Hydrocephalus in tuberculous meningitis: Incidence, its predictive factors and impact on the prognosis

An 11-month-old boy with tuberculous meningitis presenting as progressive limb weakness, fever, developmental retardation, and loss of consciousness: a case report

BACKGROUND

Tuberculous meningitis (TBM) accounts for about 1% of all tuberculosis cases and about 5% of extrapulmonary tuberculosis cases. However, it poses major importance because approximately half of those affected die or become severely disabled. Herein, the successful treatment of an 11-month-old boy with progressive limb weakness, fever, developmental retardation, and loss of consciousness due to tuberculosis, was reported.

CASE PRESENTATION

An 11-month-old (Iranian Turk) boy was referred to Loghman Hakim hospital for progressive limb weakness and loss of previously attained developmental milestones for the past 2 months. He also had persistent fever and loss of consciousness for about 14 to 21 days. Before being referred to our center, the patient had been diagnosed with hydrocephalus at another center due to possible acute bacterial meningitis based on a CT scan and MRI imaging. On physical examination, anterior fontanel bulging and neck stiffness were observed on the admission. His body temperature and heart rate were 38.1 C and 86 beats per minute (bpm), respectively. He had left 6 cranial nerve palsy and spastic quadriparesis with a power of grade 3/5. Other systemic examinations were normal. Endoscopic third ventriculostomy (ETV) (and leptomeningeal biopsy) revealed diffuse thickening of the floor and lateral walls of the 3rd ventricle and also a cobblestone appearance in the form of multiple white patchy lesions was detected on the floor of the 3rd ventricle. CSF analysis and polymerase chain reaction confirmed the TB meningitis. During hospitalization, a temporary EVD (external ventricular drain) was initially inserted. Eventually, defervescence was denoted 5-6 days after initiation of anti-TB medications, and a permanent ventriculoperitoneal shunt was inserted due to hydrocephalus. Gradually his truncal and limb tone and motor function improved, as did his emotional responses to his parents and ability to eat. The patient can walk without help in the 15th month following the operation and resolved hydrocephalus demonstrated on follow-up imaging.

CONCLUSION

Over half of treated TB meningitis patients die or suffer severe neurological sequelae, mainly due to late diagnosis. Hence, early diagnosis and prompt initiation of TB treatment offer the best chance of a good neurological outcome.

A, Kis L, Király K, Varga S, Marcsik A, Schütz O, Török T, Hunt DR, Tihanyi B. White plague among the "forgotten people" from the Barbaricum of the Carpathian Basin-Cases with tuberculosis from the Sarmatian-period (3rd-4th centuries CE) archaeological site of Hódmezővásárhely-Kenyere-ér, Bereczki-tanya (Hungary)

Tuberculosis (TB) is a bacterial infection that is well-known in the palaeopathological record because it can affect the skeleton and consequently leaves readily identifiable macroscopic alterations. Palaeopathological case studies provide invaluable information about the spatio-temporal distribution of TB in the past. This is true for those archaeological periods and geographical regions from when and where no or very few TB cases have been published until now-as in the Sarmatian period (1st-5th centuries CE) in the Barbaricum of the Carpathian Basin. The aim of our paper is to discuss five newly discovered TB cases (HK199, HK201, HK225, HK253, and HK309) from the Sarmatian-period archaeological site of Hódmezővásárhely-Kenyere-ér, Bereczki-tanya (Csongrád-Csanád county, Hungary). Detailed macromorphological evaluation of the skeletons focused on the detection of bony changes likely associated with different forms of TB. In all five cases, the presence of endocranial alterations (especially TB-specific granular impressions) suggests that these individuals suffered from TB meningitis. Furthermore, the skeletal lesions observed in the spine and both hip joints of HK225 indicate that this juvenile also had multifocal osteoarticular TB. Thanks to the discovery of HK199, HK201, HK225, HK253, and HK309, the number of TB cases known from the Sarmatian-period Carpathian Basin doubled, implying that the disease was likely more frequent in the Barbaricum than previously thought. Without the application of granular impressions, the diagnosis of TB could not have been established in these five cases. Thus, the identification of TB in these individuals highlights the importance of diagnostics development, especially the refinement of diagnostic criteria. Based on the above, the systematic macromorphological (re-)evaluation of osteoarchaeological series from the Sarmatian-period Carpathian Basin would be advantageous to provide a more accurate picture of how TB may have impacted the ancestral human communities of the Barbaricum.

The Neuro-Ophthalmology of Tuberculosis

Tuberculosis (TB) is a global health concern and central nervous system (CNS) TB leads to high mortality and morbidity. CNS TB can manifest as tubercular meningitis, tuberculoma, myelitis, and arachnoiditis. Neuro-ophthalmological involvement by TB can lead to permanent blindness, ocular nerve palsies and gaze restriction. Visual impairment is a dreaded complication of tubercular meningitis (TBM), which can result from visual pathway involvement at different levels with varying pathogenesis. Efferent pathway involvement includes cranial nerve palsies and disorders of gaze. The purpose of this review is to outline the various neuro-ophthalmological manifestations of TB along with a description of their unique pathogenesis and management. Optochiasmatic arachnoiditis and tuberculomas are the most common causes of vision loss followed by chronic papilloedema. Abducens nerve palsy is the most commonly seen ocular nerve palsy in TBM. Gaze palsies with deficits in saccades and pursuits can occur due to brainstem tuberculomas. Corticosteroids are the cornerstone in the management of paradoxical reactions, but other immunomodulators such as thalidomide and infliximab are being explored. Toxic optic neuropathy caused by ethambutol necessitates careful monitoring and immediate drug discontinuation. Cerebrospinal fluid diversion through ventriculo-peritoneal shunting may be required in patients with hydrocephalus in stage I and II of TBM to prevent visual impairment. Early diagnosis and prompt management are crucial to prevent permanent disability. Prevention strategies, public health initiatives, regular follow-up and timely intervention are essential in reducing the burden of CNS TB and its neuro-ophthalmological complications.

