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Tan DTM, See KC. Diagnosis and management of severe pulmonary and extrapulmonary tuberculosis in critically ill patients: A mini review for clinicians. World J Crit Care Med 2024; 13:91435. [DOI: 10.5492/wjccm.v13.i2.91435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/04/2024] [Accepted: 03/25/2024] [Indexed: 06/03/2024] Open
Abstract
Among critically ill patients, severe pulmonary and extrapulmonary tuberculosis has high morbidity and mortality. Yet, it is a diagnostic challenge given its nonspecific clinical symptoms and signs in early stages of the disease. In addition, management of severe pulmonary and extrapulmonary tuberculosis is complicated given the high risk of drug-drug interactions, drug-disease interactions, and adverse drug reactions. To help clinicians acquire an up-to-date approach to severe tuberculosis, this paper will provide a narrative review of contemporary diagnosis and management of severe pulmonary and extrapulmonary tuberculosis in critically ill patients.
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Affiliation(s)
- Dominic Ti Ming Tan
- Department of Medicine, National University Hospital, Singapore 119228, Singapore
| | - Kay Choong See
- Department of Medicine, National University Hospital, Singapore 119228, Singapore
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Koesbandono, Muljadi R, Sutanto R, Fransiska SR, Takaliuang D, Erico A. Intracranial tuberculomas: review of MRI findings and clinical features. Clin Radiol 2024; 79:354-362. [PMID: 38286718 DOI: 10.1016/j.crad.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/14/2023] [Accepted: 12/24/2023] [Indexed: 01/31/2024]
Abstract
AIM To present a comprehensive analysis of the clinical features and magnetic resonance imaging (MRI) findings of intracranial tuberculomas in Indonesia. MATERIALS AND METHODS This was a retrospective analysis of brain MRI from 58 patients (29 women), mean age ± SD = 39 ± 2 years, diagnosed with intracranial tuberculomas. Clinical data, including symptoms, cerebrospinal fluid examination results, and MRI were also analysed. The diagnosis of intracranial tuberculoma was confirmed based on observed MRI changes following anti-tuberculosis therapy. RESULTS A total of 603 tuberculomas were fully detected via MRI in all patients. Among these lesions, 507 (84%) were located in the cerebrum, 61 (10%) in the cerebellum, 19 (3%) in the basal ganglia, 12 (2%) in the brain stem, and four (1%) in the thalamus. The MRI signals were classified into two groups: tuberculomas with caseating granulomas and tuberculomas with non-caseating granulomas. Among the patients, 29 had concomitant meningitis, seven had hydrocephalus, and four had cerebral infarction. Evidence of pulmonary tuberculosis was found in 16 patients, with one patient having coexisting thoracic vertebral tuberculosis. CONCLUSION The present study confirmed the significance of MRI as a valuable tool in the diagnosis of intracranial tuberculomas and the detection of associated abnormalities. The combination of MRI findings with clinical features can enhance the overall diagnostic accuracy for intracranial tuberculomas.
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Affiliation(s)
- Koesbandono
- Pelita Harapan University, Faculty of Medicine, Tangerang, Indonesia; Department of Radiology, Siloam Hospital Lippo Village, Tangerang, Indonesia
| | - R Muljadi
- Pelita Harapan University, Faculty of Medicine, Tangerang, Indonesia; Department of Radiology, Siloam Hospital Lippo Village, Tangerang, Indonesia
| | - R Sutanto
- Pelita Harapan University, Faculty of Medicine, Tangerang, Indonesia; Department of Radiology, Siloam Hospital Lippo Village, Tangerang, Indonesia
| | - S R Fransiska
- Pelita Harapan University, Faculty of Medicine, Tangerang, Indonesia; Department of Neurology, Siloam Hospital Lippo Village, Tangerang, Indonesia
| | - D Takaliuang
- Pelita Harapan University, Faculty of Medicine, Tangerang, Indonesia; Department of Radiology, Siloam Hospital Lippo Village, Tangerang, Indonesia.
| | - A Erico
- Pelita Harapan University, Faculty of Medicine, Tangerang, Indonesia; Department of Radiology, Siloam Hospital Lippo Village, Tangerang, Indonesia
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Dahal P, Parajuli S. Magnetic resonance imaging findings in central nervous system tuberculosis: A pictorial review. Heliyon 2024; 10:e29779. [PMID: 38699716 PMCID: PMC11063446 DOI: 10.1016/j.heliyon.2024.e29779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 04/13/2024] [Accepted: 04/15/2024] [Indexed: 05/05/2024] Open
Abstract
Central nervous system (CNS) tuberculosis is a post-primary form of tuberculosis. It has high mortality and morbidity rates despite early diagnosis and treatment. CNS tuberculosis can manifest as subacute/chronic meningitis, parenchymal tuberculous lesions, and spinal tuberculosis. Hematogenous spread of tuberculous bacilli to the brain results in the development of so called "rich foci" on the pial surface, ependyma, and grey-white matter junction. Rupture of these "rich foci" into the subarachnoid space triggers an intense granulomatous inflammatory reaction. Tuberculous meningitis can manifest as leptomeningitis or pachymeningitis. Intracranial parenchymal tuberculous lesions may present as tuberculoma, tuberculous abscess, cerebritis, rhombencephalitis, and encephalopathy, with atypical presentations not uncommon. Complications of CNS tuberculosis encompass hydrocephalus, syrinx formation, vasculitis, infarcts, neuritis, and enduring neurological deficits. Post-contrast 3D fluid-attenuated inversion recovery (FLAIR) and post-contrast T1 spin-echo sequences excel in detecting tuberculous meningitis compared to other conventional magnetic resonance imaging (MRI) sequences. In proton magnetic resonance spectroscopy (PMRS), the presence of a lipid peak at 1.3 ppm is indicative of tuberculous lesions. Magnetization transfer (MT) imaging enhances the detection of tuberculous lesions, as the magnetization transfer ratio (MTR) of tuberculous pathologies, owing to their high lipid content, is lower than that in bacterial or fungal pathologies and higher than that in viral pathologies. This review article delves into the various typical and atypical imaging presentations of CNS tuberculosis in MRI, along with recent advances in imaging techniques.
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Affiliation(s)
- Prajwal Dahal
- Department of Radiology and Imaging, Grande International Hospital, Kathmandu, Nepal
| | - Sabina Parajuli
- Resident PGY-1 Pathology, Department of Pathology, Bir Hospital, Kathmandu, Nepal
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Sahara K, Shinno K, Sato K, Watari Y, Tamura T, Kudo E. A Case of Multiple Brain Tuberculomas in the Subarachnoid Cisterns: Recognition of Radiological Characteristics Regarding the Development of Paradoxical Response during Antituberculosis Treatment. NMC Case Rep J 2024; 11:93-98. [PMID: 38666034 PMCID: PMC11043798 DOI: 10.2176/jns-nmc.2023-0270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/30/2024] [Indexed: 04/28/2024] Open
Abstract
Brain tuberculoma and its occurrence within the subarachnoid cisterns is rare in Japan. Serological and cerebrospinal fluid (CSF) examinations and imaging findings lack specificity; thus, preoperative diagnosis is often challenging. This report presents the case of a 70-year-old woman admitted to our hospital with a one-month history of low-grade fever and altered mental status. Based on the CSF analysis and her history of latent tuberculosis infection seven years ago, she was strongly suspected of suffering from tuberculous meningitis (TBM). Consequently, the patient was enrolled in a clinical trial for antituberculosis treatment (ATT). CSF soluble interleukin-2 receptor level decreased from 2,926 U/mL on day 1 to 225 U/mL 42 days after initiating ATT. Her condition improved after five weeks; however, contrast-enhanced T1-weighted magnetic resonance imaging (MRI) revealed multiple enhanced lesions within the basal subarachnoid cisterns 25 days after admission. As the number and size of these lesions increased, a biopsy confirmed brain tuberculoma diagnosis, and the treatment was continued. In conclusion, when intracisternal scattered mass lesions are identified during TBM treatment, we should consider the possibility of tuberculoma developments arising from a paradoxical response (PR) during the treatment. Serial MRIs are crucial in monitoring PR development in cisternal tuberculomas, an extension of severe TBM. Finally, a PR can be effectively managed by continuing ATT with adjunctive corticosteroids.
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Affiliation(s)
- Kazuma Sahara
- Department of Neurosurgery, Tokushima Prefectural Central Hospital, Tokushima, Tokushima, Japan
| | - Kiyohito Shinno
- Department of Neurosurgery, Tokushima Prefectural Central Hospital, Tokushima, Tokushima, Japan
| | - Kenta Sato
- Department of Neurology, Tokushima Prefectural Central Hospital, Tokushima, Tokushima, Japan
| | - Yuya Watari
- Department of Neurosurgery, Tokushima Prefectural Central Hospital, Tokushima, Tokushima, Japan
| | - Tetsuya Tamura
- Department of Neurosurgery, Tokushima Prefectural Central Hospital, Tokushima, Tokushima, Japan
| | - Eiji Kudo
- Department of Pathology, Tokushima Prefectural Central Hospital, Tokushima, Tokushima, Japan
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Ma Q, Chen J, Kong X, Zeng Y, Chen Z, Liu H, Liu L, Lu S, Wang X. Interactions between CNS and immune cells in tuberculous meningitis. Front Immunol 2024; 15:1326859. [PMID: 38361935 PMCID: PMC10867975 DOI: 10.3389/fimmu.2024.1326859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/10/2024] [Indexed: 02/17/2024] Open
Abstract
The central nervous system (CNS) harbors its own special immune system composed of microglia in the parenchyma, CNS-associated macrophages (CAMs), dendritic cells, monocytes, and the barrier systems within the brain. Recently, advances in the immune cells in the CNS provided new insights to understand the development of tuberculous meningitis (TBM), which is the predominant form of Mycobacterium tuberculosis (M.tb) infection in the CNS and accompanied with high mortality and disability. The development of the CNS requires the protection of immune cells, including macrophages and microglia, during embryogenesis to ensure the accurate development of the CNS and immune response following pathogenic invasion. In this review, we summarize the current understanding on the CNS immune cells during the initiation and development of the TBM. We also explore the interactions of immune cells with the CNS in TBM. In the future, the combination of modern techniques should be applied to explore the role of immune cells of CNS in TBM.
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Affiliation(s)
| | | | | | | | | | | | | | - Shuihua Lu
- National Clinical Research Center for Infectious Disease, Shenzhen Third People's Hospital, Shenzhen, Guangdong, China
| | - Xiaomin Wang
- National Clinical Research Center for Infectious Disease, Shenzhen Third People's Hospital, Shenzhen, Guangdong, China
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Ono Y, Higashida K, Yamanouchi K, Nomura S, Hanamatsu Y, Saigo C, Tetsuka N, Shimohata T. Balamuthia mandrillaris amoebic encephalitis mimicking tuberculous meningitis. Neuropathology 2024; 44:68-75. [PMID: 37381626 DOI: 10.1111/neup.12932] [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: 04/09/2023] [Revised: 06/07/2023] [Accepted: 06/12/2023] [Indexed: 06/30/2023]
Abstract
A 76-year-old female with no apparent immunosuppressive conditions and no history of exposure to freshwater and international travel presented with headache and nausea 3 weeks before the presentation. On admission, her consciousness was E4V4V6. Cerebrospinal fluid analysis showed pleocytosis with mononuclear cell predominance, elevated protein, and decreased glucose. Despite antibiotic and antiviral therapy, her consciousness and neck stiffness gradually worsened, right eye-movement restriction appeared, and the right direct light reflex became absent. Brain magnetic resonance imaging revealed hydrocephalus in the inferior horn of the left lateral ventricle and meningeal enhancement around the brainstem and cerebellum. Tuberculous meningitis was suspected, and pyrazinamide, ethambutol, rifampicin, isoniazid, and dexamethasone were started. In addition, endoscopic biopsy was performed from the white matter around the inferior horn of the left lateral ventricle to exclude brain tumor. A brain biopsy specimen revealed eosinophilic round cytoplasm with vacuoles around blood vessels, and we diagnosed with amoebic encephalitis. We started azithromycin, flucytosine, rifampicin, and fluconazole, but her symptoms did not improve. She died 42 days after admission. In autopsy, the brain had not retained its structure due to autolysis. Hematoxylin and eosin staining of her brain biopsy specimen showed numerous amoebic cysts in the perivascular brain tissue. Analysis of the 16S ribosomal RNA region of amoebas from brain biopsy and autopsy specimens revealed a sequence consistent with Balamuthia mandrillaris. Amoebic meningoencephalitis can present with features characteristic of tuberculous meningitis, such as cranial nerve palsies, hydrocephalus, and basal meningeal enhancement. Difficulties in diagnosing amoebic meningoencephalitis are attributed to the following factors: (1) excluding tuberculous meningitis by microbial testing is difficult, (2) amoebic meningoencephalitis has low incidence and can occur without obvious exposure history, (3) invasive brain biopsy is essential in diagnosing amoebic meningoencephalitis. We should recognize the possibility of amoebic meningoencephalitis when evidence of tuberculosis meningitis cannot be demonstrated.
