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Predicting unfavorable outcome is of paramount importance in clinical decision making. Accordingly, we designed this multinational study, which provided the largest case series of tuberculous meningitis (TBM). 43 centers from 14 countries (Turkey) submitted data of microbiologically confirmed TBM patients hospitalized between 2000 and 2012. Unfavor...
Citations
... [194][195][196][197] Unfavorable outcomes in TBM correlate with older age, immunosuppression, presence of hydrocephalus and/or vasculitis and more advanced clinical stage at time of presentation. 193,198,199 Prognostic models have been developed for the prediction of unfavorable outcomes among adults (greater than 14 years of age) with TBM. 198,200 Neurologic imaging in TBM can support the diagnosis; inform prognosis; and identify a need for neurosurgical inter vention. ...
... 193,198,199 Prognostic models have been developed for the prediction of unfavorable outcomes among adults (greater than 14 years of age) with TBM. 198,200 Neurologic imaging in TBM can support the diagnosis; inform prognosis; and identify a need for neurosurgical inter vention. Basal meningeal enhancement on contrast-enhanced CT has high specificity for TBM (greater than 90% in adults and children), further increased by additional findings of infarcts and hydrocephalus that may become more apparent in later-stage disease. ...
... 14,15 Recent data suggest that mortality in TBM patients is associated with many factors, such as HIV infection, older age, multidrug resistance, neurological deficit, and low numbers of CSF white cell counts. [16][17][18][19][20] HIV-infected individuals are more susceptible to developing severe disseminated forms of TB, included CNS involvement, 21 and mortality in these patients can exceed 60%. 9,22 Because of the devastating mortality rate of TBM, especially in patients with HIV coinfection, we conducted a study to compare the clinical characteristics, presentation, laboratory investigations, and outcomes of TBM patients with and without HIV coinfection. ...
To compare the characteristics, presentation, investigations, and outcomes in tuberculous meningitis (TBM) patients with and without human immunodeficiency virus (HIV) coinfection. A retrospective cohort study was conducted on adult (age > 18 years) patients whose final diagnosis was TBM and who were treated at Vajira Hospital, Navamindradhiraj University, Thailand, between January 2005 and December 2016. A final total of 174 individuals were included in the study. Of these, 97 (55.75%) were HIV positive. Treatment was successful in 53 (30.5%) individuals. In HIV-infected TBM patients, there were higher proportions of patients who were younger in age (≤40 years), patients with a low body mass index, history of previous tuberculosis infection, or hepatitis C virus coinfection. A successful treatment outcome rate was lower in HIV-infected TBM patients than in HIV-uninfected TBM patients. Since HIV infection decreases the chance of successful treatment outcomes of TBM patients, future studies are needed to determine the clinical indicators for poorer survival outcomes in HIV-positive TBM patients.
... 6 It is particularly seen in patients with miliary or disseminated tuberculosis, immunocompromised patients, with shorter duration of illness, lymphopenia, and elevated serum alanine aminotransferase. 2 The diagnosis of tuberculosis-related ARDS is based on Berlin's criteria. 8 The severity of ARDS is explained by PaO 2 -to-FiO 2 ratio as follows ( Table 1): ...
... Tuberculous meningitis is the most severe form of tuberculosis with a mortality of more than 60% and residual neurological disability in 25% of cases. 8,9 It is the second most common cause of admission to ICU after acute respiratory failure. It accounts for around 6 to 18% of all tuberculosis-related ICU admissions. ...