Reasons for re-hospitalization in patients with tuberculous meningitis, and its impact on outcome: a prospective observational study

BACKGROUND

Patients with tuberculous meningitis may worsen despite being treated adequately with anti-tuberculosis drugs. This worsening may lead to re-hospitalization. The exact frequency and causes of re-hospitalization have not been studied previously. We aimed to study the causes of clinical worsening leading to re-hospitalization and its impact on prognosis.

METHODS

This was a prospective observational study. Newly diagnosed patients with tuberculous meningitis (N = 150) were enrolled. Baseline clinical evaluation, neuroimaging, and cerebrospinal fluid examination were performed. Anti-tuberculosis drug regimen and corticosteroids were given as per WHO guidelines. Patients were followed for 6 months. Re-hospitalized patients were worked up and clinical evaluation, neuroimaging, and cerebrospinal fluid examination were performed again. Outcome assessment was done at the end of 6 months, and a modified Barthel index of ≤ 12 was considered a poor outcome.

RESULTS

Twenty-three (15.3%) out of 150 patients needed re-hospitalization. The median time between discharge after the first hospitalization and re-hospitalization was 60 days. The common reasons for re-hospitalization were paradoxical neurological deterioration seen in 19 (82.6%) out of 23 patients, followed by drug toxicities (N = 2) and systemic involvement (N = 2). Paradoxically developed spinal arachnoiditis and opto-chiasmatic arachnoiditis were amongst the predominant reasons for re-hospitalization. At six months, re-hospitalization was an independent predictor of poor outcome (OR = 7.39, 95% CI 2.26-24.19).

CONCLUSION

Approximately 15% of tuberculous meningitis patients needed re-hospitalization. Paradoxically developed spinal arachnoiditis and opto-chiasmatic arachnoiditis were predominant reasons for re-hospitalization. Re-hospitalization adversely affected the outcome.

The clinic-based predictive modeling for prognosis of patients with cryptococcal meningitis

BACKGROUND

Cryptococcal meningitis (CM) is the most common fungal infection of the central nervous system that can cause significant morbidity and mortality. Although several prognostic factors have been identified, their clinical efficacy and use in combination to predict outcomes in immunocompetent patients with CM are not clear. Therefore, we aimed to determine the utility of those prognostic factors alone or in combination in predicting outcomes of immunocompetent patients with CM.

METHODS

The demographic and clinical data of patients with CM were collected and analyzed. The clinical outcome was graded by the Glasgow outcome scale (GOS) at discharge, and patients were divided into good (score of 5) and unfavorable (score of 1-4) outcome groups. Prognostic model was created and receiver-operating characteristic curve analyses were conducted.

RESULTS

A total of 156 patients were included in our study. Patients with higher age at onset (p = 0.021), ventriculoperitoneal shunt placement (p = 0.010), Glasgow Coma Scale (GCS) score of less than 15(p< 0.001), lower CSF glucose concentration (p = 0.037) and immunocompromised condition (p = 0.002) tended to have worse outcomes. Logistic regression analysis was used to create a combined score which had a higher AUC (0.815) than those factors used alone for predicting outcome.

CONCLUSIONS

Our study shows that a prediction model based on clinical characteristics had satisfactory accuracy in prognostic prediction. Early recognition of CM patients at risk of poor prognosis using this model would be helpful in providing timely management and therapy to improve outcomes and to identify individuals who warrant early follow-up and intervention.

Seizures and epilepsy associated with central nervous system tuberculosis

Central nervous system (CNS) tuberculosis is a life-threatening condition that usually presents with seizures, particularly in children and HIV-infected patients. Tuberculous meningitis (TBM) and tuberculomas are the two forms of CNS tuberculosis that can present with seizures. Seizures usually resolve after successful treatment of the underlying infection. However, the success of the treatment is usually based on an early diagnosis. Delay in the treatment of CNS tuberculosis increases the risk of its associated complications, such as stroke. This would lead to the development of epilepsy. Early seizures may be related to meningeal irritation and cerebral edema, whereas late seizures are often associated with structural brain lesions that generally require more advanced and prolonged treatment. Risk factors associated with the development of epilepsy include young age, refractory seizures, tuberculoma, cortical involvement, epileptiform discharges, and residual lesions. Treatment of CNS tuberculosis is based on early initiation of appropriate anti-tuberculous drugs, antiseizure medications, and correction of associated predisposing factors. Finally, further research into the mechanisms of seizures and the development of epilepsy in CNS tuberculosis could help improve management of these conditions.

Lumbosacral tuberculosis, a rare manifestation of Pott's disease - How identified human skeletons from the pre-antibiotic era can be used as reference cases to establish a palaeopathological diagnosis of tuberculosis

The macromorphological examination of identified human osteological collections from the pre-antibiotic era (e.g., Terry Collection) can provide invaluable information about the skeletal manifestations of tuberculosis (TB) in individuals who did not receive pharmaceutical therapy. With analysis of such collections, new diagnostic criteria for TB can be recognised which can be used in palaeopathological interpretation. The aim of our paper is to provide a reference and aid for the identification of TB in past populations by demonstrating and discussing in detail the vertebral alterations indicative of one of its rare skeletal manifestations, lumbosacral TB. These changes were detected in two individuals from the Terry Collection (Terry No. 760 and Terry No. 1093). These two case studies furnish palaeopathologists with a stronger basis for diagnosing lumbosacral TB in skeletons which exhibit similar vertebral lesions from osteoarchaeological series. To illustrate this, an archaeological case from Hungary (KK146) is also presented, displaying vertebral alterations resembling that of the two cases from the Terry Collection. Through the demonstrated case studies, we can derive a better insight into the disease experience of people who lived in the past and suffered from TB.

High cerebrospinal fluid lactate concentration at 48 h of hospital admission predicts poor outcomes in patients with tuberculous meningitis: A multicenter retrospective cohort study

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.

Paroxysmal sympathetic hyperactivity syndrome in tuberculous meningitis with paradoxical reaction

INTRODUCTION AND IMPORTANCE

Paroxysmal sympathetic hyperactivity syndrome is frequently reported in traumatic brain injury. However, it may occur in non-traumatic brain injury, such as tuberculous meningitis with hydrocephalus.