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Affiliation(s)
- Yoya Ono
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kazuhiro Higashida
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kanako Yamanouchi
- Department of Bioscience and Laboratory Medicine, Hirosaki University Graduate School of Health Sciences, Hirosaki, Japan
| | - Shusuke Nomura
- Department of Pathology and Translational Research, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yuki Hanamatsu
- Department of Pathology and Translational Research, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Chiemi Saigo
- Department of Pathology and Translational Research, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Nobuyuki Tetsuka
- Department of Infection Control, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takayoshi Shimohata
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
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Liu Q, Cao M, Shao N, Qin Y, Liu L, Zhang Q, Yang X. Development and validation of a new model for the early diagnosis of tuberculous meningitis in adults based on simple clinical and laboratory parameters. BMC Infect Dis 2023; 23:901. [PMID: 38129813 PMCID: PMC10740218 DOI: 10.1186/s12879-023-08922-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 12/15/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND The differential diagnosis between tuberculous meningitis (TBM) and viral meningitis (VM) or bacterial meningitis (BM) remains challenging in clinical practice, particularly in resource-limited settings. This study aimed to establish a diagnostic model that can accurately and early distinguish TBM from both VM and BM in adults based on simple clinical and laboratory parameters. METHODS Patients diagnosed with TBM or non-TBM (VM or BM) between January 2012 and October 2021 were retrospectively enrolled from the General Hospital (derivation cohort) and Branch Hospital (validation cohort) of Ningxia Medical University. Demographic characteristics, clinical symptoms, concomitant diseases, and cerebrospinal fluid (CSF) parameters were collated. Univariable logistic analysis was performed in the derivation cohort to identify significant variables (P < 0.05). A multivariable logistic regression model was constructed using these variables. We verified the performance including discrimination, calibration, and applicability of the model in both derivation and validation cohorts. RESULTS A total of 222 patients (70 TBM and 152 non-TBM [75 BM and 77 VM]) and 100 patients (32 TBM and 68 non-TBM [31 BM and 37 VM]) were enrolled as derivation and validation cohorts, respectively. The multivariable logistic regression model showed that disturbance of consciousness for > 5 days, weight loss > 5% of the original weight within 6 months, CSF lymphocyte ratio > 50%, CSF glucose concentration < 2.2 mmol/L, and secondary cerebral infarction were independently correlated with the diagnosis of TBM (P < 0.05). The nomogram model showed excellent discrimination (area under the curve 0.959 vs. 0.962) and great calibration (P-value in the Hosmer-Lemeshow test 0.128 vs. 0.863) in both derivation and validation cohorts. Clinical decision curve analysis showed that the model had good applicability in clinical practice and may benefit the entire population. CONCLUSIONS This multivariable diagnostic model may help clinicians in the early discrimination of TBM from VM and BM in adults based on simple clinical and laboratory parameters.
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Affiliation(s)
- Qiang Liu
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, 750004, Ningxia Province, China
- Graduate College of Ningxia Medical University, Yinchuan, 750004, Ningxia Province, China
| | - Meiling Cao
- Department of Internal Medicine, The Inner Mongolia Autonomous Region, The People's Hospital of Wushen Banner, Erdos, 017000, China
| | - Na Shao
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, 750004, Ningxia Province, China
| | - Yixin Qin
- Department of Neurology, The First People's Hospital of Yinchuan, Yinchuan, 750004, Ningxia Province, China
| | - Lu Liu
- Graduate College of Ningxia Medical University, Yinchuan, 750004, Ningxia Province, China
| | - Qing Zhang
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, 750004, Ningxia Province, China.
| | - Xiao Yang
- Department of Neurology, General Hospital of Ningxia Medical University, Ningxia Key Laboratory of Cerebrocranial Diseases, Incubation Base of National Key Laboratory, Yinchuan, 750004, Ningxia Province, China.
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Kimuda S, Kasozi D, Namombwe S, Gakuru J, Mugabi T, Kagimu E, Rutakingirwa MK, Leon KE, Chow F, Wasserman S, Boulware DR, Cresswell FV, Bahr NC. Advancing Diagnosis and Treatment in People Living with HIV and Tuberculosis Meningitis. Curr HIV/AIDS Rep 2023; 20:379-393. [PMID: 37947980 PMCID: PMC10719136 DOI: 10.1007/s11904-023-00678-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE OF REVIEW Tuberculous meningitis (TBM) is the most severe form of tuberculosis. Inadequate diagnostic testing and treatment regimens adapted from pulmonary tuberculosis without consideration of the unique nature of TBM are among the potential drivers. This review focuses on the progress being made in relation to both diagnosis and treatment of TBM, emphasizing promising future directions. RECENT FINDINGS The molecular assay GeneXpert MTB/Rif Ultra has improved sensitivity but has inadequate negative predictive value to "rule-out" TBM. Evaluations of tests focused on the host response and bacterial components are ongoing. Clinical trials are in progress to explore the roles of rifampin, fluoroquinolones, linezolid, and adjunctive aspirin. Though diagnosis has improved, novel modalities are being explored to improve the rapid diagnosis of TBM. Multiple ongoing clinical trials may change current therapies for TBM in the near future.
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Affiliation(s)
- Sarah Kimuda
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Derrick Kasozi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Suzan Namombwe
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Timothy Mugabi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Kristoffer E Leon
- Departments of Neurology and Medicine (Infectious Diseases), University of California San Francisco, San Francisco, CA, USA
| | - Felicia Chow
- Departments of Neurology and Medicine (Infectious Diseases), University of California San Francisco, San Francisco, CA, USA
| | - Sean Wasserman
- Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Fiona V Cresswell
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- HIV Interventions, MRC/UVRI-LSHTM Uganda Research Unit, Entebbe, Uganda
- Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, KS, USA.
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Fong TH, Shi W, Ruan G, Li S, Liu G, Yang L, Wu K, Fan J, Ng CL, Hu Y, Jiang H. Tuberculostearic acid incorporated predictive model contributes to the clinical diagnosis of tuberculous meningitis. iScience 2023; 26:107858. [PMID: 37766994 PMCID: PMC10520543 DOI: 10.1016/j.isci.2023.107858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 08/05/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
The conventional confirmation tests of tuberculous meningitis (TBM) are usually low in sensitivity, leading to high TBM mortality. Hence, sensitive methods for indicating the presence of bacilli are required. Tuberculostearic acid (TBSA), a constituent from Mycobacterium tuberculosis had been evaluated as a promising marker, but fails to demonstrate consistent results for definite TBM. This study retrospectively reviewed medical records of 113 TBM suspects, constructing a TBSA-combined scoring system based on multiple factors, which show sensitivity and specificity of 0.8148 and 0.8814, respectively, and the area under the receiver operating characteristic curve of 0.9010. Multivariate analyses revealed four co-predictive factors strongly associated with TBSA: extra-neural tuberculosis, basal meningeal enhancement, CSF glucose/Serum glucose <0.595, and coinfection in CNS (Total). The subsequent machine learning-based validation showed correspondent importance to factors in the TBSA model. This study demonstrates a simple scoring system to facilitate TBM prediction, yield reliable diagnoses and allow timely treatment initiation.
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Affiliation(s)
- Tsz Hei Fong
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Wangpan Shi
- The First Clinical Medical School, Southern Medical University, Guangzhou 510515, China
| | - Guohui Ruan
- School of Biomedical Engineering, Southern Medical University, Guangzhou 510515, China
| | - Siyi Li
- The First Clinical Medical School, Southern Medical University, Guangzhou 510515, China
| | - Guanghui Liu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Leyun Yang
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, DC 20057-1484, USA
| | - Kaibin Wu
- School of Biomedical Engineering, Southern Medical University, Guangzhou 510515, China
| | - Jingxian Fan
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Chung Lam Ng
- The First Clinical Medical School, Southern Medical University, Guangzhou 510515, China
| | - Yafang Hu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Haishan Jiang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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Donovan J, Bang ND, Imran D, Nghia HDT, Burhan E, Huong DTT, Hiep NTT, Ngoc LHB, Thanh DV, Thanh NT, Wardhani ALS, Maharani K, Gasmara CP, Hanh NHH, Oanh PKN, Estiasari R, Thu DDA, Kusumaningrum A, Dung LT, Giang DC, Ha DTM, Lan NH, Chau NVV, Nguyet NTM, Geskus RB, Thuong NTT, Kestelyn E, Hamers RL, Phu NH, Thwaites GE. Adjunctive Dexamethasone for Tuberculous Meningitis in HIV-Positive Adults. N Engl J Med 2023; 389:1357-1367. [PMID: 37819954 PMCID: PMC7615197 DOI: 10.1056/nejmoa2216218] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Adjunctive glucocorticoids are widely used to treat human immunodeficiency virus (HIV)-associated tuberculous meningitis despite limited data supporting their safety and efficacy. METHODS We conducted a double-blind, randomized, placebo-controlled trial involving HIV-positive adults (≥18 years of age) with tuberculous meningitis in Vietnam and Indonesia. Participants were randomly assigned to receive a 6-to-8-week tapering course of either dexamethasone or placebo in addition to 12 months of antituberculosis chemotherapy. The primary end point was death from any cause during the 12 months after randomization. RESULTS A total of 520 adults were randomly assigned to receive either dexamethasone (263 participants) or placebo (257 participants). The median age was 36 years; 255 of 520 participants (49.0%) had never received antiretroviral therapy, and 251 of 484 participants (51.9%) with available data had a baseline CD4 count of 50 cells per cubic millimeter or less. Six participants withdrew from the trial, and five were lost to follow-up. During the 12 months of follow-up, death occurred in 116 of 263 participants (44.1%) in the dexamethasone group and in 126 of 257 participants (49.0%) in the placebo group (hazard ratio, 0.85; 95% confidence interval, 0.66 to 1.10; P = 0.22). Prespecified analyses did not reveal a subgroup that clearly benefited from dexamethasone. The incidence of secondary end-point events, including cases of immune reconstitution inflammatory syndrome during the first 6 months, was similar in the two trial groups. The numbers of participants with at least one serious adverse event were similar in the dexamethasone group (192 of 263 participants [73.0%]) and the placebo group (194 of 257 participants [75.5%]) (P = 0.52). CONCLUSIONS Among HIV-positive adults with tuberculous meningitis, adjunctive dexamethasone, as compared with placebo, did not confer a benefit with respect to survival or any secondary end point. (Funded by the Wellcome Trust; ACT HIV ClinicalTrials.gov number, NCT03092817.).
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Affiliation(s)
- Joseph Donovan
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Nguyen D Bang
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Darma Imran
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Ho D T Nghia
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Erlina Burhan
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Dau T T Huong
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Nguyen T T Hiep
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Lam H B Ngoc
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Dang V Thanh
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Nguyen T Thanh
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Anna L S Wardhani
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Kartika Maharani
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Cakra P Gasmara
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Nguyen H H Hanh
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Pham K N Oanh
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Riwanti Estiasari
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Do D A Thu
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Ardiana Kusumaningrum
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Le T Dung
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Do C Giang
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Dang T M Ha
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Nguyen H Lan
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Nguyen V V Chau
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Nguyen T M Nguyet
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Ronald B Geskus
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Nguyen T T Thuong
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Evelyne Kestelyn
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Raph L Hamers
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Nguyen H Phu
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Guy E Thwaites
- From the Oxford University Clinical Research Unit (J.D., D.T.T.H., N.T.T.H., L.H.B.N., D.V.T., N.T.T., D.D.A.T., N.T.M.N., R.B.G., N.T.T.T., E.K., N.H.P., G.E.T.), Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease (N.D.B., L.T.D., D.C.G., D.T.M.H., N.H.L.), the Hospital for Tropical Diseases (H.D.T.N., N.T.T., N.H.H.H., P.K.N.O., N.V.V.C.), Pham Ngoc Thach University of Medicine (H.D.T.N.), and the School of Medicine, Vietnam National University of Ho Chi Minh City (N.H.H.H., N.H.P.) - all in Ho Chi Minh City, Vietnam; the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford (J.D., R.B.G., N.T.T.T., E.K., R.L.H., N.H.P., G.E.T.), and London School of Hygiene and Tropical Medicine, London (J.D.) - both in the United Kingdom; and Dr. Cipto Mangunkusumo National Reference Hospital (D.I., K.M., C.P.G., R.E., A.K.), Persahabatan National Respiratory Referral Hospital (E.B.), and Oxford University Clinical Research Unit Indonesia (A.L.S.W., R.L.H.), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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Sajjad F, Baloch MF, Ashraf M, Gillespie CS, Umar H, Zafar A, Zulfiqar J, Ullah I, Ali S, Ashraf N. Focal dystonia and ataxic hemiparesis as the initial presentation of a thalamic tuberculoma: A diagnostic challenge in an immunocompetent pediatric patient. Surg Neurol Int 2023; 14:350. [PMID: 37810325 PMCID: PMC10559370 DOI: 10.25259/sni_581_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 09/05/2023] [Indexed: 10/10/2023] Open
Abstract
Background Central nervous system (CNS) tuberculomas are rare and account for approximately 1% of all tuberculosis (TB) cases. These intracranial lesions are more commonly observed in immunocompromised individuals, often as part of disseminated miliary TB or after latent infection reactivation. This case report presents the occurrence of a thalamic tuberculoma in an immunocompetent girl. Case Description An 11-year-old girl presented with a 3-month history of progressive right-sided ataxic hemiparesis, hand dystonia/thalamic hand, and headache. There was only a mildly elevated erythrocyte sedimentation rate (25 mm/h.), and her remaining biochemistry and vitals were unremarkable. Magnetic resonance imaging (MRI) brain revealed an ill-defined intra-axial heterogeneous lobulated lesion with crenated margins involving the thalamus and the posterior limb of the internal capsule with significant vasogenic edema. Given the clinical picture, the working diagnosis was a high-grade brain tumor. Due to the absence of a viable operative corridor for a meaningful resection and the diagnostic uncertainty, a stereotactic biopsy was performed, and histopathological analysis confirmed the presence of granulomas consistent with TB. A human immunodeficiency virus test (negative) and interferon-gamma release assay (positive) were then obtained. The patient was commenced on a regimen of anti-TB drugs with a tapering steroid dose. At 8 months, her most recent MRI showed a significant reduction in the size of her tuberculoma, and there is a complete resolution of her hand dystonia and hemiparesis to allow for independence in her activities of daily living. Conclusion This report emphasizes the importance of considering causes other than degenerative, vascular, or neoplasms in patients with hemiparesis with dystonia. CNS tuberculomas can present as such without prior history or specific clinical symptoms of TB, making them a diagnostic challenge. In cases with such uncertainty regarding the nature of an intracranial lesion and the role of resection, a stereotactic biopsy is invaluable.