About 3.4% of the hospitalized tubercular patients need admission to the intensive care unit (ICU). Patients requiring ICU admission had a poor prognosis and high mortality rate (60 vs 25%) as compared to other causes of severe pneumonia. The most common indication for tuberculosis-related ICU admission is acute respiratory failure due to pneumonia or acute respiratory distress syndrome (ARDS) (with or without miliary tuberculosis) followed by septic shock with multiple organ dysfunction, adrenal insufficiency, and neurological involvement, especially tubercular meningitis. Tuberculosis patients who require admission to ICU are mostly immunocompromised [human immunodeficiency virus (HIV) coinfection] and have underlying miliary tuberculosis or disseminated tuberculosis. Pulmonary tuberculosis presenting as ARDS is a rare phenomenon, but a most common cause of admission of tuberculosis patients to ICU. Tuberculous meningitis is the most severe form of tuberculosis with mortality more than 60% and residual neurological disability in 25% cases. Tuberculosis-related septic shock has been found in only 1% of all septic shock patients admitted to ICU. Patients with tuberculosis with refractory shock should be suspected for adrenal insufficiency. A trial of physiologic stress replacement dose of hydrocortisone (200–300 mg) should be given to all critically ill patients with vasopressor-dependent shock after correcting other causes. Diagnosis and treatment of tuberculosis in critically ill patients has various challenges, namely appropriate sample collection, issues with the route of administration, drug absorption, bioavailability, dose modification in hepatic and renal dysfunction, and interaction with other drugs.
How to cite this article: Chaudhry D, Tyagi D. Tuberculosis in Intensive Care Unit. Indian J Crit Care Med 2021;25(Suppl 2):S150–S154.
... TBM is the severe form of CNS tuberculosis 6 . The relative incidence of this disease is 0.4% to 1.0% of all cases of TB [7][8][9] . The disease affects all the age groups. ...
... The actual incidence and prevalence of TBM is not yet clearly defined in our country. The worldwide mortality rate of this disease is 20.0% to 69.0% and about half of the survivors developed neurological sequelae like visual loss, motor and cognitive deficits 5,7,[11][12][13] . Early diagnosis is an essential component in management of tuberculous meningitis to prevent mortality and morbidity 5 . ...
Background: Outcome of TBM can be modified by several predictors. Objective: This study was undertaken to evaluate the predictors of outcome of tuberculous meningitis (TBM) at 6 and 9 months. Methodology: This hospital based prospective cohort study was carried out from October, 2016 to September, 2017 (1 year) in the in-patient Department of Neurology at the National Institute of Neurosciences & Hospital (NINS & H), Dhaka, Bangladesh. All the patients with age 18 years or more of both sexes with features of TBM fulfilling the case definition criteria was included as the study population. The outcome was measured at 6 and 9 months by modified Rankin Scale (mRS) with no disability (score=0-1), mild disability (score = 2), moderate disability (score=3-4), severe disability (score=5) and dead (score=6). For statistical analysis outcome was classified as death and survival group. A number of clinical, laboratory and radiological parameters were evaluated initially by univariate and finally multiple regression analysis. Results: A total 54 TBM patients were included in this study. Over 70% of the patients were adolescent or young adult (< 30 years) with mean age of 28.2 ± 12.3 years and 63% were female. Staging of the TBM showed that nearly half (48.1%) were at stage II and 37% cases were in stage III disease. Baseline imaging (CT-scan and MRI) showed basal meningeal enhancement in 40.7% cases, hydrocephalus in 40.7%, infarction 46.3% and tuberculoma in 29.6% cases. Final diagnosis was established as definite TBM in 3(5.6%) cases, probable TBM 30(55.6%) and possible TBM in 21(38.9%) cases. In terms of 6-months outcome, 16(29.6%) cases died and 10(18.5%) had recovered without any neurological sequelae; however, mild, moderate and severe disability were in11.1%, 27.8% and 13% cases respectively. At the 9 months of evaluation 13 (24.0%) had complete recovery without any neurological sequelae, 22 (40.9%) patients survived with various degree of disabilities like visual impairment, hemi or paraplegia, cognitive impairment, rests died giving a total mortality of 19(35.1%). In univariate analysis, age >50 years (p=0.019), duration of illness before initiation of treatment (>45 d) (p = 0.041), convulsion (p = 0.010), altered sensorium (p<0.001), delayed initiation of treatment >1 month (p=0.041) and stage III TBM (p<0.001) were significantly associated with mortality. In multivariate analyses stage III TBM (p=0.004), altered sensorium (p=0.036), delayed initiation of treatment >1 month (p=0.043) emerged as independent predictors of mortality. Conclusions: In conclusion stage III TBM, altered sensorium and delayed initiation of treatment more than 1 month are the independent predictors of mortality in TBM patients. Journal of National Institute of Neurosciences Bangladesh, January 2021, Vol. 7, No. 1, pp. 14-19
... [2] The estimated mortality in a large multicountry study was nearly 17%. [3] Early diagnosis and treatment is essential to decrease morbidity and mortality. ...