CASE PRESENTATION

We reported a 38-year-old male who presented with acute decrease of consciousness and hemiparesis that was developed during antitubercular drugs therapy. CT Scan showed hydrocephalus and granuloma lesion. Emergency ventriculoperitoneal shunting were performed. During treatment, the patient developed paroxysmal sympathetic syndrome during treatment that was controlled based on symptom elimination and prevention.

CLINICAL DISCUSSION

Brain tuberculosis remains a difficult problem for clinicians. Even when antitubercular drugs are administered according to protocol, paradoxical reactions can occur. If hydrocephalus develops, ventriculoperitoneal shunting is one of the options for lowering intracranial pressure. Paroxysmal sympathetic hyperactivity may occur in brain tuberculosis and should be detected as soon as possible to avoid serious morbidity.

CONCLUSION

Paroxysmal sympathetic hyperactivity may be developed in brain tuberculosis. Early identification and treatment are mandatory.

Global Frequency and Clinical Features of Stroke in Patients With Tuberculous Meningitis: A Systematic Review

IMPORTANCE

Stroke in tuberculous meningitis (TBM) is associated with significant morbidity and mortality.

OBJECTIVE

To determine the country-specific, regional, and overall prevalence of stroke among patients with TBM, including their clinical manifestations, stroke locations, and outcomes.

EVIDENCE REVIEW

This systematic review searched records in MEDLINE by PubMed, Scopus, and EMBASE until July 2020 for relevant articles on the occurrence and characteristics of stroke in TBM. Randomized clinical trials and cohort studies that included a population of patients with TBM were analyzed for clinical manifestations, type of stroke, area of stroke, vascular territory, and outcomes. Studies that did not report the occurrence of stroke, reported as abstract only with no full-texts available, and articles not in English were excluded. The country-specific, regional, and overall frequencies of stroke among patients with TBM were determined; secondary analysis enumerated the summary estimates of the clinical presentations, common locations of stroke, and outcomes. The Murad tool was used to assess methodological quality.

FINDINGS

From 852 articles identified, 71 studies involving 2194 patients with stroke in TBM were included. The sample size for each study ranged from 17 to 806 patients. The frequency of stroke in TBM showed an estimate of 0.30 (95% CI, 0.26-0.33). The most common clinical manifestations were fever and headache. The lateral striate, middle cerebral, and medial striate arteries were typically affected. The basal ganglia, cortex and lobar, and internal capsule were the frequently involved areas of the brain. The pooled proportions of mortality and poor outcomes were 0.22 (95% CI, 0.16-0.29) and 0.51 (95% CI, 0.37-0.66), respectively.

CONCLUSIONS AND RELEVANCE

The results of this systematic review suggest that stroke is considerably frequent among patients with TBM. The reported frequencies of stroke in TBM and its clinical features vary across the studies and populations.

Quantitative proteomics on the cerebrospinal fluid of hydrocephalus in neonatal bacterial meningitis

Objective

Hydrocephalus in bacterial meningitis (BM) is a devastating infectious neurological disease and the proteins and pathways involved in its pathophysiology are not fully understood.

Materials and methods

Label-free quantitative (LFQ) proteomics analyses was used to identify differentially expressed proteins (DEPs) in cerebrospinal fluid (CSF) samples from infants with hydrocephalus and bacterial meningitis (HBM group, N = 8), infants with bacterial meningitis (BM group, N = 9); and healthy infants (N group, N = 11). Bioinformatics analysis was subsequently performed to investigate Gene Ontology (GO) functional annotation and Kyoto Encyclopedia of Genes and Genomes (KEGG) enriched signaling pathways of these DEPs. Six proteins (AZU1, COX4I1, EDF1, KRT31, MMP12, and PRG2) were selected for further validation via enzyme-linked immunosorbent assay (ELISA).

Results

Compared with BM group and N group, HBM group had a higher whole CSF protein level (5.6 ± 2.7 vs. 1.7 ± 1.0 vs. 1.2 ± 0.5 g/l) and lower whole CSF glucose level (0.8 ± 0.6 vs. 1.8 ± 0.7 vs. 3.3 ± 0.8 mmol/l) (both P < 0.05). Over 300 DEPs were differentially expressed in HBM group compared with BM group and BM compared with N group, of which 78% were common to both. Cluster analysis indicated that the levels of 226 proteins were increased in BM group compared with N group and were decreased in HBM group compared with BM group. Bioinformatics analysis indicated the involvement of the cell adhesion, immune response and extracellular exosome signaling were significantly enriched in HBM compared with BM group and BM compared with N group. 267 DEPs were identified between HBM group with N group, KEGG analysis indicated that DEPs mainly involved in filament cytoskeleton and immune response. The ELISA results further verified that the expression levels of AZU1 were significantly different from among three groups (both P < 0.05).

Conclusion

This is the first reported characterization of quantitative proteomics from the CSF of infants with HBM. Our study also demonstrated that AZU1 could be a potential biomarker for the diagnosis of hydrocephalus in bacterial meningitis.

Tuberculous Meningitis in Children: Treatment Outcomes at Discharge and Its Associated Factors in Eastern Ethiopia: A Five Years Retrospective Study

Background

Tuberculous meningitis is a serious public health problem, particularly in low-income countries. It is associated with high rates of mortality and morbidity. The outcome of tuberculous meningitis in children is not well documented in Ethiopia, particularly in eastern Ethiopia. This study aimed to determine the treatment outcomes of tuberculous meningitis at discharge and its associated factors in eastern Ethiopia.

Methods

An institutional-based retrospective cross-sectional study was conducted on 121 children who were admitted and treated for tuberculous meningitis between January 2017 and December 2021. Data were collected using a pretested checklist, coded and entered into EpiData version 3.1, and analyzed using Statistical Package for the Social Sciences (SPSS) version 25. Factors associated with treatment outcomes were identified using multivariable logistic regression analyses. The association was described using the adjusted odds ratio (AOR) at a 95% confidence interval (CI). Finally, statistical significance was set at a p-value <0.05.

