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| Findings on head computed tomography of patients with tuberculous meningitis. (A) Axial unenhanced head computed tomography (CT) shows diffuse brain edema. (B) Axial contrastenhanced head CT shows an ischemic lesion near the body of the left caudate nucleus (arrow). (C) Axial unenhanced head CT demonstrates hydrocephalus and diffuse brain edema. (D) Axial unenhanced head CT shows severe hydrocephalus that required surgical treatment with a bilateral ventriculoperitoneal shunt (arrows).
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Tuberculous Meningitis (TBM) is the most common form of central nervous system Tuberculosis (TB), accounting for 5–6% of extrapulmonary TB cases. Nowadays, TBM continues to be a major topic in public health because of its high prevalence worldwide. This retrospective study aimed to describe the clinical, laboratory, and imaging characteristics at a...
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Tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS) is an abnormal, excessive immune response against live or dead Mycobacteria tuberculosis that may occur during or even after completion of anti-TB therapy, commonly in HIV-infected patients. However, this has also been reported amongst HIV negative patients. We report a case of CNS...
Citations
... Vasopressor support and associated lung disease are the main indicators of mortality in the intensive care unit 7 . In turn, the hospital stay in patients with tuberculous meningitis is an average of 15 days, the same length of hospitalization observed 8 . ...
... Tuberculous meningitis presents as headache, weight loss, fever, altered level of consciousness, neck stiffness, and only 17% present neurological focal data, consistent with the clinical findings of our patient who presented left hemiparesis 8 . ...
... The British Medical Research Council staging test has shown that advanced impairment stages upon hospital admission predict a clinical worsening and provide a long-term functionality prognosis 1,32 . In our series, no patients with CNS TB/ HIV were in stage III or higher upon admission. ...
Introduction: Central nervous system tuberculosis (CNS TB), the most serious form of TB, is usually associated with an intense neuroinflammatory response and severe sequels, and it is often accompanied by human immunodeficiency virus (HIV) coinfection. Few works have studied mental functioning sequels in this population. Objective: The aim of this study was to characterize long-term neuropsychiatric sequels in central nervous system tuberculosis (CNS TB) patients and CNS TB/ Human Immunodeficiency Virus (HIV) co-infected patients, and to describe some associated factors. Methods: Retrospective cohort study in CNS TB patients admitted from 2008 to 2018 in a Mexican neurological center in which sociodemographic, clinical, neuroimaging, cognitive, and neuropsychiatric data were collected. Cognitive sequel data were obtained from a screening tool that has been standardized and normalized for the Hispanic population. Neuropsychiatric data were obtained from the Neuropsychiatric Inventory Questionnaire and from medical records. Results: A total of 86 subjects were included, 23 had CNSTB and HIV. The mean age was 40.4 years, and 23% of patients had a history of pulmonary TB. The main symptoms were headache, fever, and cranial nerve palsy. Executive functions, visuospatial, and memory impairment were the most common neurocognitive sequels, while the most frequent neuropsychiatric sequels were depression, irritability, and anxiety. There was a correlation between immunity (CD4+ T cell count) and executive functions. Conclusions: This is the first report in Mexican patients evaluating long-term neurocognitive sequels in CNS TB. Some clinical and sociodemographic traits seem to be neuroprotective factors against long-term neuropsychiatric sequels.
... The white matter involvement in BM may mimic other inflammatory or infectious disease, such as multiple sclerosis and acute disseminated encephalomyelitis (ADEM) [21]. The frequently observed imaging manifestations of TBM include hydrocephalus, tuberculomas, periventricular infarcts, meningeal enhancement, and basilar exudates [22][23][24][25][26]. These findings align with our study, revealing that infarction foci (RR: 4.8), meningeal enhancement (RR: 5.6), and hydrocephalus (RR: 7.4) were significantly more prevalent in TBM compared to BM. ...
Background
In regions endemic for tuberculosis and brucellosis, distinguishing between tuberculous meningitis (TBM) and brucella meningitis (BM) poses a substantial challenge. This study investigates the clinical and paraclinical characteristics of patients with TBM and BM.
Methods
Adult patients diagnosed with either TBM or BM who were admitted to two referral hospitals between March 2015 and October 2022, were included, and the characteristics of the patients were analyzed.
