Cerebral hemorrhage due to tuberculosis meningitis: a rare case report and literature review

The Diagnostic Deceiver: Radiological Pictorial Review of Tuberculosis

Tuberculosis (TB) is a bacterial infection with Mycobacterium tuberculosis; it is a public health problem worldwide and one of the leading causes of mortality. Since December 2019, the COVID-19 pandemic has created unprecedented health challenges and disrupted the TB health services, especially in high-burden countries with ever-increasing prevalence. Extrapulmonary and even pulmonary TB are an important cause of nonspecific clinical and radiological manifestations and can masquerade as any benign or malignant medical case, thus causing disastrous conditions and diagnostic dilemmas. Clinical manifestations and routine laboratory tests have limitations in directing physicians to diagnose TB. Medical-imaging examinations play an essential role in detecting tissue abnormalities and early suspecting diagnosis of TB in different organs. Radiologists and physicians should be familiar with and aware of the radiological manifestations of TB to contribute to the early suspicion and diagnosis of TB. The purpose of this article is to illustrate the common radiologic patterns of pulmonary and extrapulmonary TB. This article will be beneficial for radiologists, medical students, chest physicians, and infectious-disease doctors who are interested in the diagnosis of TB.

Uncommon presentation of craniospinal tuberculosis

Tuberculosis (TB) is a bacterial infection with multisystem presentations. Involvement of the central nervous system (CNS) is considered the most lethal form among all types. In addition to possible fatality, CNS TB has serious neurological sequelae. These morbidity issues along with diagnostic challenges doubles the clinical burden. In recent years, there have been improvements in diagnostic sensitivity and specificity due to advances in technology. Herein, we report an atypical case of a patient with TB who presented to our department and discuss the flow of the diagnostic workup.

Autophagy Inhibition by ATG3 Knockdown Remits Oxygen-Glucose Deprivation/Reoxygenation-Induced Injury and Inflammation in Brain Microvascular Endothelial Cells

Autophagy participates in the development of cerebral ischemia stroke. Autophagy-related 3 (ATG3), an important autophagy regulator, was reported to be upregulated in a rat model of cerebral ischemia/reperfusion (CI/R) injury and an oxygen-glucose deprivation/reoxygenation (OGD/R) cell model. However, the detailed role of ATG3 in CI/R injury remains elusive. An in vitro cellular model was established to mimic CI/R injury by exposing hBMECs and bEnd.3 cells to OGD/R. OGD/R-induced injury were evaluated by cell counting kit-8 (CCK-8), LDH release assay, caspase-3 activity assay and TUNEL assay. Inflammation was assessed by detecting mRNA expression and concentrations of interleukin-1β (IL-1β), IL-6 and tumor necrosis factor-α (TNF-α) using qRT-PCR and ELISA, respectively. The protein levels of ATG3, light chain 3 (LC3)-I, LC3-II, p62, protein kinase B (Akt), and phosphorylated Akt (p-Akt) were determined by western blot analysis. We successfully established an in vitro OGD/R injury model using hBMECs and bEnd.3 cells. ATG3 was time-dependently upregulated and ATG3 knockdown inhibited autophagy in OGD/R-challenged brain microvascular endothelial cells. Moreover, autophagy inhibition by ATG3 interference attenuated OGD/R-induced viability inhibition and increase of LDH release, caspase-3 activity, programmed cell death, and production of IL-1β, IL-6 and TNF-α. Inhibition of autophagy by ATG3 silencing activated the phosphoinositide 3-kinase (PI3K)/Akt pathway in OGD/R-challenged brain microvascular endothelial cells. Furthermore, inhibition of the PI3K/Akt pathway reversed the protective effects of ATG3 silencing on OGD/R-induced injury and inflammation. In conclusion, autophagy inhibition by ATG3 knockdown remitted OGD/R-induced injury and inflammation in brain microvascular endothelial cells via activation of the PI3K/Akt pathway.

Neurotuberculosis: an update

Tuberculous (TB) meningitis (TBM), accounting for 70-80% of cases of neurotuberculosis, is one of the most severe forms of extrapulmonary tuberculosis. Two-thirds of new TB cases come from eight countries. Polymorphisms in toll-interleukin-1 receptor domain and in leukotriene A4 hydrolase (LTA4H) gene, affect the risk of inflammation in TBM. The common site of tuberculoma in children is cerebellum, and they may rarely develop tuberculous encephalopathy which has a high mortality. Young females with a high cerebrospinal fluid (CSF) protein have an increased predisposition to develop optochiasmatic arachnoiditis. Spinal TB meningitis may mimic transverse myelitis or Guillain-Barre syndrome. An extra-neural focus of TB should be sought clinically and radiologically as it may indicate safer and more accessible sites for diagnostic samplings. Cartridge-based nucleic acid amplification test (CBNAAT), also known as Genexpert test, is a polymerase chain reaction (PCR)-based method for detection of TB which also detects rifampicin resistance as it targets the rpob gene of mycobacteria. Line probe assays, based on PCR and reverse hybridization methods, identify mutations associated with drug resistance within a week. TBM being a paucibacillary disease, often evades a definite diagnosis and empirical treatment for a minimum of 9 months is warranted based on clinical judgement. All TBM patients should receive adjunctive corticosteroids, even those with HIV infection. Drug resistance is strongly associated with previous treatment and bedaquiline as well as delamanid have received approvals for multidrug resistant (MDR) TB. The key principle of managing MDR TB is never to add a single drug to a failing regimen. Correct combination and duration of most effective second line drugs in MDR TB require further modifications. Early shunting should be considered in those with hydrocephalus failing medical management. The single most important determinant of outcome is the stage of TBM at which treatment has been started.