Results

Of the 121 medical records of children, 33.9% (95% CI:25-42%) died. Among the survivors, 28.1% were discharged with neurological sequelae and the remains (38.0%) were discharged with normal outcomes. In multivariable analyses, nutritional status (AOR=2.87; 95% CI:1.04-7.94), duration of illness (AOR = 0.33; 95% CI: 0.15-0.86), hydrocephalus (AOR=3.78; 95% CI:1.08-13.34), and stage-III Tuberculous Meningitis (AOR = 5.29; 95% CI:1.88-14.84) were identified as significantly associated factors with poor clinical outcomes.

Conclusion

The treatment outcomes for tuberculous meningitis in children are unfavorable. Two-thirds of children had poor treatment outcomes. Malnutrition, disease stage, hydrocephalus, and illness duration were associated with poor treatment outcomes at discharge. Health workers in primary health care should be aware of the importance of early screening, diagnosis, and treatment to improve clinical outcomes and reduce associated mortality and disability. In practice, more attention should be paid to children with malnutrition and hydrocephalus.

Challenges and Controversies in the Management of Tuberculous Meningitis with Hydrocephalus: A Systematic Review and Sarawak Institution's Experience

Introduction To date, there are no standard practice guidelines available and no universal consensus regarding treatment protocol in management of tuberculous meningitis (TBM) with hydrocephalus. Over the years, diverse views have existed in neurosurgical management of TBM with hydrocephalus. Some authors advocate ventriculo-peritoneal (VP) shunt, while others suggest that external ventricular drainage (EVD) may be the preferable neurosurgical procedure for a poor-grade patient.

Method We systematically reviewed published literature and presented our institution's experience. We performed a retrospective case study in our Sarawak neurosurgical center from 2018 to 2020. We tabulated the outcome according to preoperative classifications, which were Vellore Grading (VG), Modified Vellore Grading (MVG), British Medical Research Council Classification (MRC), and others: author-defined.

Result In our center, there were 20 cases of TBM with hydrocephalus treated by EVD and VP shunt from 2018 to 2020. We systematically searched published medical literature, and 23 articles were retrieved and analyzed. Poor outcomes were observed in poor-grade patients, especially VG/MVG 3/4 and MRC 3, from both institution and systemic review data. Shunt complication rate was lower in our center as compared with published literature.

Conclusion Unfortunately, morbidity and mortality were approximately twofold higher in poor-grade as compared with good-grade patients. However, about one-third of poor-grade patients achieved a good outcome. Cerebrospinal fluid (CSF) diversion would be an unavoidable treatment for hydrocephalus. Poor-grade patients tend to have cerebral infarcts in addition to hydrocephalus. An extended duration of EVD placement could be a potential measure to assess Glasgow coma scale recovery and monitor serial CSF samples.

Cerebral Infarction and Evan's Ratio on MRI Affect the Severity and Prognosis of Tuberculosis Meningitis Patients

Background: Magnetic resonance imaging (MRI) is widely used in the diagnosis of tuberculous meningitis (TBM) and its complications. We aimed to explore the relationship between MRI features and neurological deficits and TBM patients’ prognosis. Methods: patients diagnosed with TBM were subjected to a neurological evaluation on admission and divided into groups based on the Medical Research Council (MRC) scale. After several years of follow-up, the patients were further divided into groups according to the Modified Rankin Score (MRS). Their MR images were analyzed for meningeal enhancement, tuberculomas, infarction, hydrocephalus, and abscess, including the location and size of the lesion. Any changes in MRI features during the follow-up were recorded. MRI features between groups were compared, and the relationship between dynamic changes in images and Rankin grading was explored. Results: We found significant differences in acute cerebral infarction (ACI) and old cerebral infarctions (OCI) between the MRC groups, and the ORs of ACI and OCI were 21.818 (95% CI: 2.440−195.075) and 6.788 (95% CI: 1.516−30.392), respectively. There were significant differences in ACI, OCI, and Evan’s ratio between the MRS groups (p < 0.05), and the ORs of ACI, OCI, and hydrocephalus were 6.375 (95% CI: 1.501−27.080), 5.556 (95% CI: 1.332−23.177), and 9.139 (95% CI: 2.052−40.700), respectively. The changes of Evan’s ratio were related to the MRS grading (r = 0.335, p = 0.040). Conclusions: For patients with TBM, the presence of ACI or OCI is associated with neurological deficits, and ACI, OCI, and hydrocephalus can be regarded as poor prognostic predictors. Changes in Evan’s ratio will affect the outcome.

Neutrophil-Mediated Immunopathology and Matrix Metalloproteinases in Central Nervous System - Tuberculosis

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.

Complicated Neurotuberculosis with sinus venous thrombosis: A case-report

INTRODUCTION

Neurotuberculosis comprises around 6% of systemic tuberculosis. It targets a younger population, and it often leads to severe neurological complications or death.

CASE REPORT

We report a young gentleman with a clinically defined tuberculous meningitis (TBM) and multiple neurological complication associated with TBM occurring simultaneously. This includes hydrocephalus requiring a ventriculoperitoneal shunt, vasculitic infarcts, cranial nerve palsies, TB granuloma and cerebral venous thrombosis. The cerebrospinal fluid polymerase chain reaction for tuberculosis as well as cultures remained negative repeatedly. The patient was treated with anti-tuberculous medication in addition to steroids based on validated scoring systems suggestive of TBM and made a good recovery.

CONCLUSION

This report highlights the different complication seen with TBM and the importance of using clinical criteria to guide management plan particularly when cultures are negative.