Results
Seventy patients formed the study group, 28 with TBM and 42 with BM, were included. TBM patients had a 2.06-fold (95% CI: 1.26 to 3.37, P-value: 0.003) higher risk of altered consciousness and a 4.80-fold (95% CI: 1.98 to 11.61, P-value: < 0.001) higher risk of extra-neural involvement as compared to BM patients. Cerebrospinal fluid (CSF) analysis revealed a significantly higher percentage of polymorphonuclear leukocytes (PMN) in TBM compared to BM (Standardized mean difference: 0.69, 95% CI: 0.18 to 1.20, P-value: 0.008). Neuroimaging findings indicated higher risks of hydrocephalus (P-value: 0.002), infarction (P-value: 0.029), and meningeal enhancement (P-value: 0.012) in TBM compared to BM. Moreover, TBM patients had a 67% (95% CI: 21% to 131%, P-value:0.002) longer median length of hospital stay and a significantly higher risk of unfavorable outcomes (Risk ratio: 6.96, 95% CI: 2.65 to 18.26, p < 0.001).
Conclusions
Our study emphasizes that TBM patients displayed increased frequencies of altered consciousness, PMN dominance in CSF, extra-neural involvement, hydrocephalus, meningeal enhancement, and brain infarction. The findings emphasize the diagnostic difficulties and underscore the importance of cautious differentiation between these two conditions to guide appropriate treatment strategies.
... The final diagnoses for the TBM case were mainly definite and possible; only a tiny proportion of the patients were classed as having a probable diagnosis. The finding was different from a previous study, in which most of the TBM cases had definite (56%) and probable (34%) diagnoses [7]. Earlier research also demonstrated the higher rates of acid-fast smear, cultures, and molecular testing of CSF and non-CSF samples [7]. ...
... The finding was different from a previous study, in which most of the TBM cases had definite (56%) and probable (34%) diagnoses [7]. Earlier research also demonstrated the higher rates of acid-fast smear, cultures, and molecular testing of CSF and non-CSF samples [7]. Those higher positive findings may explain why the previous research had more excellent rates for the definite and probable TBM diagnoses than ours. ...
... This finding is atypical for CNS tuberculomas and abscesses, usually located at the grey-white matter junction and the periventricular areas [19,20]. Similar to previous studies, the CSF profiles of the overall patients in the current investigation showed typical but non-specific features, such as mildly elevated opening pressures, CSF pleocytosis with lymphocytes predominating, elevated protein levels, and low glucose levels [2,7,21,22]. However, CSF profiles of TBM in another ID group had a significantly lower percentage of CSF lymphocytes and a more significant percentage of CSF neutrophils than other groups ( Table 2). ...
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.
... With approximately 100,000 new cases each year, TBM accounts for roughly 1% of all TB cases and ~ 5% of extrapulmonary TB cases [1,2]. Despite adequate anti-TB treatment, its mortality ranges from 20 to 50%, being significantly higher for human immunodeficiency virus (HIV)-infected patients [4][5][6]. Paradoxical manifestations in TBM are characterized by clinical or paraclinical worsening after 1 month of effective anti-TB treatment in patients who initially responded to treatment despite the use of adjunctive corticosteroids [7][8][9]. Its diagnosis requires excluding other causes of deterioration, mainly poor treatment compliance, treatment failure due to microbiological resistance to first-line anti-tuberculosis drugs, and co-existence of another CNS infection [7,8]. ...
Background: Tuberculous meningitis (TBM) is the most frequent, severe, and disabling form of central nervous system (CNS) tuberculosis (TB). TBM paradoxical manifestations are characterized by clinical or paraclinical worsening after 1 month of effective anti-TB treatment in patients who initially responded to treatment despite the use of adjunctive corticosteroids.
Methods: Retrospective descriptive study of consecutive HIV-negative adult patients (≥ 18 years) with definitive TBM who developed a paradoxical manifestation following anti-TB in a tertiary-care hospital in Mexico from 2009 to 2019; we also conducted a literature review of published cases/series of paradoxical manifestations in HIV-negative patients from 1980 to 2020.
Results: We detected 84 cases of definitive TBM; 55 (68.7%) HIV-negative patients and 29 (36.3%) HIV-infected patients. Among HIV-negative patients, four (7.3%), three female and one male (19-49 years old), developed a paradoxical manifestation within 4-14 weeks following treatment initiation despite receiving adequate corticosteroid doses; Mycobacterium bovis was isolated from the cerebrospinal fluid of three cases and Mycobacterium tuberculosis in one more. Two patients developed vasculopathy-related cerebral infarctions, one severe basilar meningitis, and hydrocephalus, one more a tuberculoma. Two were treated with intravenous cyclophosphamide, and two with steroids. One of the patients treated with steroids died; patients who received cyclophosphamide had a good clinical response.