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Affiliation(s)
- Fauzia Sajjad
- Department of Neurosurgery, Services Institute of Medical Sciences, Lahore, Pakistan
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | | | - Mohammad Ashraf
- Wolfson School of Medicine, University of Glasgow, Scotland, United Kingdom
| | - Conor S. Gillespie
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Hira Umar
- Department of Neurosurgery, Services Institute of Medical Sciences, Lahore, Pakistan
| | - Ammara Zafar
- Department of Neurosurgery, Services Institute of Medical Sciences, Lahore, Pakistan
| | - Javaria Zulfiqar
- Department of Neurosurgery, Services Institute of Medical Sciences, Lahore, Pakistan
| | - Imdad Ullah
- Department of Neurosurgery, Services Institute of Medical Sciences, Lahore, Pakistan
| | - Sundus Ali
- Department of Neurosurgery, King Edward Medical University, Mayo Hospital, Lahore, Pakistan
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Katsumi S, Shinohara A, Arimura D, Obata S, Ikegami T, Saito M. Paradoxical Response after MISt for Spinal Tuberculosis Worsened Neurologic Symptoms: A Case Report. Spine Surg Relat Res 2023; 7:458-460. [PMID: 37841034 PMCID: PMC10569806 DOI: 10.22603/ssrr.2023-0003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/06/2023] [Indexed: 10/17/2023] Open
Affiliation(s)
- Shunsuke Katsumi
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Akira Shinohara
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Daigo Arimura
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shintaro Obata
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Taku Ikegami
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Mitsuru Saito
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, Tokyo, Japan
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13
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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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Laya BF, Concepcion NDP, Andronikou S, Abdul Manaf Z, Atienza MIM, Sodhi KS. Imaging recommendations and algorithms for pediatric tuberculosis: part 2-extrathoracic tuberculosis. Pediatr Radiol 2023; 53:1782-1798. [PMID: 37074457 DOI: 10.1007/s00247-023-05650-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 04/20/2023]
Abstract
Despite advances in diagnosis and treatment in recent years, tuberculosis (TB) remains a global health concern. Children are amongst the most vulnerable groups affected by this disease. Although TB primarily involves the lungs and mediastinal lymph nodes, it can affect virtually any organ system of the body. Along with clinical history combined with physical examination and laboratory tests, various medical imaging tools help establish the diagnosis. Medical imaging tests are also helpful for follow-up during therapy, to assess complications and exclude other underlying pathologies. This article aims to discuss the utility, strengths and limitations of medical imaging tools in the evaluation of suspected extrathoracic TB in the pediatric population. Imaging recommendations for the diagnosis will be presented along with practical and evidence-based imaging algorithms to serve as a guide for both radiologists and clinicians.
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Affiliation(s)
- Bernard F Laya
- Section of Pediatric Radiology, Institute of Radiology, St. Luke's Medical Center - Quezon City, 279 E. Rodriguez Sr. Ave., Quezon City, 1112, Philippines
- Department of Radiology, St. Luke's Medical Center College of Medicine William H. Quasha Memorial, Quezon City, Philippines
- Section of Pediatric Radiology, Institute of Radiology, St. Luke's Medical Center - Global City, Rizal Drive cor. 32nd St. and 5th Ave., 1634, Taguig, Philippines
| | - Nathan David P Concepcion
- Section of Pediatric Radiology, Institute of Radiology, St. Luke's Medical Center - Quezon City, 279 E. Rodriguez Sr. Ave., Quezon City, 1112, Philippines.
- Section of Pediatric Radiology, Institute of Radiology, St. Luke's Medical Center - Global City, Rizal Drive cor. 32nd St. and 5th Ave., 1634, Taguig, Philippines.
| | - Savvas Andronikou
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, and the Children's Hospital of Philadelphia, Philadelphia, USA
| | - Zaleha Abdul Manaf
- Al Islam Specialist Hospital, Kuala Lumpur, Malaysia
- Faculty of Medicine, Bioscience & Nursing, MAHSA University, Kuala Lumpur, Malaysia
| | - Maria Isabel M Atienza
- Institute of Pediatrics and Child Health, St Luke's Medical Center - Quezon City, 279 E. Rodriguez Sr. Ave., Quezon City, 1112, Philippines
- Department of Pediatrics, St. Luke's Medical Center College of Medicine William H. Quasha Memorial, Quezon City, Philippines
| | - Kushaljit Singh Sodhi
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
- Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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Ma H, Wang Y, Liu J, Du L, Wang X, Wang Y. Misdiagnosis of Systemic Lupus Erythematosus Combined with Urinary Tuberculosis Leading to Tuberculous Meningitis: A Case Report and Literature Review. Infect Drug Resist 2023; 16:4677-4686. [PMID: 37484903 PMCID: PMC10362915 DOI: 10.2147/idr.s420833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 07/05/2023] [Indexed: 07/25/2023] Open
Abstract
Purpose To explore the lessons learned from the misdiagnosis of systemic lupus erythematosus (SLE) combined with urinary tuberculosis leading to tuberculous meningitis (TBM) and the diagnosis and treatment of TBM through case reports and review of the literature. Methods We report a case of an SLE patient presenting with urinary tuberculosis infection misdiagnosed as interstitial cystitis and complex urinary tract infection, who developed neurological infection after a cystocentesis biopsy and was eventually diagnosed with TBM. In addition, all cases of SLE combined with TBM from January 1975 to February 2022 were summarised and reviewed to compare current diagnostic and treatment strategies for the disease. Results The patient suddenly developed neurological symptoms after cystocentesis biopsy, and we detected Mycobacterium tuberculosis in the macrogenomic next-generation sequence (mNGS) of the cerebrospinal fluid. We therefore excluded interstitial cystitis and neuropsychiatric lupus to confirm the diagnosis of Mycobacterium tuberculosis infection leading to urinary tract tuberculosis and TBM. Conclusion SLE is complicated by urological tuberculosis, surgery triggering hematogenous dissemination leading to tuberculous meningitis. At the same time, the lack of specificity in the clinical presentation of patients makes it easy to misdiagnose neuropsychiatric lupus and delay treatment, so timely and accurate diagnosis and effective anti-tuberculosis treatment are essential.
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Affiliation(s)
- Honglei Ma
- Affiliated Hospital of Weifang Medical University, School of Clinical Medicine, Weifang Medical University, Weifang, Shandong Province, People’s Republic of China
| | - Yuqun Wang
- Affiliated Hospital of Weifang Medical University, School of Clinical Medicine, Weifang Medical University, Weifang, Shandong Province, People’s Republic of China
| | - Junhong Liu
- Affiliated Hospital of Weifang Medical University, School of Clinical Medicine, Weifang Medical University, Weifang, Shandong Province, People’s Republic of China
| | - Linping Du
- Affiliated Hospital of Weifang Medical University, School of Clinical Medicine, Weifang Medical University, Weifang, Shandong Province, People’s Republic of China
| | - Xiaodong Wang
- Rheumatology and Immunology, Affiliated Hospital of Weifang Medical University, Weifang, Shandong Province, People’s Republic of China
| | - Yingliang Wang
- Rheumatology and Immunology, Affiliated Hospital of Weifang Medical University, Weifang, Shandong Province, People’s Republic of China
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Reynaldo B, Illahi MN, Iqbal T, Nayyar SM, Nashwan AJ. Tuberculous meningitis initially manifesting as acute areflexic paraparesis: A case report. Clin Case Rep 2023; 11:e7698. [PMID: 37476602 PMCID: PMC10354349 DOI: 10.1002/ccr3.7698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/25/2023] [Accepted: 07/04/2023] [Indexed: 07/22/2023] Open
Abstract
Key Clinical Message TBM has a very high rate of adverse sequelae if not treated immediately. Diagnosing can be challenging due to overlapping symptoms with other disease processes, and diagnostic tests are often inconclusive. Abstract A 20-year-old man experienced progressive paraplegia and urinary retention. After extensive laboratory and imaging evaluation for tuberculous meningitis and alternative diagnoses, spinal MRI showed features suggestive of arachnoiditis. He was treated empirically with anti-tuberculosis drugs and corticosteroids. This led to significant improvement and eventual recovery.
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Affiliation(s)
- Balintona Reynaldo
- Department of Medicine, Hazm Mebaireek General HospitalHamad Medical CorporationDohaQatar
| | - Memon Noor Illahi
- Department of Medicine, Hazm Mebaireek General HospitalHamad Medical CorporationDohaQatar
| | - Tarab Iqbal
- Department of Medicine, Hazm Mebaireek General HospitalHamad Medical CorporationDohaQatar
| | - Sidra M. Nayyar
- Department of Medicine, Hazm Mebaireek General HospitalHamad Medical CorporationDohaQatar
| | - Abdulqadir J. Nashwan
- Department of Nursing, Hazm Mebaireek General HospitalHamad Medical CorporationDohaQatar
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Martinez-Poles J, Saldaña-Díaz AI, Esteban J, Lara-Almunia M, Vizarreta Figueroa AT, Martín-Gil L, Cebrián-Escudero J, Fernández-Ferro J. Meningoencephalitis due to Mycobacterium lentiflavum in an immunocompromised patient: Case report. Eur J Neurol 2023; 30:1152-1154. [PMID: 36478338 DOI: 10.1111/ene.15659] [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: 09/19/2022] [Revised: 11/23/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022]
Abstract
The first case of meningoencephalitis due to Mycobacterium lentiflavum in an immunocompromised patient is reported. Clinical and radiological characteristics are described, as well as the treatment and prognosis of the patient.
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Affiliation(s)
- Javier Martinez-Poles
- Servicio Integrado de Neurología, Hospital Universitario Infanta Elena, Hospital Universitario Rey Juan Carlos, Hospital Universitario General de Villalba, Madrid, Spain
| | - Ana Isabel Saldaña-Díaz
- Servicio Integrado de Neurología, Hospital Universitario Infanta Elena, Hospital Universitario Rey Juan Carlos, Hospital Universitario General de Villalba, Madrid, Spain
| | - Jaime Esteban
- Servicio de Microbiología Clínica, IIS-Fundación Jiménez Díaz, UAM, CIBERINFEC-CIBER de Enfermedades Infecciosas, Madrid, Spain
| | - Mónica Lara-Almunia
- Servicio de Neurocirugía, Hospital Universitario Rey Juan Carlos, Madrid, Spain
| | | | - Leticia Martín-Gil
- Servicio Integrado de Neurología, Hospital Universitario Infanta Elena, Hospital Universitario Rey Juan Carlos, Hospital Universitario General de Villalba, Madrid, Spain
| | - José Cebrián-Escudero
- Servicio Integrado de Neurología, Hospital Universitario Infanta Elena, Hospital Universitario Rey Juan Carlos, Hospital Universitario General de Villalba, Madrid, Spain
| | - José Fernández-Ferro
- Servicio Integrado de Neurología, Hospital Universitario Infanta Elena, Hospital Universitario Rey Juan Carlos, Hospital Universitario General de Villalba, Madrid, Spain
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18
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Rochtus A, Lagae L, Jansen K, De Somer L, Vermeulen F, de Zegher F. Reversible Hypothalamic Obesity in a Girl with Suprasellar Tuberculoma. Horm Res Paediatr 2023; 97:165-171. [PMID: 36977392 DOI: 10.1159/000530384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
INTRODUCTION Suprasellar tuberculoma are extremely rare in children and most of those patients present with headache, vomiting, visual disturbances, and hypofunction of the pituitary gland. In this case report, we present a girl with tuberculosis, who developed significant weight gain in combination with pituitary dysfunction, which recovered after antituberculosis treatment. CASE PRESENTATION An 11-year old girl presented with headache, fever and anorexia that progressively evolved into an encephalopathic status with cranial nerves III and VI paresis. Brain MRI showed meningeal contrast capture along cranial nerves II (including optic chiasm), III, V and VI bilaterally and multiple contrast enhancing brain parenchyma lesions. Tuberculin skin test was negative but interferon-gamma release assay was positive. The clinical and radiological working diagnosis was consistent with tuberculous meningoencephalitis. Pulse corticosteroids for 3 days and quadruple antituberculosis therapy were started and the girl demonstrated obvious improvement of her neurological symptoms. However, after a few months of therapy she developed remarkable weight gain (+20 kg in 1 year) and growth arrest. Her hormone profile revealed insulin resistance (homeostasis model assessment-estimated insulin resistance [HOMA-IR] 6.8) despite putative growth hormone deficiency (circulating insulin-like growth factor-I [IGF-I] 104 μg/L [-2.4 SD]). Follow-up brain MRI showed a decrease in basal meningitis, but increased parenchymal lesions in the suprasellar region extending medially into the nucleus lentiformis, with now a voluminous tuberculoma at this site. Antituberculosis treatment was continued for a total of 18 months. The patient improved clinically, she regained her pre-illness Body Mass Index (BMI) SDS and her growth rate increased slightly. On the hormonal side, disappearance of insulin resistance (HOMA-IR 2.5) and an increase in IGF-I (175 μg/L, -1.4 SD) was noted, and her last brain MRI showed a remarkable volume reduction of the suprasellar tuberculoma. CONCLUSION Suprasellar tuberculoma can have a very dynamic presentation during the active stage of the disease, which can be reversed by prolonged antituberculosis treatment. Previous studies showed that the tuberculous process can also cause long term and irreversible changes in the hypothalamic-pituitary axis. Prospective studies are however needed in the pediatric population to know the exact incidence and type of pituitary dysfunction.