Neuro-ophthalmic manifestations of tuberculosis

Neuro-ophthalmic features are a known association in tuberculosis, especially common in central nervous system tuberculosis (CNS-TB). They are mostly the result of the visual pathway and/or ocular motor and other cranial nerve involvement. Furthermore, toxic optic neuropathy and paradoxical response to anti-tubercular drugs (ATT) are also not uncommon. The etiopathogenesis is by the complex interplay of various factors like exudates, vasculitis, arachnoiditis, presence of tuberculomas, hydrocephalus, brain infarcts and/or immune-mediated reaction. The entity often poses a diagnostic dilemma for the ophthalmologists/neuro-ophthalmologists and may lead to irreversible vision loss. The presence of neuro-ophthalmic features not only affect the visual outcome but are also predictors of systemic morbidity of the disease. Therefore, understanding and knowledge about this entity are necessary for the comprehensive management of the disease. While various forms of TB including CNS-TB have been well-dealt with in literature, little is discussed specifically about the neuro-ophthalmic manifestations of tuberculosis. Therefore, the purpose of this review is to highlight current understanding of the types of neuro-ophthalmic involvement in tuberculosis, its etiopathogenesis, diagnosis and management.

A clinical, aetiological, and public health perspective on central nervous system infections in Bolivia, 2017-2018

Central nervous system (CNS) infections are important causes of morbidity and mortality worldwide. In Bolivia, aetiologies, case fatality, and determinants of outcome are poorly characterised. We attempted to investigate such parameters to guide diagnosis, treatment, prevention, and health policy. From Nov-2017 to Oct-2018, we prospectively enrolled 257 inpatients (20.2% HIV-positive patients) of all ages from healthcare centers of Cochabamba and Santa Cruz, Bolivia with a suspected CNS infection and a lumbar puncture performed. Biological diagnosis included classical microbiology, molecular, serological and immunohistochemical tests. An infectious aetiology was confirmed in 128/257 (49.8%) inpatients, including, notably among confirmed single and co-infections, Cryptococcus spp. (41.7%) and Mycobacterium tuberculosis (27.8%) in HIV-positive patients, and Mycobacterium tuberculosis (26.1%) and Streptococcus pneumoniae (18.5%) in HIV-negative patients. The total mortality rate was high (94/223, 42.1%), including six rabies cases. In multivariate logistic regression analysis, mortality was associated with thrombocytopenia (Odds ratio (OR) 5.40, 95%-CI 2.40-11.83) and hydrocephalus (OR 4.07, 95%-CI 1.35-12.23). The proportion of untreated HIV patients, late presentations of neurotuberculosis, the rate of pneumococcal cases, and rabies patients who did not benefit from a post-exposure prophylaxis, suggest that decreasing the burden of CNS infections requires reinforcing health policy regarding tuberculosis, rabies, S. pneumoniae vaccination, and HIV-infections.

Paradoxical manifestations during tuberculous meningitis treatment among HIV-negative patients: a retrospective descriptive study and literature review

BACKGROUND

Tuberculous meningitis (TBM) is the most frequent, severe, and disabling form of central nervous system (CNS) tuberculosis (TB). TBM paradoxical manifestations are characterized by clinical or paraclinical worsening after 1 month of effective anti-TB treatment in patients who initially responded to treatment despite the use of adjunctive corticosteroids.

METHODS

Retrospective descriptive study of consecutive HIV-negative adult patients (≥ 18 years) with definitive TBM who developed a paradoxical manifestation following anti-TB in a tertiary-care hospital in Mexico from 2009 to 2019; we also conducted a literature review of published cases/series of paradoxical manifestations in HIV-negative patients from 1980 to 2020.

RESULTS

We detected 84 cases of definitive TBM; 55 (68.7%) HIV-negative patients and 29 (36.3%) HIV-infected patients. Among HIV-negative patients, four (7.3%), three female and one male (19-49 years old), developed a paradoxical manifestation within 4-14 weeks following treatment initiation despite receiving adequate corticosteroid doses; Mycobacterium bovis was isolated from the cerebrospinal fluid of three cases and Mycobacterium tuberculosis in one more. Two patients developed vasculopathy-related cerebral infarctions, one severe basilar meningitis, and hydrocephalus, one more a tuberculoma. Two were treated with intravenous cyclophosphamide, and two with steroids. One of the patients treated with steroids died; patients who received cyclophosphamide had a good clinical response.

CONCLUSIONS

This case series illustrates the diverse clinical/radiologic paradoxical manifestations of TBM in HIV-negative patients. Cyclophosphamide may be safe and effective in treating TBM-associated paradoxical manifestations. Specific diagnostic and care protocols for these patients are needed.

Clinical Outcome of Tuberculous Meningitis with Hydrocephalus - A Retrospective Study

BACKGROUND

To study the clinical outcome of tuberculous meningitis with hydrocephalus (TBMH) and the factors contributing to its poor clinical outcome.

METHODS

Clinical data of 143 adult patients diagnosed with TBM over a 6-year period in two tertiary hospitals in Malaysia were retrospectively reviewed. Relevant clinical and radiological data were studied. Patients with TBMH were further analysed based on their clinical grade and rendered treatment to identify associated factors and outcome of this subgroup of patients. The functional outcome of patients was assessed at 12 months from treatment.

RESULTS

The mean age of patients was 35.6 (12.4) years old, with a male gender predominance of 67.1%. Forty-four percent had TBMH, of which 42.9% had surgical intervention. In the good modified Vellore grade, 76.5% was managed medically with concurrent anti-tuberculosis treatment (ATT), steroids and osmotic agents. Four patients had surgery early in the disease as they did not respond to medical therapy and reported a good outcome subsequently. Poor outcome (65.2%) was seen in the poor modified Vellore grade despite medical and surgical intervention. Multivariate model multiple Cox regression showed significant results for seizure (adjusted hazard ratio [aHR]: 15.05; 95% CI: 3.73, 60.78), Glasgow coma scale (GCS) (aHR: 0.79; 95% CI: 0.70, 0.89) and cerebrospinal fluid (CSF) cell count (aHR: 1.11; 95% CI: 1.05, 1.17).

CONCLUSION

Hydrocephalus was seen in 44% of patients in this study. GCS score, seizure and high CSF cell count were factors associated with a poor prognosis in TBM. Patients with TBMH treated medically (TBMHM) had better survival function compared to TBMH patients undergoing surgical intervention (TBMHS) (P-value < 0.001). This retrospective study emphasises that TBMH is still a serious illness as 47.6% of the patients had poor outcome despite adequate treatment.

