Road, Xi’an, Shaanxi, 710032, P.R.China
| | - Ping Chen
- Department of Neurology, Xijing Hospital, the Fourth Military Medical University, no.169 Changle West Road, Xi’an, Shaanxi, 710032, P.R.China
| | - Li-Ping Zhan
- Department of Neurology, Kunming Medical University affiliated Yan’an Hospital, 245 Renming East Road, Kunming, Yunnan, 650200, P.R.China
| | - Ben J Marais
- The Children’s Hospital at Westmead and the Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Australia
| | - Yan-Lin Zhao
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, no.155 Changbai Road, Beijing, 102206, P.R.China
| | - Gang Zhao
- Department of Neurology, Xijing Hospital, the Fourth Military Medical University, no.169 Changle West Road, Xi’an, Shaanxi, 710032, P.R.China
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31
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Confusion. Neurology 2016. [DOI: 10.1007/978-3-319-29632-6_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Shirani K, Talaei Z, Yaran M, Ataei B, Mehrabi-Koushki A, Khorvash F. Diagnosed tuberculous meningitis using cerebrospinal fluid polymerase chain reaction in patients hospitalized with the diagnosis of meningitis in referral hospitals in Isfahan. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2015; 20:224-7. [PMID: 26109966 PMCID: PMC4468224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 01/01/2015] [Accepted: 03/09/2015] [Indexed: 11/01/2022]
Abstract
BACKGROUND Tuberculosis (TB) remains one of the leading infectious diseases throughout the world. Among various forms of extrapulmonary TB, tuberculous meningitis (TBM) is the most severe form and remains a major global health problem with a high mortality rate. Our study was designed to evaluate tuberculous polymerase chain reaction (PCR) positive rate in patients who present with fairly long symptoms of meningitis. MATERIALS AND METHODS The 162 Patients with an indolent onset of symptoms compatible with central nervous system infection were admitted. Sample of cerebrospinal fluid (CSF) was evaluated for biochemistry and tuberculous real-time PCR. Data analyzed by Student's t-test and Fisher's test. RESULTS Patients were mostly male (69.8%), with a median age of 43.69 ± 22.67 years. CSF real-time PCR results in 6 patients (3.7%) were positive for tuberculous DNA. Of these 6 patients, 4 of whom were men and two of whom were women. In other words, the frequency of positive tuberculous DNA was in male 5.3% and female 1.4%, respectively. CONCLUSION Given that we live in Iran and in the vicinity of the tuberculous endemic countries, if we face a meningitis case with lasting symptoms and tendency to be chronic, TBM should be considered.
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Affiliation(s)
- Kiana Shirani
- Nosocomial Infection Research Center, Infectious Diseases Department, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Talaei
- Infectious Diseases Department, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Majid Yaran
- Medical Laboratory Doctor, Acquired Immunodeficiency Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Behrooz Ataei
- Infectious Diseases and Tropical Medicine Research Center, Infectious Diseases Department, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Farzin Khorvash
- Nosocomial Infection Research Center, Infectious Diseases Department, Isfahan University of Medical Sciences, Isfahan, Iran,Address for correspondence: Prof. Farzin Khorvash, Alzahra Hospital, Soffe Avenue, Isfahan, Iran. E-mail:
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Jha SK, Garg RK, Jain A, Malhotra HS, Verma R, Sharma PK. Definite (microbiologically confirmed) tuberculous meningitis: predictors and prognostic impact. Infection 2015; 43:639-45. [DOI: 10.1007/s15010-015-0756-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 02/20/2015] [Indexed: 11/24/2022]
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34
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Hu X, Shang M, Chen X, Xie Y, Ye Y, Zhou J, Song X, Lu X, Ying B, Wang L. Evaluation of three rapid assays for Mycobacterium tuberculosis complex detection in a comprehensive hospital from West China. Clin Biochem 2014; 48:79-84. [PMID: 25444951 DOI: 10.1016/j.clinbiochem.2014.