A study to assess the clinico-radiological presentation and outcome predictors in cases of tubercular meningitis

INTRODUCTION

Tubercular bacterial meningitis continues to be an important cause of morbidity (especially neurologic handicap) in children from resource-poor countries. The present study was planned to assess the clinical and radiological presentation in cases of tubercular meningitis as well as to study the factors associated with mortality.

METHODOLOGY

This study was done over a period of 12 months on children between 5 years and 13 years with suspected TBM. Staging of tubercular meningitis was done according to RNTCP Pediatric TB guideline 2019.

RESULT

The study was conducted on a total of 47 pediatric patients with TBM. Mean age of children in present study was 8.77 ± 2.5 years. Our study documented male preponderance for TBM. Severe thinness was observed in 38.3% patients with TBM. Only 59.6% patients were immunized against tuberculosis and history of contact was documented in 40.5% patients. Maximum children belonged to stage I of TBM (59.6%) followed by stage III and stage II in 34% and 6.4% patients respectively. Montoux test positivity was observed in 14.9% patients only. CSF CBNAAT was positive in 6.4% patients. The most common finding was meningeal enhancement seen in 27.7% of patients followed by tuberculomas in 10.6%.Chest X ray was abnormal in 44.7% patients. In present study mortality was observed in 11 (23.4%) cases. Out of various risk factors, mortality was significantly associated with nutritional status and stage of TBM (p < 0.01).

CONCLUSION

TBM is associated with high morbidity and mortality in children especially in India where Burden of TB is high. Our study emphasized on the risk factors associated with mortality in children with TBM and need for early diagnosis and appropriate treatment.

Prediction model for pneumonia in primary care patients with an acute respiratory tract infection: role of symptoms, signs, and biomarkers

BACKGROUND

Diagnosing pneumonia can be challenging in general practice but is essential to distinguish from other respiratory tract infections because of treatment choice and outcome prediction. We determined predictive signs, symptoms and biomarkers for the presence of pneumonia in patients with acute respiratory tract infection in primary care.

METHODS

From March 2012 until May 2016 we did a prospective observational cohort study in three radiology departments in the Leiden-The Hague area, The Netherlands. From adult patients we collected clinical characteristics and biomarkers, chest X ray results and outcome. To assess the predictive value of C-reactive protein (CRP), procalcitonin and midregional pro-adrenomedullin for pneumonia, univariate and multivariate binary logistic regression were used to determine risk factors and to develop a prediction model.

RESULTS

Two hundred forty-nine patients were included of whom 30 (12%) displayed a consolidation on chest X ray. Absence of runny nose and whether or not a patient felt ill were independent predictors for pneumonia. CRP predicts pneumonia better than the other biomarkers but adding CRP to the clinical model did not improve classification (- 4%); however, CRP helped guidance of the decision which patients should be given antibiotics.

CONCLUSIONS

Adding CRP measurements to a clinical model in selected patients with an acute respiratory infection does not improve prediction of pneumonia, but does help in giving guidance on which patients to treat with antibiotics. Our findings put the use of biomarkers and chest X ray in diagnosing pneumonia and for treatment decisions into some perspective for general practitioners.

Unusual cause of chest pain, Bornholm disease, a forgotten entity; case report and review of literature

Chest pain is a common symptom culminating in hospital admissions and specialist referrals. Although cardiac work up is pursued in most of the cases, cardiac etiology is found to be the culprit in minority of the cases. Acute chest pain is a clinical syndrome that may be caused by almost any condition affecting the thorax, abdomen, or internal organs. On occasions this extensive and expensive diagnostic work up can be avoided with awareness of commoner and non-lethal reasons. We report a case of a woman with Bornholm disease secondary to Coxsackievirus B5 (CB5) infection and supplementary review of literature till date.

[Role of imaging procedures in clarification of complications of pneumonia]

CLINICAL ISSUE

Despite a considerable number of antimicrobial agents and interdisciplinary treatment options, lower respiratory tract infections are still associated with high morbidity and mortality rates. Infections of the respiratory tract can lead to severe complications, such as empyema, lung abscesses and acute respiratory distress syndrome (ARDS). Besides intrapulmonary complications pneumonia can also impair other organs due to a systemic inflammatory response. Underlying cardiovascular diseases, such as chronic heart failure, arteriosclerosis and dysrhythmia can either deteriorate due to infections or be newly manifested as a result of pneumonia. Early diagnosis and therapy of these sometimes life-threatening complications are crucial and can have a severe impact on disease outcome.