Risk Factors for Hydrocephalus in Neonatal Purulent Meningitis: A Single-Center Retrospective Analysis

OBJECTIVE

Hydrocephalus is a potentially lethal complication of neonatal purulent meningitis. Early detection of hydrocephalus helps to determine optimal treatment, improve prognosis, and reduce financial burden. We aimed to analyze the risk factors for hydrocephalus in neonates with purulent meningitis and discuss the characteristics of the disease.

METHODS

The records of neonatal purulent meningitis admitted to the Children Hospital of Fudan University from January 2013 to September 2019 were retrospectively included in the study cohort. The data of clinical, laboratory, and cranial magnetic resonance images (MRIs) were collected and analyzed (except discharge data) by univariate analysis, and P values <.05 were further analyzed by multivariate logistic regression.

RESULTS

A total of 197 children who met the inclusion criteria were enrolled in the study cohort. Overall, 39.6% (78/197) of the patients had positive pathogen cultures, and 60.4% (119/197) of patients had clinical diagnosis of meningitis with negative pathogen cultures. Among 197 children, 67 of them experienced hydrocephalus, and the factors that were significantly associated with hydrocephalus in multivariate analysis were female sex, cerebrospinal fluid glucose <2 mmol/L, periventricular leukomalacia, punctate white matter lesions, and pyogenic intraventricular empyema. Children with hydrocephalus had a lower cure rate of meningitis (31.3% vs 75.4%), and poor discharge outcomes. In addition, they had longer length of hospital stay and higher hospital cost.

CONCLUSIONS

Female sex, cerebrospinal fluid glucose <2 mmol/L, periventricular leukomalacia, punctate white matter lesions, and pyogenic intraventricular empyema were identified as risk factors for hydrocephalus in neonatal purulent meningitis. Children with hydrocephalus had poor discharge outcomes and increased financial burden on their families.

Tracking down the White Plague. Chapter three: Revision of endocranial abnormally pronounced digital impressions as paleopathological diagnostic criteria for tuberculous meningitis

Abnormally pronounced digital impressions (APDIs) on the endocranial surface develop secondary to a prolonged rise in the intracranial pressure. This can result from a number of pathological conditions, including hydrocephalus due to tuberculous meningitis (TBM). APDIs have been described with relation to TBM not only in the modern medical literature but also in several paleopathological studies. However, APDIs are not pathognomonic for TBM and their diagnostic value for identifying TBM in past human populations has not been evaluated in identified pre-antibiotic era skeletons. To assess the diagnostic value of APDIs for the first time, a macroscopic investigation was performed on skeletons from the Terry Collection (Smithsonian Institution, Washington, DC, USA). Our material consisted of 234 skeletons with tuberculosis (TB) as the cause of death (TB group) and 193 skeletons with non-tuberculous (NTB) causes of death (NTB group). The macroscopic examination focused on the stage of the prominence and frequency of APDIs in the TB group and NTB group. To determine the significance of difference (if any) in the frequency of APDIs between the two groups, χ2 testing of our data was conducted. We found that APDIs were twice as common in the TB group than in the NTB group. The χ2 comparison of the frequencies of APDIs revealed a statistically significant difference between the two groups. In addition, APDIs with more pronounced stages were recorded more frequently in the TB group. Our results indicate that APDIs can be considered as diagnostic criteria for TBM in the paleopathological practice. With suitable circumspection, their utilization provides paleopathologists with a stronger basis for identifying TB and consequently, with a more sensitive means of assessing TB frequency in past human populations.

Frequency of Hyponatremia in Patients of Tuberculosis Bacterial Meningitis in a Tertiary Care Hospital

Introduction Tuberculous meningitis (TBM) brings significant morbidity and mortality worldwide. Hyponatremia has long been documented as a potentially grave metabolic result of TBM. The syndrome of inappropriate antidiuretic hormone (SIADH) secretion has been supposed to be accountable for the majority of cases of hyponatremia in TBM. Cerebral salt wasting syndrome (CSWS) is being progressively reported as a basis of hyponatremia in some of these cases. Differentiating CSWS from SIADH can be challenging but is vital because treatment of these two conditions is profoundly different. Objective The rationale of our study is to determine the frequency of hyponatremia and etiology in patients presenting with TBM in a tertiary care hospital in order to establish the local perspective as there is paucity of local data. Methods A total of 160 hospitalized patients at a tertiary care hospital in Pakistan who fulfilled the inclusion criteria were enrolled in this study after informed consent. The study was conducted for six months at the department of neurology, Jinnah Postgraduate Medical Centre (JPMC), Karachi, Pakistan. Brief history was taken and demographic information was entered in the performa by researchers. The data was collected and analyzed on Statistical Package for Social Sciences (SPSS) version 18.0 (IBM Corp., Armonk NY, USA). Demographic data were presented as simple descriptive statistics giving mean and standard deviation for age, height, weight, GCS (Glasgow Coma Scale), serum sodium and duration of symptoms. Frequencies and percentages were calculated for categorical variables like gender, hypertension, smoking status, T2DM (Type 2 Diabetes Mellitus), BMRC (British Medical Research Council Contemporary Clinical Criteria for TBM) stage, hyponatremia, SIADH and CSWS. Effect modifiers were controlled through stratification of age, gender, hypertension, smoking status, T2DM, BMRC stage and duration of symptoms to see the effect of these on the outcome variable (hyponatremia). Quantitative data were presented as simple descriptive statistics giving mean and standard deviation and qualitative variables were presented as frequency and percentages. Post stratification chi-square test was applied with a p-value of ≤0.05 taken as significant. Results In our study, out of 160 patients with TBM, 40% (64) had hyponatremia. Moreover, 14.4% and 25.6% had SIADH and CSWS, respectively with 60% (96) of patients were male and 40% (64) were female. Mean age of patients in our study was 46.78±2.81 years. Whereas, mean duration of symptoms, serum sodium, GCS, height and weight in our study was 1.2±0.78 weeks, 128.65±7.52 mmol/L and 11.21±3.14%, 158±7.28 cm and 78.7±9.87 kg, respectively. Conclusion This study concluded that the frequency of hyponatremia among patients of TBM was significant, consistent with previous studies. Privation of proper assessment and management can lead to grave and permanent neurological consequences, as well as death. Healthcare providers should be aware of the implication of sodium deregulation among patients of TBM and differentiate between the numerous therapeutic preferences in order to advocate safe and effective treatment.