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Affiliation(s)
- Anne Rochtus
- Department of Development and Regeneration, Section Pediatric Endocrinology, University Hospital Leuven, Leuven, Belgium
- Department of Development and Regeneration, Section Pediatric Neurology, University Hospital Leuven, Leuven, Belgium
| | - Lieven Lagae
- Department of Development and Regeneration, Section Pediatric Neurology, University Hospital Leuven, Leuven, Belgium
| | - Katrien Jansen
- Department of Development and Regeneration, Section Pediatric Neurology, University Hospital Leuven, Leuven, Belgium
| | - Lien De Somer
- Department of Microbiology, Immunology and Transplantation, Section Pediatric Rheumatology, University Hospital Leuven, Leuven, Belgium
| | - François Vermeulen
- Department of Development and Regeneration, Section Pediatric Infectiology, University Hospital Leuven, Leuven, Belgium
| | - Francis de Zegher
- Department of Development and Regeneration, Section Pediatric Endocrinology, University Hospital Leuven, Leuven, Belgium
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19
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Hu N, Zhang L, Yang X, Fu H, Cui L, Liu M. Facial onset sensory and motor neuronopathy (FOSMN syndrome): Cases series and systematic review. Neurol Sci 2023; 44:1969-1978. [PMID: 36864244 DOI: 10.1007/s10072-023-06703-1] [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: 12/30/2022] [Accepted: 02/19/2023] [Indexed: 03/04/2023]
Abstract
OBJECTIVE To provide new and comprehensive evidence for diagnosis and management of FOSMN syndrome. METHODS We reviewed our database to identify patients with FOSMN syndrome. Online database including PubMed, EMBASE, and OVID were also searched for relevant cases. RESULTS We identified a total of 71 cases, including 4 cases from our database and 67 ones from online searching. A predominance of male was observed [44 (62.0%)] with median onset age of 53 (range: 7-75) years old. The median (range) disease duration was 60 (3-552) months at the time of the visit. The initial symptoms could be sensory deficits in face (80.3%) or oral cavity (4.2%), bulbar paralysis (7.0%), dysosmia (1.4%), dysgeusia (4.2%), weakness or numbness of upper limbs (5.6%), or lower limbs (1.4%). Abnormal blink reflex was presented in 64 (90.1%) patients. CSF tests showed elevated protein level in 5 (7.0%) patients. Six (8.5%) patients had MND-related gene mutation. Five (7.0%) patients showed transient responsiveness to immunosuppressive therapy, then deteriorated relentlessly. Fourteen (19.7%) patients died, with an average survival time of around 4 years. Among them, five patients died of respiratory insufficiency. CONCLUSION The age of onset, progress of disease course, and prognosis of FOSMN syndrome could be varied significantly. The prerequisites of diagnosis were progressive and asymmetric lower motor neuron dysfunction, with sensory dysfunction which usually showed in face at the onset. Immunosuppressive therapy could be tried in some patients with suspected inflammatory clues. In general, FOSMN syndrome tended to be motor neuron disease with sensory involvement.
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Affiliation(s)
- Nan Hu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 100730, Beijing, China
| | - Lei Zhang
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 100730, Beijing, China
| | - Xunzhe Yang
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 100730, Beijing, China
| | - Hanhui Fu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 100730, Beijing, China
| | - Liying Cui
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 100730, Beijing, China
| | - Mingsheng Liu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 100730, Beijing, China.
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20
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Seid G, Alemu A, Dagne B, Gamtesa DF. Microbiological diagnosis and mortality of tuberculosis meningitis: Systematic review and meta-analysis. PLoS One 2023; 18:e0279203. [PMID: 36795648 PMCID: PMC9934382 DOI: 10.1371/journal.pone.0279203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 12/01/2022] [Indexed: 02/17/2023] Open
Abstract
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.
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Affiliation(s)
- Getachew Seid
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ayinalem Alemu
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Biniyam Dagne
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
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21
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Swamy SBG, Jaikumar V, Nagaraj NM, Khandelwal S. Intracranial giant tuberculoma: A 7-year institutional experience and literature review. Clin Neurol Neurosurg 2023; 225:107593. [PMID: 36701938 DOI: 10.1016/j.clineuro.2023.107593] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 12/07/2022] [Accepted: 01/10/2023] [Indexed: 01/18/2023]
Abstract
BACKGROUND Intracranial tuberculomas are infrequent with a lower morbidity and mortality compared to tubercular meningitis. Giant intracranial tuberculomas are rarer but important differentials for intracranial space-occupying lesions causing focal neurological deficits depending on anatomical location and size. METHODS Histopathologically confirmed giant intracranial tuberculomas selected based on institutional size criteria (<12 Years-old: ≥25 mm; 12-18 Years-old: ≥35 mm; ≥18 Years-old: ≥40 mm) were retrospectively reviewed and analyzed for clinical features, radiology, surgical management, and outcomes in patients admitted from 2015 to 2022. RESULTS Ten patients were included (Males:Females = 3:7; Age: 8-68 Years, Average: 30.1 Years). Mean duration of symptoms was 2.84 months. Two patients demonstrated active systemic tuberculosis. Previous tubercular infections included pulmonary involvement in four, meningeal in three, and a cerebellar tuberculoma in one patient. Cerebrospinal fluid analysis in five patients demonstrated no tubercle bacilli. Seven lesions were supratentorial and three infratentorial. Giant tuberculomas demonstrated profound T2 hypointensity, sub-marginal T2 hyperintense crescents, and significant perilesional vasogenic edema. Craniotomy and excision were mainstay except in one case treated only with ventriculoperitoneal shunting. Three additional patients underwent ventriculoperitoneal shunting for hydrocephalus. One patient died from aspiration pneumonia and sepsis following a postoperative seizure. Anti-Tubercular Therapy (ATT) was advised for 18 months. Follow up ranged from 4 to 18 months. One patient was medically managed for ATT-induced hepatitis, hepatic encephalopathy, and coincidental paradoxical reaction. Remainder of patients showed complete resolution of symptomatology and absence of new symptoms till latest follow up. CONCLUSION Clinical course of giant tuberculomas differ from non-giant variants in characteristic radiology, more intensive ATT, and possibility for partial debulking/excision.
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Affiliation(s)
- Srihari Bangalore Gangadhar Swamy
- Department of Neurosurgery, Bangalore Medical College and Research Institute, KR Road, Near Fort, Bengaluru, Karnataka State, India.
| | - Vinay Jaikumar
- Affiliated with Department of Neurosurgery, Bangalore Medical College and Research Institute, KR Road, Near Fort, Bengaluru, Karnataka State, India.
| | - Nagarjun Maulyavantham Nagaraj
- Department of Neurosurgery, Bangalore Medical College and Research Institute, KR Road, Near Fort, Bengaluru, Karnataka State, India.
| | - Sandesh Khandelwal
- Department of Neurosurgery, Bangalore Medical College and Research Institute, KR Road, Near Fort, Bengaluru, Karnataka State, India.
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22
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Corniola MV, Egervari K, Vargas MI, Meling TR. A tumor like no other. J Neurosurg Sci 2023; 67:130-132. [PMID: 33709671 DOI: 10.23736/s0390-5616.21.05345-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Marco V Corniola
- Department of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland - .,Faculty of Medicine, University of Geneva, Geneva, Switzerland - .,Department of Neurosurgery, Centre Hospitalier Universitaire de Rennes, Rennes, France - .,MediCIS Research Group, INSERM UR1, UMR 1099 LTSI, Rennes, France -
| | - Kristof Egervari
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Department of Pathology and Immunology, Service of Clinical Pathology, Geneva University Hospitals, Geneva, Switzerland
| | - Maria I Vargas
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Department of Radiology, Geneva University Hospitals, Geneva, Switzerland
| | - Torstein R Meling
- Department of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
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23
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Cherraqi A, Haddad SE, Abide Z, Messaoud O, Lrhorfi N, Allali N, Chat L. Cerebral tuberculoma and convulsion in infants: A case report. Radiol Case Rep 2023; 18:974-978. [PMID: 36636484 PMCID: PMC9829549 DOI: 10.1016/j.radcr.2022.11.082] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/18/2022] [Accepted: 11/29/2022] [Indexed: 01/06/2023] Open
Abstract
Tuberculosis of the central nervous system is the second most common site after tuberculous meningitis. It represents 0.2% of intracranial expansive lesions in some Western countries compared to 10%-30% in developing countries. We report the case of an infant of 1 year and 2 months old who presented for 15 days with convulsions with asthenia, hypotonia, without fever. The clinical examination and laboratory workup were without abnormalities. His father had ongoing pulmonary tuberculosis, but the infant had no clinical or radiological signs of pulmonary tuberculosis. A brain MRI was showed multiple punctiform brain lesions, suggesting intracerebral tuberculomas in the first place, given the clinical and radiological appearance and the father's history of tuberculosis. The patient was put on anti-convulsant and antibacillary treatment. Through this case, we can see the clinical and radiological polymorphism of cerebral tuberculoma. The diagnosis of certainty remains anatomopathological. The prognosis is poor when it is detected late.
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24
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Muacevic A, Adler JR, LNU P, Sharma K, Sharma A, Sharma N, Modi M. Comparison of Protein B Polymerase Chain Reaction (PCR) With IS6110 PCR for Diagnosis of Tuberculous Meningitis Patients. Cureus 2023; 15:e33783. [PMID: 36798623 PMCID: PMC9926138 DOI: 10.7759/cureus.33783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2023] [Indexed: 01/16/2023] Open
Abstract
Purpose Tuberculous meningitis (TBM) is a diagnostic challenge. With the conventional staining and culture techniques being too insensitive and time-consuming, and the commercial detection systems being costly, polymerase chain reaction (PCR) seems lucrative for routine laboratories. The purpose of this study was to evaluate the diagnostic potential of protein b antigen polymerase chain reaction (Pab PCR) for TBM, in comparison to IS6110. Another purpose was to compute a cut-off at which adenosine deaminase (ADA) could diagnose TBM. Material and methods This is a prospective case-control study to measure the diagnostic accuracy of PCR, BACTEC culture, Lowenstein-Jensen (LJ) culture, ADA, and acid-fast bacilli (AFB) smear tests in TBM. CSF from 50 TBM patients (10 confirmed, 40 clinically suspected) and 40 controls was subjected to Pab PCR and IS6110 PCR, and performance was compared against culture and composite reference standards. Results The overall sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of Pab PCR in diagnosing TBM were 82%, 100%, 100%, and 81.63%, respectively, and that of IS6110 PCR were 74%, 100%, 100%, and 75.47%, respectively. Both PCRs outperformed culture (p<0.001). Though performance of both PCRs was comparable (p=0.335) with excellent agreement (k=0.86), Pab PCR detected four additional cases, one culture-positive and three culture-negative clinically suspected. ADA of 6.5 IU/L was able to differentiate between TBM and non-TBM with 86% sensitivity and 63% specificity. Conclusions Molecular tools such as PCR have the potential to increase the clinician's ability to diagnose tuberculous meningitis. Pab PCR is a rapid and reliable method for diagnosing TBM in routine microbiology laboratories.