Background: Definite diagnosis of tuberculous meningitis (TBM) requires demonstration of TB bacilli in the cerebrospinal fluid (CSF) on smear, culture, or nucleic acid amplification. However, the sensitivity of these tests is low. This study was done to see if smear and culture done on a larger volume and repeated samples of CSF increases the diagnostic yield of these tests. Methods: Adult patients with clinical features of meningitis for >5 days were prospectively and consecutively recruited. At admission, the usual 1 ml of CSF was taken for mycobacterial testing; another 4–8 ml was also taken for the same as the comparison. On the 3rd hospital day, 4–8 ml of CSF was taken for mycobacterial testing. Mycobacterial smear and culture were done by Auramine O stains and on modified Lowenstein–Jensen medium, respectively. The composite reference standard for TBM was considered the gold standard for the diagnosis of TBM. Definite and probable diagnosis was taken as positive, while a possible diagnosis and no TB were considered negative for TBM. In a subset, Xpert MTB/Rif assay was also performed on the CSF samples as per the routine diagnostic protocol. Results: 66/80 (82.5%) had the initial CSF examination in the emergency department, 80 (100%) had large-volume CSF on day 1, while 22/80 (27.5%) consented for the second large-volume CSF examination on day 3. There was a marginal increase in sensitivity from 22% to 26% with increasing CSF volume from 1 ml to 4–8 ml and 36% if another large-volume CSF was collected at 72 h. The specificity was 100% at all times. The negative likelihood ratios were 0.78, 0.74, and 0.64, respectively. The sensitivity of Xpert MTB/RI compared to the composite reference standard of TBM was 30.4%. Conclusions: Increasing the volume and frequency of CSF testing for Mycobacterium tuberculosis, marginally improves the sensitivity and negative likelihood ratios, but may not be adequate to rule out TBM with the certainty required to withhold antitubercular therapy. The feasibility of repeat CSF examinations needs to be considered while making guidelines.
... Inflammation caused by tuberculosis infection can involve the cerebral artery system, leading to arterial spasms, stenosis, occlusion or rupture. Vascular insults further cause ischemic or hemorrhagic brain damage, which is a charac-teristic feature of the disease and an important factor for the poor prognosis of TBM patients [4]. The mechanisms of arterial injury include infiltration of arteries by exudates, stretching of arteries caused by coexisting hydrocephalus, release of vasoactive autacoids and prethrombotic state [5]. ...
Purpose
The features of intracranial arterial injury in tuberculous meningitis (TBM) are of important diagnostic and prognostic value. The study aimed to elucidate the high-resolution vessel wall imaging (HR-VWI) manifestations of intracranial arterial insults in TBM.
Methods
The clinical data, routine cranial magnetic resonance imaging, magnetic resonance angiography (MRA) and HR-VWI before and after contrast enhancement of intracranial arteries in clinically diagnosed TBM patients were retrospectively analyzed.
Results
In this study 27 TBM patients were included. Abnormalities in the intracranial arteries were detected in all patients using HR-VWI. Typical vessel insults included nodular or granular lesions, related thickness and prominent enhancement in the wall, and lumen narrowing or occlusion. The most frequently involved arteries were the C4 segment of the internal carotid artery and the P1 segment of the posterior cerebral artery. The lesions were consistent with disease stage and disease duration and correlated with infarction.
Conclusion
The use of HR-VWI revealed that cerebral artery involvement in patients with TBM is much more common and extensive than in previous radiological reports. The use of HR-VWI improves recognition of arterial pathologies and has diagnostic value in patients with TBM.
... With the advent of neuroimaging techniques and other advanced investigations it was proposed that other than clinical features, neuroimaging and laboratory findings can also play a role in predicting the prognosis of tuberculous meningitis. Several studies have identified certain prognostic predictors, with the common ones being stage of the disease at presentation, hydrocephalus, altered sensorium, age, seizures, cranial neuropathies, hemiplegia and stroke [3][4][5][6][7][8][9][10]. ...