Brain MRI findings in relation to clinical characteristics and outcome of tuberculous meningitis

Neuroradiological abnormalities in tuberculous meningitis (TBM) are common, but the exact relationship with clinical and inflammatory markers has not been well established. We performed magnetic resonance imaging (MRI) at baseline and after two months treatment to characterise neuroradiological patterns in a prospective cohort of adult TBM patients in Indonesia. We included 48 TBM patients (median age 30, 52% female, 8% HIV-infected), most of whom had grade II (90%), bacteriologically confirmed (71%) disease, without antituberculotic resistance. Most patients had more than one brain lesion (83%); baseline MRIs showed meningeal enhancement (89%), tuberculomas (77%), brain infarction (60%) and hydrocephalus (56%). We also performed an exploratory analysis associating MRI findings to clinical parameters, response to treatment, paradoxical reactions and survival. The presence of multiple brain lesion was associated with a lower Glasgow Coma Scale and more pronounced motor, lung, and CSF abnormalities (p-value <0.05). After two months, 33/37 patients (89%) showed worsening of MRI findings, mostly consisting of new or enlarged tuberculomas. Baseline and follow-up MRI findings and paradoxical responses showed no association with six-month mortality. Severe TBM is characterized by extensive MRI abnormalities at baseline, and frequent radiological worsening during treatment.

Presentations and outcomes of central nervous system TB in a UK cohort: The high burden of neurological morbidity

OBJECTIVES

Most data for Central Nervous System Tuberculosis (CNS-TB) derive from high-incidence, resource-limited countries. We sought to determine the presentation, management and outcomes of CNS-TB in a low-incidence setting with accessible healthcare.

METHODS

We undertook a retrospective, observational study of CNS-TB in adults at a single tertiary-referral London hospital (2001-2017). Cases were categorised as either TB meningitis (TBM) or TB mass lesions without meningitis (TBML), applying novel criteria for definite, probable, and possible TBML.

RESULTS

We identified sixty-two cases of TBM (37% definite; 31% probable; 32% possible) alongside 14 TBML cases (36% definite; 29% probable; and 36% possible). Clinical presentation was highly variable. Among CSF parameters, hypoglycorrhachia proved most discriminatory for "definite" TBM. Neurosurgical intervention was required for mass-effect or hydrocephalus in 16%. Mortality was higher in TBM versus TBML (16% vs. 0%) but overall morbidity was significant; 33% of TBM and 29% of TBML survivors suffered persisting neurological disability at 12-months. In TBM, hydrocephalus, infarct, basal enhancement and low CSF white cell count were independently associated with worse neurological outcomes.

CONCLUSION

Although mortality was lower than previously reported in other settings, morbidity was significant, highlighting the need for improved CNS-TB diagnostics, therapeutics and interventions to mitigate neurological sequelae.

Standardized approaches for clinical sampling and endpoint ascertainment in tuberculous meningitis studies

Tuberculous meningitis (TBM), the most severe manifestation of tuberculosis, has poorly understood immunopathology and high mortality and morbidity despite antituberculous therapy. This calls for accelerated clinical and basic science research in this field. As TBM disproportionally affects poorer communities, studies are often performed in resource-limited environments, creating challenges for data collection and harmonisation. Comparison of TBM studies has been hampered by variation in sampling strategies, study design and choice of study endpoints.  Based on literature review and expert consensus, this paper provides firstly, practical recommendations to enable thorough diagnostic, pathophysiological and pharmacokinetic studies using clinical samples, and facilitates better data aggregation and comparisons across populations and settings. Secondly, we discuss clinically relevant study endpoints, including neuroimaging, functional outcome, and cause of death, with suggestions of how these could be applied in different designs for future TBM studies.

Standardized approaches for clinical sampling and endpoint ascertainment in tuberculous meningitis studies

Tuberculous meningitis (TBM), the most severe manifestation of tuberculosis, has poorly understood immunopathology and high mortality and morbidity despite antituberculous therapy. This calls for accelerated clinical and basic science research in this field. As TBM disproportionally affects poorer communities, studies are often performed in resource-limited environments, creating challenges for data collection and harmonisation. Comparison of TBM studies has been hampered by variation in sampling strategies, study design and choice of study endpoints.  Based on literature review and expert consensus, this paper provides firstly, practical recommendations to enable thorough diagnostic, pathophysiological and pharmacokinetic studies using clinical samples, and facilitates better data aggregation and comparisons across populations and settings. Secondly, we discuss clinically relevant study endpoints, including neuroimaging, functional outcome, and cause of death, with suggestions of how these could be applied in different designs for future TBM studies.

[Parardoxical reaction following tuberculosis treatment in non HIV-infected patients]

A paradoxical reaction is the worsening of prior existing, or the appearance of, new tuberculous lesions, following the initiation of treatment with anti-tuberculous drugs, after the exclusion of poor compliance, malabsorption, drug interaction or multiresistant mycobacteria. Well known and well managed in the context of HIV coinfection, it is not well known outside this context. An increasing number of publications have described this syndrome. This review aims to describe the pathogenic, epidemiological, clinical, prognostic and therapeutic elements of non-HIV-associated paradoxical reactions. It involves a reversal of the Mycobacterium tuberculosis-induced immunodepression along with a heightened detrimental pro-inflammatory profile caused by efficient drug treatment. Extra-thoracic locations, especially lymph nodes and neurological, malnutrition and initial lymphopenia are the principal risk factors. The median delay is 40±20 days after the onset of treatment. Corticosteroids are the mainstay of the management. Anti-TNF-α drugs show good results in corticosteroid refractory cases. The prognosis is good overall except in neurological forms. The place of preventive methods remains to be established.