Analysis of Tuberculosis Meningitis Pathogenesis, Diagnosis, and Treatment

Tuberculosis (TB) is the most prevalent infectious disease in the world. In recent years there has been a significant increase in the incidence of TB due to the emergence of multidrug resistant strains of Mycobacterium tuberculosis (M. tuberculosis) and the increased numbers of highly susceptible immuno-compromised individuals. Central nervous system TB, includes TB meningitis (TBM-the most common presentation), intracranial tuberculomas, and spinal tuberculous arachnoiditis. Individuals with TBM have an initial phase of malaise, headache, fever, or personality change, followed by protracted headache, stroke, meningismus, vomiting, confusion, and focal neurologic findings in two to three weeks. If untreated, mental status deteriorates into stupor or coma. Delay in the treatment of TBM results in, either death or substantial neurological morbidity. This review provides latest developments in the biomedical research on TB meningitis mainly in the areas of host immune responses, pathogenesis, diagnosis, and treatment of this disease.

BILATERAL GANGLIONIC HAEMORRHAGIC STROKE COMPLICATING SUSPECTED MENINGOCOCCAEMIA: A CASE REPORT

Haemorrhagic stroke in pyogenic meningitis is a rare complication accounting for about 2% of all complications1,2. It often results from disseminated intravascular coagulation, which is a complication of bacterial meningitis and portends a poor prognosis. A superimposed intracranial haemorrhage, although extremely rare, is associated with high mortality rate. We report a child who had haemorrhagic stroke during the acute phase of bacterial meningitis. The diagnosis was made during post mortem examination. It was discovered that she had suffered haemorrhagic necrosis of both basal ganglion nuclei. Early imaging is advised in meningitis patient presenting with altered levels of consciousness to detect cerebrovascular complications.

Neuroimaging Findings in Tuberculosis: A Single-Center Experience in 559 Cases

BACKGROUND AND PURPOSE

There is a paucity of literature related to the neuroimaging of CNS tuberculosis (TB) and largely covers pediatric CNS TB. The objective of this study was to determine the frequency of different forms of CNS TB and its associated complications and to study longitudinal disease course using computed tomography (CT) and MRI.

METHODS

Retrospective chart and imaging review of patients diagnosed with CNS TB in a tertiary care hospital in Pakistan over a 10-year period. A total of 452 initial brain MRI and 209 CT scans were reviewed by an expert radiologist specialized in neuroimaging. This was followed by review of 53 MRI/52 CT and 7 MRI/14 CT first and second follow-up scans, respectively.

RESULTS

Note that 559 patients, 296 males and 263 females were included in the study. On the initial CT scans, tuberculomas were found in 25 (12%), infarction in 54 (25%), basal meningeal enhancement in 29 (14%), and hydrocephalus in 84 (40%). On initial MRI, tuberculomas were found in 182 (40%), infarction in 120 (27%), basal meningeal enhancement in 184 (41%), and hydrocephalus in 116 (26%). On review of follow-up CT scans, 13 (25%) showed new or worsening hydrocephalus, 8 (15%) showed new infarcts, 1 exhibited new tuberculoma, and 5 showed worsening cerebral edema. On review of follow-up MRI scans, new or worsening hydrocephalus was seen in 3 (6%), new infarcts in 3 (6%), new tuberculoma in 10 (19%), worsening cerebral edema in 7 (13%), and TB myelitis in 4 (8%) patients.

CONCLUSIONS

Tuberculoma, hydrocephalus, and cerebral infarcts are the most prominent findings in CNS tuberculosis. Our study showed development of new lesions on subsequent neuroimaging suggesting a dynamic and progressive nature of the disease process in some individuals.

Long noncoding RNA MEG3 mediated angiogenesis after cerebral infarction through regulating p53/NOX4 axis

OBJECTIVE

This study aimed to explore the mechanism of lncRNA MEG3 on angiogenesis after cerebral infarction (CI).

METHODS

The rat brain microvascular endothelial cells (RBMVECs) isolated from rat was used to establish CI model, which were treated with oxygen-glucose deprivation/reoxygenation (OGD/R). The genes mRNA and protein expression levels in RBMVECs were determined by the quantitative real-time polymerase chain reaction (RT-qPCR) and western blot, respectively. The flow cytometry was used to measured cell apoptosis and intracellular reactive oxygen species (ROS) generation. The RBMVECs activities was detected by MTT method. The RNA-immunoprecipitation (RIP) assay was used to detect the interaction between MEG3 and p53, and the relationship between p53 and NOX4 was proved by chromatin co-immunoprecipitation (chip) assay.

RESULTS

The results showed that OGD or OGD/R increased MEG3 and NOX4 expression, and there was positive correlation between MEG3 and NOX4 expression in RBMVECs. Next, knockdown of MEG3 indicated that inhibition of MEG3 was conducive to protect RBMVECs against OGD/R-induced apoptosis, with decreased NOX4 and p53 expression, further enhanced pro-angiogenic factors (HIF-1α and VEGF) expression, and reduced intracellular ROS generation. And then the RIP and CHIP assay demonstrated that MEG3 could interacted with p53 and regulated its expression, and p53 exerted significant binding in the promoters for NOX4, suggesting that MEG3 regulated NOX4 expression via p53. At last, knockdown of NOX4 indicated that inhibition of NOX4 protected RBMVECs against OGD/R-induced apoptosis, with increased cell viability and pro-angiogenic factors expression, and reduced ROS generation.

CONCLUSION

LncRNA MEG3 was an important regulator in OGD/R induced-RBMVECs apoptosis and the mechanism of MEG3 on angiogenesis after CI was reduced ROS by p53/NOX4 axis.