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25
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Im H, Kim T, Na S, Song IU, Kim SH, Oh YS, Oh J, Kim W. Low serum complement level is associated with higher mortality in tuberculous meningitis: a retrospective cohort study. ENCEPHALITIS 2023; 3:7-14. [PMID: 37469713 PMCID: PMC10295820 DOI: 10.47936/encephalitis.2022.00059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/22/2022] [Accepted: 09/22/2022] [Indexed: 07/21/2023] Open
Abstract
Purpose We evaluated the associations between serum complement levels and tuberculous meningitis (TBM), bacterial meningitis (BM), and viral meningitis (VM), as well as the association between serum complement levels and mortality in TBM. Methods Background information and blood/cerebrospinal fluid analysis results were collected from 2009 to 2019. Patients who had serum complement level data collected at admission and who were diagnosed with TBM (n = 97), BM (n = 31), or VM (n = 557) were enrolled. Results Initial serum complement levels were significantly lower in the TBM group than the VM group in both the total population and the propensity score-matched population. In the TBM and VM groups, compared to patients with initial highest-quartile C4 level, patients in the lowest quartile (C4 < 24.3 mg/dL) had significantly greater odds of TBM diagnosis (odds ratio, 2.2; 95% confidence interval, 1.0-4.5; p = 0.038). In the TBM group, patients with the lowest-quartile C3 level (<96.9 mg/dL) experienced a significantly higher 90-day mortality rate compared to other TBM patients (hazard ratio, 19.0; 95% confidence interval, 2.1-167.4.5; p = 0.008). Conclusion Both serum C3 and C4 levels were significantly lower in the TBM group than in the VM group. TBM patients with lower serum C3 level had a significantly higher mortality rate than those with higher C3 level.
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Affiliation(s)
- Hansol Im
- Department of Neurology, The Catholic University of Korea, Incheon St. Mary’s Hospital, Seoul, Korea
| | - Taewon Kim
- Department of Neurology, The Catholic University of Korea, Incheon St. Mary’s Hospital, Seoul, Korea
| | - Seunghee Na
- Department of Neurology, The Catholic University of Korea, Incheon St. Mary’s Hospital, Seoul, Korea
| | - In-Uk Song
- Department of Neurology, The Catholic University of Korea, Incheon St. Mary’s Hospital, Seoul, Korea
| | - Seong-Hoon Kim
- Department of Neurology, The Catholic University of Korea, Uijeongbu St. Mary’s Hospital, Seoul, Korea
| | - Yoon-Sang Oh
- Department of Neurology, The Catholic University of Korea, Uijeongbu St. Mary’s Hospital, Seoul, Korea
| | - Juhee Oh
- Department of Neurology, The Catholic University of Korea, St. Vincent’s Hospital, Seoul, Korea
| | - Woojun Kim
- Department of Neurology, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea
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Ibrahim EAA, Ahmed Hamza Mohammed NIM, Abbasher Hussien Mohamed Ahmed K, A. Manhal GA, Mahmmoud Fadelallah Eljack M, Tahir MJ. The pattern of neurological manifestations of tuberculosis among adult patients attending multineurological centres and hospitals in Sudan: A hospital-based cross-sectional study. Health Sci Rep 2023; 6:e1068. [PMID: 36698702 PMCID: PMC9852676 DOI: 10.1002/hsr2.1068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 01/22/2023] Open
Abstract
Background Tuberculosis (TB) can involve almost any organ of the body. In the central nervous system (CNS), it can cause Pott's disease, meningitis, tuberculoma, abscess, or other manifestations. Tuberculosis is rampant in the developing world and has become a significant public health menace with the human immunodeficiency virus (HIV) dissemination. This study aimed to determine the frequency of neurological manifestations of tuberculosis among adult Sudanese patients. Methodology A hospital-based cross-sectional study carried out in the period from September to December 2020 at multineurological centers and hospitals in Khartoum State, including Ibrahim Malik Teaching Hospital, Alshaab Teaching Hospital, Bashier, Abu Anga, Omdurman Teaching Hospitals, included adult patients diagnosed with tuberculosis-associated neurological manifestations. The data were collected by predesigned questionnaire, and then analyzed by computer using SPSS-version 25. Results A total of 43 patients were evaluated, male patients were 24 (55.8%) and female patients were 19 (44.2%). About 31 (72.1%) of the participants had extra-pulmonary TB and 12 (27.9%) had pulmonary and extrapulmonary TB. The neurological manifestations of tuberculosis include Pott's disease in 29 (67.4%) patients (with thoracic spine most affected part), tuberculoma was second-most, occurring in 8 (18.7%) patients (with a single lesion in most of the patients), whereas tuberculous meningitis was found in 6 (13.9%). Clinical presentation was headache in 14 (32.6%) patients, convulsions in 10 (23.3%), loss of consciousness in 9 (20.9%), hemiparesis in 7 (16.3%) patients, and paraparesis in 23 (53.5%). Cranial nerve affected in 5 (11.6%) patients. All patients received antituberculosis medication and steroids, and 10 (23.2%) received anticonvulsants. Conclusions Neurological tuberculosis should be ruled out in any young male from an endemic area who exhibits abnormalities in motor, sensory, special sense, or higher mental function. To avoid potentially fatal complications, diagnoses and treatments should be initiated as soon as possible.
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Harahap MIR, Soetikno RD, Anwary F. Relationship between neutrophil count in cerebrospinal fluid and cerebral infarct appearance in head MRI on tuberculous meningitis patients. Eur J Radiol Open 2022; 10:100469. [PMID: 36578907 PMCID: PMC9791119 DOI: 10.1016/j.ejro.2022.100469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/27/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022] Open
Abstract
Objectives To determine the relationship between neutrophils count in cerebrospinal fluid and cerebral infarction in head magnetic resonance imaging (MRI) on patients with tuberculous meningitis. Methods A diagnostic study was done on patients with tuberculous meningitis (TBM) who underwent head MRI examination and cerebrospinal fluid analysis at Dr. Hasan Sadikin General Hospital from January 2015 to September 2016. TBM was diagnosed by Mycobacterium tuberculosis isolation from cerebrospinal fluid. Cut-off value of neutrophil count was determined using receiver operating characteristics (ROC) curve. Conformity test was done using Kappa test. Results Thirty seven subjects were recruited in this study. Higher neutrophil count in CSF was observed on subjects with cerebral infarction (p < 0.05). Cut-off value of neutrophil count in CSF was determined as > 41 %. There was a moderate conformity between higher neutrophil count in CSF and cerebral infarction appearance in MRI (p < 0.05, Kappa score 0.529). Conclusion Higher neutrophil count was associated with the appearance of cerebral infarct in head MRI on adult patients with tuberculous meningitis.
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Affiliation(s)
- Muhammad Irvanie Rama Harahap
- Correspondence to: Department of Radiology, Hasan Sadikin National General Hospital, Jl. Pasteur No.38, Kota, Bandung, Jawa Barat 40161, Indonesia.
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Hou J, Liu XJ, He Y, Zhang YA, Wang MS. Cerebrospinal fluid findings of infant tuberculous meningitis: a scoping review. Ann Med 2022; 54:2517-2521. [PMID: 36120927 PMCID: PMC9518261 DOI: 10.1080/07853890.2022.2123560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Cerebrospinal fluid (CSF) examinations play an important role in the diagnosis of tuberculous meningitis (TBM). However, their yield in the diagnosis of infant TBM remains unclear. This scoping review aims to detail the role of CSF examination for the diagnosis of infant TBM. METHODS A comprehensive literature search of PubMed, EBSCO, Embase, Scopus, Web of Science, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials was performed to identify articles published prior to October 14th, 2021. Articles describing the results of CSF exanimations among infant TBM were eligible for inclusion. Data extracted from each study included age, sex, CSF microbiological evidence (such as AFB smear, TB PCR, and TB culture), and routine CSF examinations (such as appearance, red blood cell count, white blood cell count, protein, and glucose). RESULTS A total of 98 cases were included in the final analysis. The yield of microbiological methods was listed as follows: CSF AFB smear, 20.5% (9/44); CSF TB culture 47.5% (29/61); CSF TB PCR, 65.0% (26/40); the combination of them, 57.3% (47/82). According to Marais criteria, the positivities of CSF examinations were calculated as follows: WBC count (ref, 50-500/μL), 65.5% (55/84); lymphocyte predominance (ref, >0.5), 75.4% (49/65); total protein (ref, >100 mg/dL), 67.8% (59/87); glucose (ref, <2.2 mmol/L, or CSF/serum ratio < 0.5), 68.2% (58/85). CONCLUSIONS Our data demonstrated that routine microbiological tools for infant TBM diagnosis have a sensitivity ranging from 20.5% to 65.0%, and most CSF features are non-specific and insufficient to predict a diagnosis of infant TBM. Therefore, further effort is required to develop new tools for infant TBM diagnosis.Key messages: Routine microbiological tools (such as acid-fast bacilli smear, PCR, and culture) have an unsatisfactory sensitivity for infant TBM diagnosis, and most CSF features are non-specific and insufficient to predict a diagnosis of infant TBM. Therefore, further effort is required to develop new tools for infant TBM diagnosis.
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Affiliation(s)
- Jie Hou
- Department of Intensive Care, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Xin-Jie Liu
- Department of Pediatrics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yu He
- Department of Clinical Laboratory, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yan-An Zhang
- Department of Cardiovascular Surgery, Shandong Public Health Clinical Center, Cheeloo College of Medicine, Shandong University, Jinan, China.,Shandong Key Laboratory of Infectious Respiratory Disease, Jinan, China
| | - Mao-Shui Wang
- Shandong Key Laboratory of Infectious Respiratory Disease, Jinan, China.,Department of Lab Medicine, Shandong Public Health Clinical Center, Cheeloo College of Medicine, Shandong University, Jinan, China
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Schaberg T, Brinkmann F, Feiterna-Sperling C, Geerdes-Fenge H, Hartmann P, Häcker B, Hauer B, Haas W, Heyckendorf J, Lange C, Maurer FP, Nienhaus A, Otto-Knapp R, Priwitzer M, Richter E, Salzer HJ, Schoch O, Schönfeld N, Stahlmann R, Bauer T. Tuberkulose im Erwachsenenalter. Pneumologie 2022; 76:727-819. [DOI: 10.1055/a-1934-8303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ZusammenfassungDie Tuberkulose ist in Deutschland eine seltene, überwiegend gut behandelbare Erkrankung. Weltweit ist sie eine der häufigsten Infektionserkrankungen mit ca. 10 Millionen Neuerkrankungen/Jahr. Auch bei einer niedrigen Inzidenz in Deutschland bleibt Tuberkulose insbesondere aufgrund der internationalen Entwicklungen und Migrationsbewegungen eine wichtige Differenzialdiagnose. In Deutschland besteht, aufgrund der niedrigen Prävalenz der Erkrankung und der damit verbundenen abnehmenden klinischen Erfahrung, ein Informationsbedarf zu allen Aspekten der Tuberkulose und ihrer Kontrolle. Diese Leitlinie umfasst die mikrobiologische Diagnostik, die Grundprinzipien der Standardtherapie, die Behandlung verschiedener Organmanifestationen, den Umgang mit typischen unerwünschten Arzneimittelwirkungen, die Besonderheiten in der Diagnostik und Therapie resistenter Tuberkulose sowie die Behandlung bei TB-HIV-Koinfektion. Sie geht darüber hinaus auf Versorgungsaspekte und gesetzliche Regelungen wie auch auf die Diagnosestellung und präventive Therapie einer latenten tuberkulösen Infektion ein. Es wird ausgeführt, wann es der Behandlung durch spezialisierte Zentren bedarf.Die Aktualisierung der S2k-Leitlinie „Tuberkulose im Erwachsenenalter“ soll allen in der Tuberkuloseversorgung Tätigen als Richtschnur für die Prävention, die Diagnose und die Therapie der Tuberkulose dienen und helfen, den heutigen Herausforderungen im Umgang mit Tuberkulose in Deutschland gewachsen zu sein.