STANDARD RADIOLOGICAL METHODS

The most important imaging techniques include chest X‑ray and computed tomography (CT) of the chest. Although a definite diagnosis is sometimes difficult or even impossible to establish using chest X‑ray or CT, there are several findings indicative of intrapulmonary or extrapulmonary complications of pneumonia. Another useful and portable tool is thoracic ultrasound directly on the patient, which can be used to further define the underlying disease or as guidance during procedures.

PRACTICAL RECOMMENDATIONS

The chest X‑ray is useful in initial diagnosis and follow-up. If complications or disease progression are suspected or the clinical course differs from the X‑ray interpretation, a subsequent CT of the chest should be performed.

[Noninfectious differential diagnoses of pneumonia]

Hintergrund

Bei der Verdachtsdiagnose Pneumonie sind die Kombination aus typischer Klinik, Labor und der Nachweis einer Verdichtung in der Röntgenthoraxaufnahme in der Regel diagnostisch und es wird umgehend mit der Therapie begonnen. Studien haben jedoch gezeigt, dass bei bis zu 5 % der Patienten mit Erstverdacht auf Pneumonie eine andere (pulmonale) Erkrankung zugrunde liegt. Ein frühzeitiges Erkennen und eine Differenzierung von Erkrankungen, die eine Pneumonie vortäuschen, sind für die weitere Behandlung essenziell.

Fragestellung

Übersicht über wesentliche nichtinfektiöse Differenzialdiagnosen der Pneumonie.

Material und Methode

Es wurde eine Literaturrecherche durchgeführt.

Ergebnisse

Da krankhafte Lungenveränderungen oft ähnliche Bilder hervorrufen und anhand der Röntgenthoraxaufnahme oder der CT-Untersuchung nicht zwischen Blut, Transsudat, Exsudat und Zellen differenziert werden kann, ist eine systematische Herangehensweise wesentlich für die Differenzialdiagnose. Dazu werden der zeitliche Verlauf, das prädominante Muster, die Verteilung der Veränderungen, zusätzliche Befunde und die Klinik berücksichtigt.

Simple screening of pulmonary artery hypertension using standard chest x ray: an old technique, new landmark

BACKGROUND

Pulmonary artery hypertension (PAH) is difficult to diagnose because of its nonspecific symptoms. Although echocardiography can reliably and rapidly recognize the presence of pulmonary hypertension, chest X ray (CXR) is more widely used because of its availability. The objective of this study was to find a parameter, which, by changing the scale of CXR, is still useful for detection of PAH.

MATERIALS AND METHODS

This case control prospective study included 100 subjects with a clinical finding of dyspnea. Additionally, thirty healthy volunteers (control group) were included in this study. Systolic pulmonary artery pressure (SPAP) was determined by echocardiography. Widening of pulmonary hilum, projection of the right side of the heart border (PRHB) and the ratio of these parameters to the chest diameter were compared to SPAP using the regression method. A cut-off point was determined for parameters that showed significant correlation.

RESULTS

The most prevalent disease in the dyspnea group was COPD (28%). Average SPAP was 41.8±17.3 (ranging from 10 to 87 mmHg). Multivariate analysis of the covariance revealed significant correlation between SPAP, age, sex and hilar widening (r = 0.44, P = 0.0001) that was higher than PRHB and hilar widening + PRHB (r= 0.374. and r= 0.438, respectively). The ROC curve showed that the area under the curve was not significantly different for all parameters and the best cut-off point with sensitivity of more than 80% was as follows: hilar size more than 112 mm, PRHB more than 44 and hilum/chest ratio more than 0.44.

CONCLUSION

Hilum/chest ratio is the proper substitution for the hilar size in case of changing the scale of the chest X ray. Evaluation of hilar widening and PRHB could lead to identifying more subjects suffering from undiagnosed PAH.