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 09/26/2014] [Accepted: 10/01/2014] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To assess the capacity of rapid and accurate confirmation of the Mycobacterium tuberculosis complex (MTBC) in a Chinese clinical laboratory. DESIGN AND METHODS This prospective study investigated three rapid assays, the Amplified Mycobacterium Tuberculosis Direct (MTD) test, real-time PCR, and acid-fast bacilli (AFB) smear, for direct detection of MTBC in a large consecutive series of different clinical specimens. Performance parameters were estimated and compared overall and for separate specimen categories using a combined reference gold standard. RESULTS The overall sensitivities were similar for MTD and real-time PCR (62.26% vs. 58.49%), significantly higher than those of AFB smear (31.13%). Among three assays, MTD had a satisfactory sensitivity in respiratory specimen (73.33%) and a nearly perfect detection for smear-positive samples (96.97%). Real-time PCR showed a high positive rate (58.97%) in regard to nonrespiratory specimen. A combination of molecular assays with conventional methods reached marked additive diagnostic values (sensitivity up to 76.42%), higher than each method individually. All detection systems showed excellent specificities (>96.00%). CONCLUSIONS The present study indicated that our lab had a moderate diagnostic performance for tuberculosis. Quality guarantee for specimen pretreatment, as well as combination analysis, will enable these assays to better incorporate into the routine laboratory workflow in China.
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Affiliation(s)
- Xuejiao Hu
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, PR China
| | - Mengqiao Shang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, PR China
| | - Xuerong Chen
- Division of Pulmonary Disease, Department of Respiratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, PR China
| | - Yi Xie
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, PR China
| | - Yuanxin Ye
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, PR China
| | - Juan Zhou
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, PR China
| | - Xingbo Song
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, PR China
| | - Xiaojun Lu
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, PR China
| | - Binwu Ying
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, PR China.
| | - Lanlan Wang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, PR China.
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Abstract
Neurologists are often the first medical providers to evaluate patients with possible infectious meningitis. Knowledge of the clinical presentations and cerebrospinal fluid, microbiologic, and neuroimaging findings for different etiologies is essential to make a prompt diagnosis and initiate appropriate treatment. Tuberculosis is a common cause of meningitis in developing countries with a high prevalence of pulmonary tuberculosis. However, tuberculosis affects populations in every country and all neurologists need to be vigilant for possible cases of tuberculous meningitis presenting to their medical facilities. This article discusses the challenges of diagnosing and treating tuberculous meningitis and highlights recent advances in diagnostic technology.
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Affiliation(s)
- Jerome H Chin
- School of Public Health, University of California, Berkeley
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36
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Solomons RS, van Elsland SL, Visser DH, Hoek KGP, Marais BJ, Schoeman JF, van Furth AM. Commercial nucleic acid amplification tests in tuberculous meningitis--a meta-analysis. Diagn Microbiol Infect Dis 2014; 78:398-403. [PMID: 24503504 DOI: 10.1016/j.diagmicrobio.2014.01.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Revised: 12/29/2013] [Accepted: 01/02/2014] [Indexed: 11/19/2022]
Abstract
Although nucleic acid amplification tests (NAATs) promise a rapid, definitive diagnosis of tuberculous meningitis, the performance of first-generation NAATs was suboptimal and variable. We conducted a meta-analysis of studies published between 2003 and 2013, using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool to evaluate methodological quality. The diagnostic accuracy of newer commercial NAATs was assessed. Pooled estimates of diagnostic accuracy for commercial NAATs measured against a cerebrospinal fluid Mycobacterium tuberculosis culture-positive gold standard were sensitivity 0.64, specificity 0.98, and diagnostic odds ratio 64.0. Heterogeneity was limited; P value = 0.147 and I(2) = 33.85%. The Xpert MTB/RIF® test was evaluated in 1 retrospective study and 4 prospective studies, with pooled sensitivity 0.70 and specificity 0.97. The QUADAS-2 tool revealed low risk of bias, as well as low concerns regarding applicability. Heterogeneity was pronounced among studies of in-house tests. Commercial NAATs proved to be highly specific with greatly reduced heterogeneity compared to in-house tests. Sub-optimal sensitivity remains a limitation.