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Affiliation(s)
- Tom Schaberg
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose e. V. (DZK), Berlin
| | - Folke Brinkmann
- Abteilung für pädiatrische Pneumologie/CF-Zentrum, Universitätskinderklinik der Ruhr-Universität Bochum, Bochum
| | - Cornelia Feiterna-Sperling
- Klinik für Pädiatrie mit Schwerpunkt Pneumologie, Immunologie und Intensivmedizin, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt-Universität zu Berlin, Berlin
| | | | - Pia Hartmann
- Labor Dr. Wisplinghoff Köln, Klinische Infektiologie, Köln
- Department für Klinische Infektiologie, St. Vinzenz-Hospital, Köln
| | - Brit Häcker
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose e. V. (DZK), Berlin
| | | | | | - Jan Heyckendorf
- Klinik für Innere Medizin I, Universitätsklinikum Schleswig-Holstein, Campus Kiel
| | - Christoph Lange
- Klinische Infektiologie, Forschungszentrum Borstel
- Deutsches Zentrum für Infektionsforschung (DZIF), Standort Hamburg-Lübeck-Borstel-Riems
- Respiratory Medicine and International Health, Universität zu Lübeck, Lübeck
- Baylor College of Medicine and Texas Childrenʼs Hospital, Global TB Program, Houston, TX, USA
| | - Florian P. Maurer
- Nationales Referenzzentrum für Mykobakterien, Forschungszentrum Borstel, Borstel
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Albert Nienhaus
- Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Universitätsklinikum Hamburg Eppendorf (UKE), Hamburg
| | - Ralf Otto-Knapp
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose e. V. (DZK), Berlin
| | | | | | | | | | | | - Ralf Stahlmann
- Institut für klinische Pharmakologie und Toxikologie, Charité Universitätsmedizin, Berlin
| | - Torsten Bauer
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose e. V. (DZK), Berlin
- Lungenklinik Heckeshorn, Helios Klinikum Emil von Behring, Berlin
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He Y, Huang Y, Wu D, Wu Y, Wang M. Clinical Management of Pathogen-Negative Tuberculous Meningitis in Adults: A Series Case Study. J Clin Med 2022; 11:6250. [PMID: 36362480 PMCID: PMC9656908 DOI: 10.3390/jcm11216250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/05/2022] [Accepted: 10/12/2022] [Indexed: 07/22/2023] Open
Abstract
Tuberculosis remains a serious world public health problem. Tuberculous meningitis (TBM) is the one of most severe forms of extrapulmonary tuberculosis. However, the insensitivity and time-consuming requirement of culturing the pathogen Mycobacterium tuberculosis, the traditional "gold standard" diagnostic test for TBM, often delays timely diagnosis and treatment, resulting in high disability and mortality rates. In our series case study, we present five pathogen-negative TBM cases who received empirical anti-tuberculosis therapy with a good clinical outcome. We describe in detail the clinical symptoms, laboratory test results, and imaging findings of the five patients from symptom onset to dynamic follow-up. We then summarize the similarities of the clinical characteristics of the presented patients, as well as shared features in laboratory and imaging tests, and proceed to analyze the challenges in the timely diagnosis of TBM. Finally, we argue that monitoring of cerebrospinal fluid markers and imaging are critical for the diagnosis and treatment of TBM, and emphasize the importance of differential diagnosis in cases when tuberculous meningitis is highly suspected despite negative findings for that etiology.
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Affiliation(s)
- Yuqin He
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Yanzhu Huang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Di Wu
- Department and Institute of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Yingying Wu
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Minghuan Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
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Liu P, Li T, Xi X, Pei N, Huang W, Liu X, Xia L, Yang Y, Lu S. Case Report: Thalidomide in the treatment of complicated central nervous system tuberculosis. FRONTIERS IN TROPICAL DISEASES 2022. [DOI: 10.3389/fitd.2022.983635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Central nervous system tuberculosis (CNSTB) is the most fatal type of tuberculosis (TB). Early administration of glucocorticoids can improve the prognosis of CNSTB patients and reduce mortality; however, some CNSTB patients do not respond well to anti-tuberculosis drugs and glucocorticoids. As an immunomodulatory drug, Thalidomide has been used under such circumstances. We retrospectively reviewed the drug to describe its clinical characteristics, efficacy, and safety in the treatment of four complicated CNSTB patients who responded well to thalidomide. Thalidomide may be an effective and well-tolerated drug for the treatment of CNSTB, and therefore requires further study.
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Liu C, Huai R, Xiang Y, Han X, Chen Z, Liu Y, Liu X, Liu H, Zhang H, Wang S, Hao L, Bo Y, Luo Y, Wang Y, Wang Y. High cerebrospinal fluid lactate concentration at 48 h of hospital admission predicts poor outcomes in patients with tuberculous meningitis: A multicenter retrospective cohort study. Front Neurol 2022; 13:989832. [PMID: 36277931 PMCID: PMC9583930 DOI: 10.3389/fneur.2022.989832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/05/2022] [Indexed: 11/17/2022] Open
Abstract
Objective This study aimed to analyze the cerebrospinal fluid (CSF) parameters affecting the outcomes of patients with tuberculous meningitis (TBM). Methods This is a multi-center, retrospective, cohort study involving 81 patients who were diagnosed with TBM and treated in Haihe Clinical College of Tianjin Medical University, Tianjin Medical University General Hospital, and General Hospital of Air Force PLA from January 2016 to December 2019. Baseline data, Glasgow Coma Scale (GCS) score, and clinical presentations of all patients were collected at admission. CSF samples were collected at 48 h, 1, 2, and 3 weeks after admission. CSF lactate, adenosine deaminase, chloride, protein, glucose levels and intracranial pressure were measured. After a follow-up of 16.14 ± 3.03 months, all patients were assessed using the modified Rankin Scale (mRS) and divided into good (mRS scores of 0–2 points) and poor outcome groups (mRS scores of 3–6 points). The differences in patients' baseline data, GCS score, clinical presentations, and levels of CSF parameters detected at 48 h, 1, 2, and 3 weeks after admission between two groups were compared. Statistically significant variables were added to the binary logistic regression model to identify the factors impacting the outcomes of patients with TBM. Receiver operating characteristic (ROC) curve was used to assess the predictive ability of the model. Results The CSF lactate level exhibited a decreasing trend within 3 weeks of admission in the two groups. For the within-group comparison, statistically significant differences in the lactate level was found in both groups between four different time points. A binary logistic regression model revealed that CSF lactate level at 48 h after admission, age, and GSC score on admission were independently associated with the outcomes of patients with TBM. ROC curve analysis showed that the area under the ROC curve (AUC) was 0.786 for the CSF lactate level (48 h), 0.814 for GCS score, and 0.764 for age. Conclusion High CSF lactate level at 48 h after admission is one of the important factors for poor outcomes in patients with TBM.
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Affiliation(s)
- Chenchao Liu
- Department of Neurology, Haihe Clinical School, Tianjin Medical University, Tianjin, China
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin, China
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Ruixue Huai
- Department of Neurology, Tianjin Jinnan Hospital, Tianjin, China
| | - Yijia Xiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Xu Han
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Zixiang Chen
- Department of Neurology, Haihe Clinical School, Tianjin Medical University, Tianjin, China
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin, China
| | - Yuhan Liu
- Department of Neurosurgery, People's Liberation Army Air Force Medical Center, Beijing, China
| | - Xingjun Liu
- Department of Neurology, Haihe Clinical School, Tianjin Medical University, Tianjin, China
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin, China
| | - Huiquan Liu
- Department of Neurology, Haihe Clinical School, Tianjin Medical University, Tianjin, China
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin, China
| | - Hong Zhang
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin, China
- Rehabilitation Department, Haihe Clinical School, Tianjin Medical University, Tianjin, China
| | - Sihan Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Lingyu Hao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Yin Bo
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Yuanbo Luo
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Yiyi Wang
- Department of Neurology, Haihe Clinical School, Tianjin Medical University, Tianjin, China
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin, China
- Yiyi Wang
| | - Yi Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
- *Correspondence: Yi Wang
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An Elusive Case of Tuberculous Meningitis in a Young Man With Altered Mental Status. J Emerg Med 2022; 63:551-556. [DOI: 10.1016/j.jemermed.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 06/08/2022] [Accepted: 07/09/2022] [Indexed: 12/05/2022]
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Zandvakili A, Kobayashi T, Kaewpoowat Q, Parsons MG, Ford B, Barker JH, Johnson M. Pelvic and central nervous system tuberculosis complicated by a paradoxical response manifesting as a spinal tuberculoma: a case report. BMC Infect Dis 2022; 22:750. [PMID: 36153478 PMCID: PMC9509540 DOI: 10.1186/s12879-022-07731-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 09/14/2022] [Indexed: 11/14/2022] Open
Abstract
Background The post-partum period is a risk factor for tuberculosis (TB), possibly including the period after miscarriage as illustrated here. This case demonstrates how non-specific symptoms can hide widely disseminated TB. Case presentation A healthy 26-year-old female with a history of recent miscarriage presented to the emergency department with non-specific symptoms of headache, abdominal pain, and sub-acute fevers. She had immigrated to the United States from the Marshall Islands 9 years prior. Two months prior to presentation she had a miscarriage at 18 weeks of pregnancy. On admission, transvaginal ultrasound revealed retained products of conception and abdominal computed tomography revealed findings consistent with tubo-ovarian abscesses and peritonitis. The obstetrics and gynecology service performed dilation and curettage (D&C) to remove retained products of conception. Acid-fast bacilli cultures from cerebrospinal fluid as well as specimens from D&C and intra-abdominal abscesses subsequently all grew TB. She was diagnosed with TB meningitis, peritonitis, endometritis, and tubo-ovarian abscesses. Her treatment course was complicated by a paradoxical response resulting in a spinal tuberculoma causing lower extremity weakness. The tuberculoma was treated with surgical decompression as well as continuation of treatment with anti-tubercular chemotherapy and steroids. Conclusion Disseminated and extrapulmonary TB can present with non-specific symptoms. Recognition of risk factors for TB is critical for prompt diagnostic evaluation and treatment of this deadly disease. A paradoxical reaction needs to be taken into consideration when any new neurological symptoms occur during TB treatment.
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Kong C, Xu D, Wang Y, Wang B, Wen J, Wang X, Zhan L, Sun Z, Jia X, Li M, Tang S, Hou D. Amplitude of low-frequency fluctuations in multiple-frequency bands in patients with intracranial tuberculosis: a prospective cross-sectional study. Quant Imaging Med Surg 2022; 12:4120-4134. [PMID: 35919063 PMCID: PMC9338357 DOI: 10.21037/qims-22-17] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/19/2022] [Indexed: 12/11/2022]
Abstract
Background Resting-state functional magnetic resonance imaging (rs-fMRI) is widely used to study brain functional alteration, but there have been no reports of research regarding the application of rs-fMRI in intracranial tuberculosis. The purpose of this prospective, cross-sectional study was to investigate spontaneous neural activity at different frequency bands in patients with intracranial tuberculosis using rs-fMRI with amplitude of low-frequency fluctuation (ALFF) and fractional ALFF (fALFF) methods. Methods The rs-fMRI data of 31 patients with intracranial tuberculosis and 30 gender-, age-, and education-matched healthy controls (HCs) were included. The ALFF and fALFF values in the conventional frequency band (0.01−0.08 Hz) and 2 sub-frequency bands (slow-4: 0.027–0.073 Hz; slow-5: 0.01–0.027 Hz) were calculated and compared between the groups. The resultant T-maps were corrected using the Gaussian random field (GRF) theory (voxel P<0.01, cluster P<0.05). Correlations between the ALFF and fALFF values and neurocognitive scores were assessed. Results Compared with the HCs, patients with intracranial tuberculosis showed decreased ALFF in the right paracentral lobule (T=−4.69) in the conventional frequency band, in the right supplementary motor area (T=−4.85) in the slow-4 band, and in the left supplementary motor area (T=−3.76) in the slow-5 band. Compared to the slow-5 band, the voxels with decreased ALFF were spatially more extensive in the slow-4 band. Compared with HCs, patients with intracranial tuberculosis showed decreased fALFF in the opercular parts of the right inferior frontal gyrus (T=−4.50) and the left inferior parietal lobe (T=−4.86) and increased fALFF in the left inferior cerebellum (T=5.84) in the conventional frequency band. In the slow-4 band, fALFF decreased in the opercular parts of the right inferior frontal gyrus (T=−5.29) and right precuneus (T=−4.34). In the slow-5 band, fALFF decreased in the left middle occipital gyrus (T=−4.65) and right middle frontal gyrus (T=−5.05). Conclusions Patients with intracranial tuberculosis showed abnormal intrinsic brain activity at different frequency bands, and ALFF abnormalities in different brain regions could be better detected in the slow-4 band. This preliminary study might provide new insights into understanding the pathophysiological mechanism in intracranial tuberculosis.