Conclusions: This case series illustrates the diverse clinical/radiologic paradoxical manifestations of TBM in HIV-negative patients. Cyclophosphamide may be safe and effective in treating TBM-associated paradoxical manifestations. Specific diagnostic and care protocols for these patients are needed.
... CSF and urine lipoarabinomannan (LAM) are very specific yet had low sensitivity for TBM diagnosis in a cohort of mainly HIV-infected TBM patients in Zambia [15]. Circumstantial evidence may be provided by chest radiography, which identifies pulmonary abnormalities in 30-50% of patients with TBM [16,17]. Brain imaging may be improved by three-dimensional (3D) magnetization-prepared rapid gradient-echo (MP-RAGE) MRI, which has improved sensitivity due to its use of thin slices (1 mm), thereby detecting more brain lesions [18 && ]. ...
Purpose of review:
Central nervous system (CNS) tuberculosis is the most devastating form of tuberculosis (TB), with mortality and or neurological sequelae in over half of individuals. We reviewed original research and systematic reviews published since 1 January 2019 for new developments in CNS TB pathophysiology, diagnosis, management and prognosis.
Recent findings:
Insight in the pathophysiology is increasing steadily since the landmark studies in 1933, focussing on granuloma type classification, the relevance of the M. tuberculosis bacterial burden and the wide range of immunological responses. Although Xpert/RIF has been recommended by the WHO for extrapulmonary TB diagnosis, culture is still needed to increase the sensitivity of TB meningitis diagnosis. Sequential MRIs can improve understanding of neurological deficits at baseline and during treatment. Pharmacokinetic/pharmacodynamic modelling suggests that higher doses of rifampicin and isoniazid in TB meningitis could improve survival.
Summary:
Recent studies in the field of CNS-TB have largely focussed on TB meningitis. The outcome may improve by optimizing treatment dosing. This needs to be confirmed in clinical trials. Due to the important role of inflammation, these trials should be used as the platform to study the inflammatory and metabolomic responses. This could improve understanding of the biology of this disease and improve patient outlook by enabling individualised host-directed therapy.
Background:
Tuberculosis (TB) which is caused by Mycobacterium tuberculosis poses a significant public health global treat. Tuberculosis meningitis (TBM) accounts for approximately 1% of all active TB cases. The diagnosis of Tuberculosis meningitis is notably difficult due to its rapid onset, nonspecific symptoms, and the difficulty of detecting Mycobacterium tuberculosis in cerebrospinal fluid (CSF). In 2019, 78,200 adults died of TB meningitis. This study aimed to assess the microbiological diagnosis TB meningitis using CSF and estimated the risk of death from TBM.
Methods:
Relevant electronic databases and gray literature sources were searched for studies that reported presumed TBM patients. The quality of included studies was assessed using the Joanna Briggs Institute Critical Appraisal tools designed for prevalence studies. Data were summarized using Microsoft excel ver 16. The proportion of culture confirmed TBM, prevalence of drug resistance and risk of death were calculated using the random-effect model. Stata version 16.0 was used perform the statistical analysis. Moreover, subgroup analysis was conducted.
Results:
After systematic searching and quality assessment, 31 studies were included in the final analysis. Ninety percent of the included studies were retrospective studies in design. The overall pooled estimates of CSF culture positive TBM was 29.72% (95% CI; 21.42-38.02). The pooled prevalence of MDR-TB among culture positive TBM cases was 5.19% (95% CI; 3.12-7.25). While, the proportion of INH mono-resistance was 9.37% (95% CI; 7.03-11.71). The pooled estimate of case fatality rate among confirmed TBM cases was 20.42% (95%CI; 14.81-26.03). Based on sub group analysis, the pooled case fatality rate among HIV positive and HIV negative TBM individuals was 53.39% (95%CI; 40.55-66.24) and 21.65% (95%CI;4.27-39.03) respectively.
Conclusion:
Definite diagnosis of TBM still remains global treat. Microbiological confirmation of TBM is not always achievable. Early microbiological confirmation of TBM has great importance to reduce mortality. There was high rate of MDR-TB among confirmed TBM patients. All TB meningitis isolates should be cultured and drug susceptibility tested using standard techniques.