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Affiliation(s)
- Regan S Solomons
- Department of Pediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, PO Box 19063, Tygerberg 7505, Cape, South Africa.
| | - Sabine L van Elsland
- Department of Pediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, PO Box 19063, Tygerberg 7505, Cape, South Africa; Department of Pediatric Infectious Diseases and Immunology, Vrije Universiteit Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Douwe H Visser
- Department of Pediatric Infectious Diseases and Immunology, Vrije Universiteit Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Kim G P Hoek
- Division of Medical Microbiology, Faculty of Health Sciences, National Health Laboratory Service and University of Stellenbosch, Tygerberg 7505, Western Cape, South Africa
| | - Ben J Marais
- Sydney Emerging Infectious Diseases and Biosecurity Institute (SEIB) and the Children's Hospital, Westmead. C29 - Children's Hospital Westmead, The University of Sydney, Westmead, NSW 2006, Australia
| | - Johan F Schoeman
- Department of Pediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, PO Box 19063, Tygerberg 7505, Cape, South Africa
| | - Anne M van Furth
- Department of Pediatric Infectious Diseases and Immunology, Vrije Universiteit Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
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Chin JH, Mateen FJ. Central Nervous System Tuberculosis: Challenges and Advances in Diagnosis and Treatment. Curr Infect Dis Rep 2013; 15:631-635. [PMID: 24122343 DOI: 10.1007/s11908-013-0385-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Mycobacterium tuberculosis is one of the most prevalent human infections. Although the largest share of the burden of disease is in Africa and Asia, tuberculosis has a global footprint due to travel and migration. Resource constraints in many low- and middle-income countries are hampering efforts to control new infections and to prevent drug resistance. Infection of the central nervous system by Mycobacterium tuberculosis includes meningitis, tuberculoma, and abscess and carries a high morbidity and mortality. High clinical suspicion, combined with cerebrospinal fluid analysis and brain imaging studies, can improve the diagnostic certainty. The recent scale-up of nucleic acid amplification technology may allow earlier diagnosis of tuberculous meningitis in many regions of the world. Treatment of tuberculous infection of the central nervous system is usually empirical and follows conventional regimens for pulmonary tuberculosis. The optimal treatment regimen is still being elucidated and has been the subject of recent clinical trials.
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Affiliation(s)
- Jerome H Chin
- School of Public Health, University of California, Berkeley, 50 University Avenue, Berkeley, CA, 94720, USA,
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38
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Abstract
Tuberculous meningitis is especially common in young children and people with untreated HIV infection, and it kills or disables roughly half of everyone affected. Childhood disease can be prevented by vaccination and by giving prophylactic isoniazid to children exposed to infectious adults, although improvements in worldwide tuberculosis control would lead to more effective prevention. Diagnosis is difficult because clinical features are non-specific and laboratory tests are insensitive, and treatment delay is the strongest risk factor for death. Large doses of rifampicin and fluoroquinolones might improve outcome, and the beneficial effect of adjunctive corticosteroids on survival might be augmented by aspirin and could be predicted by screening for a polymorphism in LTA4H, which encodes an enzyme involved in eicosanoid synthesis. However, these advances are insufficient in the face of drug-resistant tuberculosis and HIV co-infection. Many questions remain about the best approaches to prevent, diagnose, and treat tuberculous meningitis, and there are still too few answers.
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39
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Ho J, Marais BJ, Gilbert GL, Ralph AP. Diagnosing tuberculous meningitis - have we made any progress? Trop Med Int Health 2013; 18:783-93. [DOI: 10.1111/tmi.12099] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Jennifer Ho
- Centre for Infectious Diseases & Microbiology - Public Health; Westmead Hospital; Sydney; NSW; Australia
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