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Affiliation(s)
- Chengcheng Kong
- Translational Medicine Center, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Dong Xu
- Department of Radiology, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Yichuan Wang
- Department of Radiology, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Bing Wang
- Department of Radiology, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Jianjie Wen
- School of Teacher Education, Zhejiang Normal University, Jinhua, China
| | - Xinguang Wang
- School of Information Science and Electronic Technology, Jiamusi University, Jiamusi, China
| | - Linlin Zhan
- Faculty of Western Languages, Heilongjiang University, Harbin, China
| | - Zhaogang Sun
- Translational Medicine Center, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Xize Jia
- School of Teacher Education, Zhejiang Normal University, Jinhua, China.,Key Laboratory of Intelligent Education Technology and Application of Zhejiang Province, Zhejiang Normal University, Jinhua, China
| | - Mengting Li
- School of Teacher Education, Zhejiang Normal University, Jinhua, China.,Key Laboratory of Intelligent Education Technology and Application of Zhejiang Province, Zhejiang Normal University, Jinhua, China
| | - Shenjie Tang
- Tuberculosis Clinical Medical Center, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Dailun Hou
- Department of Radiology, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing Chest Hospital, Capital Medical University, Beijing, China
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Rahimi BA, Niazi N, Rahimi AF, Faizee MI, Khan MS, Taylor WR. Treatment outcomes and risk factors of death in childhood tuberculous meningitis in Kandahar, Afghanistan: a prospective observational cohort study. Trans R Soc Trop Med Hyg 2022; 116:1181-1190. [PMID: 35902999 PMCID: PMC9717388 DOI: 10.1093/trstmh/trac066] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 05/05/2022] [Accepted: 06/28/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Tuberculous meningitis (TBM) is the most severe form of TB. We prospectively documented the treatment outcomes and the risk factors for death in children with TBM from Kandahar, Afghanistan. METHODS This prospective observational cohort study was conducted from February 2017 to January 2020 in hospitalised TBM children. All the patients were prospectively followed up for 12 mo. Data were analysed by using descriptive statistics, χ2 and multivariate logistic regression. RESULTS A total of 818 TBM hospitalised patients with median age 4.8 (0.8-14.5) y were recruited. Females accounted for 60.9% (498/818). Upon admission 53.9% (n=441) and 15.2% (n=124) had TBM stages II and III, respectively, and 23.2% (n=190) had focal neurological signs. The case fatality rate was 20.2% (160/794) and 30.6% (243/794) survived with neurological sequelae. Independent risk factors for death were being unvaccinated for BCG (adjusted OR [AOR] 3.8, 95% CI 1.8 to 8.1), not receiving dexamethasone (AOR 2.5, 95% CI 1.5 to 4.2), being male (AOR 2.3, 95% CI 1.5 to 3.6), history of recent weight loss (AOR 2.2, 95% CI 1.3 to 3.9) and having stage III TBM (AOR 2.0, 95% CI 1.2 to 3.3). CONCLUSIONS TBM continues to cause high morbidity and mortality in Afghan children. Strategies to reduce mortality should emphasise early diagnosis and treatment, routine use of dexamethasone and increased BCG vaccination.
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Affiliation(s)
- Bilal Ahmad Rahimi
- Corresponding author: Department of Paediatrics, Faculty of Medicine, Kandahar University, Durahi, Beside Aino Mena Town, District 10, Kandahar 3801, Afghanistan; Tel: +93700309692; E-mail:
| | - Najeebullah Niazi
- Department of Surgery, Faculty of Medicine, Kandahar University, Kandahar 3809, Afghanistan
| | - Ahmad Farshad Rahimi
- Kandahar Tuberculosis Centre, Directorate of Public Health, Kandahar 3809, Afghanistan
| | - Muhammad Ishaque Faizee
- Department of Histopathology, Faculty of Medicine, Kandahar University, Kandahar 3809, Afghanistan
| | - Mohmmad Sidiq Khan
- Head of Paediatric Ward, Mirwais Regional Hospital, Kandahar 3809, Afghanistan
| | - Walter R Taylor
- Mahidol Oxford Tropical Medicine Clinical Research unit (MORU), Mahidol University, Bangkok 10400, Thailand,Centre for Tropical Medicine and Global Health, University of Oxford, OX3 7LG, UK
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Diagnostic and Prognostic Value of Cerebrospinal Fluid Lactate and Glucose in HIV-Associated Tuberculosis Meningitis. Microbiol Spectr 2022; 10:e0161822. [PMID: 35727068 PMCID: PMC9430741 DOI: 10.1128/spectrum.01618-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The role of cerebrospinal fluid (CSF) lactate in tuberculosis meningitis (TBM) diagnosis and prognosis is unclear. The aim of this study was to evaluate the performance of CSF lactate alone and in combination with CSF glucose in predicting a diagnosis of TBM and 14-day survival. HIV-positive Ugandan adults were investigated for suspected meningitis. The baseline CSF tests included smear microscopy; Gram stain; cell count; protein; and point-of-care glucose, lactate, and cryptococcal antigen (CrAg) assays. Where CrAg was negative or there was suspicion of TBM, a CSF Xpert MTB/RIF Ultra (Xpert Ultra) test was performed. We recorded baseline demographic and clinical data and 2-week outcomes. Of 667 patients, 25% (n = 166) had TBM, and of these, 49 had definite, 47 probable, and 70 possible TBM. CSF lactate was higher in patients with definite TBM (8.0 mmol/L; interquartile ratio [IQR], 6.1 to 9.8 mmol/L) than in those with probable TBM (3.4 [IQR, 2.5 to 7.0] mmol/L), possible TBM (2.6 [IQR 2.1 to 3.8] mmol/L), and non-TBM disease (3.5 [IQR 2.5 to 5.0] mmol/L). A 2-fold increase in CSF lactate was associated with 8-fold increased odds of definite TBM (odds ratio, 8.3; 95% confidence interval [CI], 3.6 to 19.1; P < 0.01) and 2-fold increased odds of definite/probable TBM (odds ratio, 2.3; 95% CI, 1.4 to 3.7; P < 0.001). At a cut point of >5.5 mmol/L, CSF lactate could be used to diagnose definite TBM with a sensitivity of 87.7%, specificity of 80.7%, and a negative predictive value of 98.8%. CSF lactate was not predictive of 2-week mortality. IMPORTANCE Tuberculosis meningitis (TBM) is the most severe form of tuberculosis, and its fatality is largely due to delays in diagnosis. The role of CSF lactate has not been evaluated in patients with HIV presenting with signs and symptoms of meningitis. In this study, using a point-of-care handheld lactate machine in patients with HIV-associated meningitis, we showed that high baseline CSF lactate (>5.5 mmol) may be used to rapidly identify patients with TBM and shorten the time to initiate treatment with a similar performance to the Xpert Ultra assay for definite TBM. Elevated CSF lactate levels, however, were not associated with increased 2-week mortality in patients with HIV-associated TBM. Due to moderate specificity, other etiologies of meningitis should be investigated.
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Chang BK, Adlawan J, Fesenmeier S, Kaminskas D, Carrazana E, Liow KK. A Rare Presentation of Central Nervous System Tuberculomas in an Immunocompetent Patient. HAWAI'I JOURNAL OF HEALTH & SOCIAL WELFARE 2022; 81:151-154. [PMID: 35673365 PMCID: PMC9168935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The uncommon presentation of simultaneous brain and lung lesions in an immunocompetent adult patient with frequent travel to a mycobacterium tuberculosis (MTB) endemic area requires high clinical suspicion for central nervous system (CNS) MTB, as this disease often results in severe neurologic morbidity and mortality. Non-specific and subacute symptoms make the diagnosis of CNS MTB clinically challenging, and a workup with imaging and microbiological studies such as acid-fast bacilli staining, nucleic acid amplification testing, and tissue culture must not delay prompt treatment with anti-tuberculosis therapy. This case illustrates the complex challenges of medical diagnosis and multi-disciplinary decision-making involved in the workup of CNS MTB.
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Affiliation(s)
- Bryce K. Chang
- John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI (BKC)
| | - Jacqueline Adlawan
- Family Medicine Residency Program, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI (JA)
| | - Samuel Fesenmeier
- Psychiatry Residency Program, Tripler Army Medical Center, Honolulu, HI (SF)
| | | | | | - Kore K. Liow
- Hawai‘i Pacific Neuroscience, Honolulu, HI (DK, EC, KKL)
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Jolobe OMP. An opportunity also for comparing rates of tuberculosis/cryptococcosis co-infection. QJM 2022; 115:335. [PMID: 34185093 DOI: 10.1093/qjmed/hcab180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- O M P Jolobe
- From the British Medical Association, Flat 6 Souchay Court, 1 Clothorn Road, Manchester M20 6BR, UK
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Huynh J, Donovan J, Phu NH, Nghia HDT, Thuong NTT, Thwaites GE. Tuberculous meningitis: progress and remaining questions. Lancet Neurol 2022; 21:450-464. [PMID: 35429482 DOI: 10.1016/s1474-4422(21)00435-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 10/03/2021] [Accepted: 11/25/2021] [Indexed: 12/23/2022]
Abstract
Tuberculous meningitis is a devastating brain infection that is caused by Mycobacterium tuberculosis and is notoriously difficult to diagnose and treat. New technologies characterising the transcriptome, proteome, and metabolome have identified new molecules and pathways associated with tuberculous meningitis severity and poor outcomes that could offer novel diagnostic and therapeutic targets. The next-generation GeneXpert MTB/RIF Ultra assay, when used on CSF, offers diagnostic sensitivity for tuberculous meningitis of approximately 70%, although it is not widely available and a negative result cannot rule out tuberculous meningitis. Small trials indicate that clinical outcomes might be improved with increased doses of rifampicin, the addition of linezolid or fluoroquinolones to standard antituberculosis therapy, or treatment with adjunctive aspirin combined with corticosteroids. Large phase 3 clinical trials are underway worldwide to address these and other questions concerning the optimal management of tuberculous meningitis; these studies also form a platform for studying pathogenesis and identifying novel diagnostic and treatment strategies, by allowing the implementation of new genomic, transcriptomic, proteomic, and metabolomic technologies in nested substudies.
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Affiliation(s)
- Julie Huynh
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK; Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Joseph Donovan
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK; Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Nguyen Hoan Phu
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK; Vietnam National University School of Medicine, Ho Chi Minh City, Vietnam
| | - Ho Dang Trung Nghia
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Nguyen Thuy Thuong Thuong
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK; Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Guy E Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK; Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam.
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Tavares-Júnior JWL, Teles Júnior JN, Magalhães SC, Cavalcante TT, Coimbra PPDA, Luiz RDSS. Parinaud syndrome due to cofirmed neurotuberculosis in a lupus eritematosis systemic patient. Eur J Ophthalmol 2022:11206721221098284. [PMID: 35482349 DOI: 10.1177/11206721221098284] [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: 11/16/2022]
Abstract
INTRODUCTION This article aims to describe a patient with Parinaud syndrome due to neurotuberculosis confirmed by cerebrospinal fluid analysis. CASE REPORT Initially, patient sought medical care, performed a chest x-ray and later a chest CT scan, with a probable diagnosis of miliary tuberculosis. In addition, she presented binocular diplopia worse at right lateral gaze, paresis of vertical gaze, light near-dissociation and convergent retraction nystagmus and presence of mycobacterium tuberculosis on PCR Xpert MTB/RIF. The treatment of miliary tuberculosis was interrupted due to pharmacodermia, but after diagnosis of neurotuberculosis, it was restarted with isoniazid, pyrazinamide and ethambutol with partial visual symptoms improvement. DISCUSSION This case demonstrates the importance of pursuing diagnosis through more accurate techniques, especially in a patient with previous treatment pharmacoderma, whose absence of proper diagnosis and treatment would be extremely deleterious.
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Clinical Efficacy of Dexamethasone in the Treatment of Patients with Tuberculous Meningitis: A Meta-Analysis. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:2180374. [PMID: 35418812 PMCID: PMC8986378 DOI: 10.1155/2022/2180374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/08/2022] [Accepted: 03/17/2022] [Indexed: 11/18/2022]
Abstract
Objective This study aimed to systematically evaluate the clinical efficacy of dexamethasone in patients with tuberculous meningitis (TBM) through meta-analysis. Method PubMed, Web of Science, Embase, China National Knowledge Infrastructure (CNKI), and the Wanfang Databases were searched, and all relevant Chinese and English literature from 2000 to 2021 were retrieved from each database. We collected randomized controlled trials of conventional antituberculosis drugs combined with dexamethasone treatment (treatment group) and conventional antituberculosis drug treatment or combined with placebo treatment (control group) in TBM patients. Meta-analysis was performed with Stata16.0 software. Results A total of 1645 articles were retrieved, and 11 articles were finally included in the study. Meta-analysis results showed that the treatment group had a significantly higher response rate and lower incidence of adverse reactions compared with the control group. Additionally, compared with the control group, the postoperative cerebrospinal fluid cell count, protein content, and glucose in the treatment group were significantly lower, while the chloride level increased. Conclusion Conventional antituberculosis drugs combined with dexamethasone therapy can improve cerebrospinal fluid cell count, protein content, glucose, and chloride levels in patients with TBM. This treatment can improve the treatment effective rate and reduce the incidence of adverse reactions, which is considered an effective treatment for TBM. Our results provide strong evidence for enhancing existing treatment regimens and developing novel combination therapy to improve TBM treatment efficacy.
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Sholeye AR, Williams AA, Loots DT, Tutu van Furth AM, van der Kuip M, Mason S. Tuberculous Granuloma: Emerging Insights From Proteomics and Metabolomics. Front Neurol 2022; 13:804838. [PMID: 35386409 PMCID: PMC8978302 DOI: 10.3389/fneur.2022.804838] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 02/24/2022] [Indexed: 12/24/2022] Open
Abstract
Mycobacterium tuberculosis infection, which claims hundreds of thousands of lives each year, is typically characterized by the formation of tuberculous granulomas — the histopathological hallmark of tuberculosis (TB). Our knowledge of granulomas, which comprise a biologically diverse body of pro- and anti-inflammatory cells from the host immune responses, is based mainly upon examination of lungs, in both human and animal studies, but little on their counterparts from other organs of the TB patient such as the brain. The biological heterogeneity of TB granulomas has led to their diverse, relatively uncoordinated, categorization, which is summarized here. However, there is a pressing need to elucidate more fully the phenotype of the granulomas from infected patients. Newly emerging studies at the protein (proteomics) and metabolite (metabolomics) levels have the potential to achieve this. In this review we summarize the diverse nature of TB granulomas based upon the literature, and amplify these accounts by reporting on the relatively few, emerging proteomics and metabolomics studies on TB granulomas. Metabolites (for example, trimethylamine-oxide) and proteins (such as the peptide PKAp) associated with TB granulomas, and knowledge of their localizations, help us to understand the resultant phenotype. Nevertheless, more multidisciplinary ‘omics studies, especially in human subjects, are required to contribute toward ushering in a new era of understanding of TB granulomas – both at the site of infection, and on a systemic level.