... These scores can also help to identify patients at higher risk of experiencing a poor outcome, so that they can be managed more aggressively. Only few such prognostic scores are available, but they are not in popular usage in day to day practice [7,9,10]. We aimed to develop a prognostic model for tuberculous meningitis taking into account baseline clinical features, neuroimaging features and cerebrospinal fluid findings, and present it as a simple bed side prognostic score that can be used in day-to-day clinical practice. ...
... This is not for the first time that researchers have tried to develop a scoring system to prognosticate patients with tuberculous meningitis. The Haydarpasa Meningitis Severity Index (HAMSI) is another bedside score which can be used to predict the prognosis of tuberculous meningitis [9].The HAMSI score predicts the outcome of tuberculous meningitis on the basis of presence of altered sensorium, diabetes mellitus, immunosuppresion, neurological deficit, hydrocephalus and vasculitis [9]. Notably, this score did not include stage of TBM and MBI as prediction variables, that are more refined and validated to produce consistent and reproducible results. ...
Background
Tuberculous meningitis is commonly associated with a poor outcome. Simple bedside prognostic scores can help immensely in predicting the outcome.
Materials and method
A total of 721 patients, from 5 of our previous studies, were included. With primary outcome measure as death, a prognostic model was derived using binary logistic regression. The model was assessed using discrimination and calibration and internally validated using the bootstrap method. A bedside prognostic score was derived by rounding of the regression coefficients to the nearest integers.
Results
A total of 126 (17.48%) patients died. The final model found that higher age, stage III disease, baseline MBI ≤ 12, papilledema and hydrocephalous were significant predictors of death. The final model showed good discrimination as evident by an AUC = 83.1% (95% confidence interval 79.5%–86.7%, P < .001) and good calibration (Hosmer and Lemeshow test P = .579). The model remained valid after internal validation by boot strapping. A simple bedside score with the acronym MASH-P to denote variables baseline MBI (M), age (A), stage (S), hydrocephalous (H) and papilledema (P), was thus derived. The score can range from 0 to 10. Higher the score the higher is the probability of death; a score of 0 carries a predicted probability of just 1.7% while a score of 10 corresponds to a predicted probability of 65%. An electronic ready reckoner has also been developed to aid prognostication on the go.
Conclusion
MASH-P is a simple prognostic scoring model that can be used at bedside and aid in decision making as well as counselling.
... Our study found that an immunocompromised state, including HIV coinfection, occurred in nearly one-fifth of patients. An immunocompromised state could reduce the immune response to M. tuberculosis, and TBM patients who are immunocompromised have increased morbidity and mortality [29,30]. Active interventions for patients who are immunocompromised and enhancement of their immune systems may help prevent or treat TBM. ...
Background
Tuberculous meningitis (TBM) is one of the most life-threatening infectious diseases. We performed a systematic review and meta-analysis of the clinical features, outcomes, and prognostic factors for TBM in adults.
Methods
PubMed, EMBASE, Cochrane CENTRAL, and Web of Science were searched for studies that reported the clinical outcomes and/or risk factors for death in adults with TBM between January 1990 and July 2018. A random-effects meta-analysis model was used to pool data on clinical features, outcomes, and risk factors for death.
Results
Thirty-two studies that examined 5023 adults who had TBM met the inclusion criteria. Overall, the mortality was 22.8% [95% confidence interval (CI) 18.9–26.8] and the risk of neurological sequelae was 28.7% (95% CI 22.8–35.1). The major risk factors for death (OR > 2 and P < 0.05) were advanced stage of disease (OR = 6.06, 95% CI 4.31–8.53), hydrocephalus (OR = 5.27, 95% CI 2.25–12.37), altered consciousness (OR 3.33, 95% CI 1.51–7.36), altered sensorium (OR 3.31, 95% CI 2.20–4.98), advanced age (> 60 years; OR = 2.64, 95% CI 1.27–5.51), and cerebral infarction (OR = 2.35, 95% CI 1.63–3.38). The clinical features and diagnostic findings present in more than four-fifths of the patients were fever (86.3%, 95% CI 82.4–89.8) and low CSF/serum glucose ratio (80.6%, 95% CI 64.8–92.6).