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Affiliation(s)
- Abisola Regina Sholeye
- Department of Biochemistry, Human Metabolomics, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom, South Africa
| | - Aurelia A. Williams
- Department of Biochemistry, Human Metabolomics, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom, South Africa
| | - Du Toit Loots
- Department of Biochemistry, Human Metabolomics, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom, South Africa
| | - A. Marceline Tutu van Furth
- Department of Pediatric Infectious Diseases and Immunology, Pediatric Infectious Diseases and Immunology, Amsterdam University Medical Center, Emma Children's Hospital, Amsterdam, Netherlands
| | - Martijn van der Kuip
- Department of Pediatric Infectious Diseases and Immunology, Pediatric Infectious Diseases and Immunology, Amsterdam University Medical Center, Emma Children's Hospital, Amsterdam, Netherlands
| | - Shayne Mason
- Department of Biochemistry, Human Metabolomics, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom, South Africa
- *Correspondence: Shayne Mason
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Jiang Y, Xu X, Guo Z, Liu Y, Lin J, Suo L, Jiang Y, Liu B, Lu T. Myelitis: A Common Complication of Tuberculous Meningitis Predicting Poor Outcome. Front Neurol 2022; 13:830029. [PMID: 35370906 PMCID: PMC8965833 DOI: 10.3389/fneur.2022.830029] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundMyelitis is an important complication in patients with tuberculous meningitis (TBM). However, a paucity of publications exists on the spectrum of neurological and MRI findings of TBM-related myelitis. The risk factors and prognosis of myelitis in patients with TBM are not fully understood. Therefore, this study aims to identify the risk factors, clinicoradiological features, and prognostic impact of myelitis for patients with TBM.MethodsWe conducted a retrospective study in our institution. Patients with TBM who were consecutively admitted during the period of August 2015 to December 2019 were included. We reviewed the demographic characteristics, clinical, laboratory and MRI findings, and clinical outcomes of all of the included patients. The diagnosis of myelitis was identified by a hyperintensity on T2-weighted images that were associated with cord edema, enlargement, and marginal or no enhancement on contrast-enhanced images.ResultsA total of 114 patients were included. Myelitis occurred in 19 (16.7%) patients, five of whom paradoxically developed myelitis. The common clinical signs of myelitis were paraparesis (738.9%), quadriparesis (844.4%), urinary retention or constipation (1,477.8%), and paresthesias in the lower limbs (1,052.6%). In the MRI findings, the hyperintensities on T2-weighted images involved more than 3 spinal cord segments. Myelitis was often combined with other forms of spinal cord injury, including 10 patients (52.6%) with spinal meningeal enhancement, 7 patients (36.8%) with enlargement of the central canal of the spinal cord, 6 patients (31.6%) with tuberculoma, and 4 patients (21.1%) with arachnoiditis and 1 patient (5.3%) with cerebrospinal fluid (CSF) loculations. None of the 5 patients with paradoxical myelitis were complicated with spinal meningeal enhancement and arachnoiditis, while 4 patients were complicated with enlargements of the central canal of the spinal cord. In multivariable analysis, a grade III disease severity on admission [p = 0.003, odds ratio (OR) = 8.131, 95% CI: 2.080–31.779] and high CSF protein (p = 0.033, OR = 1.698, 95% CI: 1.043–2.763) were independent risk factors for myelitis. After the 6 months follow-up, myelitis (p = 0.030, OR = 13.297, 95% CI: 1.283–137.812) and disturbance of consciousness (p = 0.042, OR = 12.625, 95% CI: 1.092–145.903) were independent risk factors for poor outcomes.ConclusionMyelitis was a common complication of TBM and independently predicted a poor outcome. A grade III disease severity and high CSF protein on admission were independent risk factors for myelitis. Paradoxical myelitis was rarely complicated with spinal meningeal enhancements and arachnoiditis, indicating that the immune reaction may play a dominant role.
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Affiliation(s)
- Yuxuan Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiangqin Xu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhuoxin Guo
- Department of Radiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yuxin Liu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jiahao Lin
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Lijun Suo
- Zibo City Key Laboratory of Respiratory Infection and Clinical Microbiology, Department of Pulmonary and Critical Care Medicine, Zibo City Engineering Technology Research Center of Etiology Molecular Diagnosis, Zibo Municipal Hospital, Zibo, China
| | - Ying Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Bo Liu
- Zibo City Key Laboratory of Respiratory Infection and Clinical Microbiology, Department of Pulmonary and Critical Care Medicine, Zibo City Engineering Technology Research Center of Etiology Molecular Diagnosis, Zibo Municipal Hospital, Zibo, China
| | - Tingting Lu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- *Correspondence: Tingting Lu
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Maya M, Maulik K, Parameswaran N, Selvan T, Gulati R, Subramanian N, Chakkalakkoombil SV, Badhe BA. Miliary nodules with recurrent air leaks in a child: A mystery. J Paediatr Child Health 2022; 58:516-518. [PMID: 33950574 DOI: 10.1111/jpc.15534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 12/06/2020] [Accepted: 04/19/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Malini Maya
- Women and Children Hospital, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Kaushik Maulik
- Women and Children Hospital, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Narayanan Parameswaran
- Women and Children Hospital, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Tamil Selvan
- Women and Children Hospital, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Reena Gulati
- Women and Children Hospital, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Nandeeswari Subramanian
- Women and Children Hospital, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Sunitha V Chakkalakkoombil
- Women and Children Hospital, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Bhawana A Badhe
- Women and Children Hospital, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER), Puducherry, India
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Poh XY, Loh FK, Friedland JS, Ong CWM. Neutrophil-Mediated Immunopathology and Matrix Metalloproteinases in Central Nervous System - Tuberculosis. Front Immunol 2022; 12:788976. [PMID: 35095865 PMCID: PMC8789671 DOI: 10.3389/fimmu.2021.788976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/20/2021] [Indexed: 12/19/2022] Open
Abstract
Tuberculosis (TB) remains one of the leading infectious killers in the world, infecting approximately a quarter of the world’s population with the causative organism Mycobacterium tuberculosis (M. tb). Central nervous system tuberculosis (CNS-TB) is the most severe form of TB, with high mortality and residual neurological sequelae even with effective TB treatment. In CNS-TB, recruited neutrophils infiltrate into the brain to carry out its antimicrobial functions of degranulation, phagocytosis and NETosis. However, neutrophils also mediate inflammation, tissue destruction and immunopathology in the CNS. Neutrophils release key mediators including matrix metalloproteinase (MMPs) which degrade brain extracellular matrix (ECM), tumor necrosis factor (TNF)-α which may drive inflammation, reactive oxygen species (ROS) that drive cellular necrosis and neutrophil extracellular traps (NETs), interacting with platelets to form thrombi that may lead to ischemic stroke. Host-directed therapies (HDTs) targeting these key mediators are potentially exciting, but currently remain of unproven effectiveness. This article reviews the key role of neutrophils and neutrophil-derived mediators in driving CNS-TB immunopathology.
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Affiliation(s)
- Xuan Ying Poh
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Fei Kean Loh
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jon S Friedland
- Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
| | - Catherine W M Ong
- Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore, Singapore.,Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, Singapore
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Wautlet A, Williams B. Miliary Tuberculosis in an Immunocompetent Male with Central Nervous System Involvement. Am J Med 2022; 135:184-186. [PMID: 34352245 DOI: 10.1016/j.amjmed.2021.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 07/05/2021] [Indexed: 11/01/2022]
Affiliation(s)
- Arnaud Wautlet
- Department of Internal Medicine, Rush University Medical Center, Chicago, Ill.
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Qi Y, Liu Z, Liu X, Fang Z, Liu Y, Li F. Tuberculosis-Specific Antigen/Phytohemagglutinin Ratio Combined With GeneXpert MTB/RIF for Early Diagnosis of Spinal Tuberculosis: A Prospective Cohort Study. Front Cell Infect Microbiol 2022; 12:781315. [PMID: 35174105 PMCID: PMC8842995 DOI: 10.3389/fcimb.2022.781315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 01/10/2022] [Indexed: 12/27/2022] Open
Abstract
Spinal tuberculosis (TB), the most common form of musculoskeletal tuberculosis, is an infection-related disease globally, with paraplegia occurring in severe cases. Therefore, identification of spinal TB at an early stage is important for early intervention and eventual therapy. In this study, we conducted a prospective cohort study in routine clinical practice to investigate the diagnosis of different TB tests. A total of 519 patients were recruited based on the radiology of spinal TB. The diagnostic model was computed by regression analysis and was determined by receiver operating characteristic (ROC) curve analysis. Specificity, sensitivity, predictive value, likelihood ratio, and accuracy were also computed and compared. GeneXpert MTB/RIF showed a higher positive rate compared to that in the acid-fast bacilli smear and Mycobacterium culture. The results also showed that the Mycobacterium tuberculosis-specific antigen/phytohemagglutinin ratio in the T-SPOT assay had a good performance in the preoperative diagnosis and prediction of spinal TB. The diagnostic model based on the ratio of tuberculosis-specific antigen/phytohemagglutinin combined with GeneXpert MTB/RIF showed better efficiency for spinal TB diagnosis. In summary, the tuberculosis-specific antigen/phytohemagglutinin ratio combined with GeneXpert MTB/RIF could provide an early diagnosis of spinal TB.
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Affiliation(s)
- Yiwei Qi
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Laboratory Sino-German Neuro-Oncology Molecular, Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhiwei Liu
- Department of Orthopedic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaojin Liu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Laboratory Sino-German Neuro-Oncology Molecular, Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhong Fang
- Department of Orthopedic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanchao Liu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Laboratory Sino-German Neuro-Oncology Molecular, Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Feng Li, ; Yanchao Liu,
| | - Feng Li
- Department of Orthopedic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Feng Li, ; Yanchao Liu,
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Memon W, Akram A, Popli K, Spriggs JB, Rehman S, Gipson G, Gehr T. Cerebral Salt-Wasting Syndrome in a Patient With Active Pulmonary Tuberculosis. Cureus 2022; 14:e21202. [PMID: 35165637 PMCID: PMC8840384 DOI: 10.7759/cureus.21202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 11/24/2022] Open
Abstract
A 37-year-old female with a medical history of recently diagnosed active pulmonary tuberculosis and a new intracranial lesion presented with altered mental status, nausea, and vomiting for two days. An initial physical examination revealed that the patient was euvolemic. Laboratory findings revealed a serum sodium concentration of 105 mEq/L. During her admission, she was initially managed with lactated ringer solution in the emergency department, followed by 3% normal saline in the intensive care unit, and, eventually, on oral sodium chloride and fluid restriction on discharge. Once she was stabilized, she had episodes of dizziness, and concerns were raised about the salt-wasting syndrome.
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Fauzi A, Permatasari A. Disseminated tuberculosis with symptoms of decreased consciousness: A rare case in Indonesian male. Ann Med Surg (Lond) 2022; 73:103209. [PMID: 35079359 PMCID: PMC8767272 DOI: 10.1016/j.amsu.2021.103209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/19/2021] [Accepted: 12/20/2021] [Indexed: 12/02/2022] Open
Abstract
Background Disseminated tuberculosis is a rare case that causes high mortality and morbidity. Case presentation A 59-year-old man with a glasgow coma scale of 12, cerebrospinal fluid was found to have dominant mononuclear, high protein level, low glucose level and shortness of breath. A chest X-ray revealed a right pleural effusion with infiltrates in both lung parenchyma and a pleural fluid adenosine deaminase (ADA) test showed 66.1 U/L. Thoracolumbar MRI revealed a compression fracture in the 6th thoracic vertebral body. The patient was given category 1 anti-tuberculosis drug (ATD) therapy plus streptomycin and dexamethasone and water seal drainage (WSD) was installed. The patient experienced improvement after taking ATD after 4 months in which the patient could stand and walk by using an object in front of him. Discussion Accurate and prompt diagnosis of disseminated tuberculosis minimizes patient's mortality and morbidity. Suspicion of tuberculosis can be raised if the patient is experiencing health problems in endemic tuberculosis. Conclusion Disseminated tuberculosis (pulmonary tuberculosis, tuberculous pleurisy, tuberculous meningitis, and tuberculous spondylitis) can be managed properly using ATD category 1. GeneXpert MTB/RIF can be considered when treating infection cases in endemic tuberculosis. The accuracy and speed of diagnosis of disseminated tuberculosis can minimize complications. Anti-tuberculosis drug category 1 is effective for disseminated tuberculosis patients.
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