Conclusions
Adults with TBM have high rates of mortality. Clinicians should maintain a high clinical suspicion for patients who present with certain clinical features, and should pay more attention to prognostic factors.
... These series of patients were diagnosed and treated in a second-tier hospital, but the morbidity and mortality were still high. The clinical course of this disease has already been described in large-scale studies worldwide; most of our findings were similar when compared to those studies [12][13][14][15]. Among the risk factors we studied, 51.2% of our patients were illicit drug users, inhaled methamphetamine being the most frequent illicit drug used in 43.9% of the patients and only two (4.8%) were Intravenous (IV) drug users, contrary to other authors describing TB to be more frequent in IV drug users [16]. ...
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 admission; and in-hospital outcome of adult Mexican patients with TBM. We collected data from medical records of patients aged ≥18 years diagnosed with TBM according to the uniform case definition for clinical research who were treated at Tijuana General Hospital between January 2015 and March 2018 and compared them according to the subtype of diagnosis. We included 41 cases (26 males, median age 28 years, range 18–57 years), 13 (31.7%) patients were HIV positive, and 21 (51.2%) were illicit drug users. At admission, 7 (17.1%) patients were in stage I, 22 (53.6%) in stage II, and 12 (29.3%) in stage III. A definitive diagnosis was established in 23 (56.1%) patients, probable in 14 (34.1%), and possible in four (9.8%). Molecular testing was positive in 83% of the cases, yielding significantly higher positive results than other microbiological studies. There were eight (19.5%) deaths, without statistical difference between mortality and not having a definitive diagnosis (p = 0.109). We found that the baseline characteristics of our population were similar to those described by other authors worldwide. In this series, molecular testing showed to be very useful when used in the early stages, particularly in subjects with subacute onset of headache, fever, weight loss, and altered mental status.
... The previous studies have reported numerous risk factors that may impact the outcome of TBM. Advanced age, altered consciousness, positive TB culture, immunosuppression, hydrocephalus, tuberculoma, neurological deficits have all been reported to predict unfavorable outcome (20)(21)(22)(23)(24). However, in recent years, these predictors might have changed with the advances in diagnosis and treatment. ...
Background: Tuberculous meningitis (TBM) is an extremely devastating inflammation of the central nervous system; however, no available optimum treatment can effectively control the disease so far.
Method: The medical records of TBM patients from May 2011 to August 2016 in West China hospital were retrospectively analyzed. Patients were divided into three groups based on their treatment regimens {Group1: 4 standard therapy; Group2: 3 standard drugs + Levofloxacin; Group3: 4 standard therapy + Levofloxacin (G3a)/ Moxifloxacin (G3b)}. Using the intention-to-treat analysis, eventually, the treatments' efficacy and safety were compared among all groups.
Results: Two hundred two patients with TBM were enrolled and followed up for at least 2 years. Among them, 99 patients were in G1; 18 in G2; and 85 in G3 (Moxifloxacin=39/ Levofloxacin=49). One hundred fifteen (56.9%) patients were males, and the median age was 42 years. At admission, 74 patients (36.6%) were in stage I, 102 (50.5%) in stage II and 26 (12.9%) in stage III. The most common symptoms were headache in 194 (96.0%) patients, fever in 162 (80.2%), vomiting in 120 (59.7%), neck stiffness in 104 (51.5%), and malaise in 96 (47.5%). The overall outcome at 1 year showed that 47 patients (47.5%) in G1, 10 patients (55.6%) in G2 and 48 patients (56.5%) in G3 had good outcome; however, there was no significant difference among all groups (P = 0.397); at 2 years there was also no difference among treatment groups (P = 0.295). However, in Group3b 22 patients (56.4%) at 1-year and 26 (66.7%) at 2-year follow up had a full recovery, which is significantly superior to other treatment groups, the P value at 1 and 2 years was 0.002 and 0.027, respectively.
Conclusion: The overall outcome in patients with TBM at 1 and 2 years follow up did not show any statistically significant difference between the standard chemotherapy and other intensified regimens. Furthermore, Hydrocephalus (OR = 3.461, 95% CI: 1.349–8.882, P = 0.010) was the only independent risk factor for a poor outcome.