Checklists to guide the supportive and critical care of tuberculous meningitis

The assessment and management of tuberculous meningitis (TBM) is often complex, yet no standardised approach exists, and evidence for the clinical care of patients, including those with critical illness, is limited. The roles of proformas and checklists are increasing in medicine; proformas provide a framework for a thorough approach to patient care, whereas checklists offer a priority-based approach that may be applied to deteriorating patients in time-critical situations. We aimed to develop a comprehensive assessment proforma and an accompanying 'priorities' checklist for patients with TBM, with the overriding goal being to improve patient outcomes. The proforma outlines what should be asked, checked, or tested at initial evaluation and daily inpatient review to assist supportive clinical care for patients, with an adapted list for patients in critical care. It is accompanied by a supporting document describing why these points are relevant to TBM. Our priorities checklist offers a useful and easy reminder of important issues to review during a time-critical period of acute patient deterioration. The benefit of these documents to patient outcomes would require investigation; however, we hope they will promote standardisation of patient assessment and care, particularly of critically unwell individuals, in whom morbidity and mortality remains unacceptably high.

Treatment outcomes of tuberculous meningitis in adults: a systematic review and meta-analysis

Background

Tuberculous meningitis is the most devastating presentation of disease with Mycobacterium tuberculosis. We sought to evaluate treatment outcomes for adult patients with this disease.

Methods

The Ovid MEDLINE, EMBASE, Cochrane Library and Web of Science databases were searched to identify all relevant studies. We pooled appropriate data to estimate treatment outcomes at the end of treatment and follow-up.

Results

Among the articles identified, 22 met our inclusion criteria, with 2437 patients. In a pooled analysis, the risk of death was 24.7% (95%CI: 18.7–31.9). The risk of neurological sequelae among survivors was 50.9% (95%CI: 40.2–61.5). Patients diagnosed in stage III or human immunodeficiency virus (HIV) positive were significantly more likely to die (64.8, 53.4% respectively) during treatment. The frequency of cerebrospinal fluid (CSF) acid-fast-bacilli smear positivity was 10.0% (95% CI 5.5–17.6), 23.8% (15.2–35.3) for CSF culture positivity, and 22.3% (17.8–27.5) for CSF polymerase chain reaction positivity. We found that the headache, fever, vomiting, and abnormal chest radiograph were the most common symptoms and diagnostic findings among tuberculous meningitis patients.

Conclusions

Despite anti-tuberculosis treatment, adult tuberculous meningitis has very poor outcomes. The mortality rate of patients diagnosed in stage III or HIV co-infection increased significantly during treatment.

Muscular hypotonia as an onset manifestation of Tuberculosis meningitis in an HIV-negative patient

Muscular hypotonia is considered as one of the rarest forms of initial onset signs of TBM, in addition to aphasia and hyponatremia, the awareness of those rare onset signs, a well-conducted diagnostic approach and early treatment can improve the outcome.

Checklists to guide the supportive and critical care of tuberculous meningitis

The assessment and management of tuberculous meningitis (TBM) is often complex, yet no standardised approach exists, and evidence for the clinical care of patients, including those with critical illness, is limited. The roles of proformas and checklists are increasing in medicine; proformas provide a framework for a thorough approach to patient care, whereas checklists offer a priority-based approach that may be applied to deteriorating patients in time-critical situations. We aimed to develop a comprehensive assessment proforma and an accompanying 'priorities' checklist for patients with TBM, with the overriding goal being to improve patient outcomes. The proforma outlines what should be asked, checked, or tested at initial evaluation and daily inpatient review to assist supportive clinical care for patients, with an adapted list for patients in critical care. It is accompanied by a supporting document describing why these points are relevant to TBM. Our priorities checklist offers a useful and easy reminder of important issues to review during a time-critical period of acute patient deterioration. The benefit of these documents to patient outcomes would require investigation; however, we hope they will promote standardisation of patient assessment and care, particularly of critically unwell individuals, in whom morbidity and mortality remains unacceptably high.

Neuroimaging in Pediatric Hydrocephalus

The objective of this review is to discuss the role of neuroimaging in evaluating pediatric and fetal hydrocephalus based on possible pathophysiologic mechanisms and in the context of differing etiology. Although conventional brain imaging with ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) is commonly used to assess for ventricular enlargement, however, the underlying mechanisms and management of hydrocephalus is a challenge in pediatric population and fetal hydrocephalus. MRI helps define the possible nature of the obstruction, and provides useful functional and anatomic information. MR imaging, in both pediatric and fetal hydrocephalus, thus may help in better understanding of the possible pathophysiologic mechanisms of the varied causal factors. The article focuses on the usage of MRI sequences in both diagnosis and follow-up of pediatric and fetal hydrocephalus, to be able to investigate all possible etiopathogenesis through the CSF pathway and to assess the efficacy of treatment in a non-invasive standardized manner.

Clinical features, outcomes and prognostic factors of tuberculous meningitis in adults worldwide: systematic review and meta-analysis

BACKGROUND

Tuberculous meningitis (TBM) is one of the most life-threatening infectious diseases. We performed a systematic review and meta-analysis of the clinical features, outcomes, and prognostic factors for TBM in adults.

METHODS

PubMed, EMBASE, Cochrane CENTRAL, and Web of Science were searched for studies that reported the clinical outcomes and/or risk factors for death in adults with TBM between January 1990 and July 2018. A random-effects meta-analysis model was used to pool data on clinical features, outcomes, and risk factors for death.

RESULTS

Thirty-two studies that examined 5023 adults who had TBM met the inclusion criteria. Overall, the mortality was 22.8% [95% confidence interval (CI) 18.9-26.8] and the risk of neurological sequelae was 28.7% (95% CI 22.8-35.1). The major risk factors for death (OR > 2 and P < 0.05) were advanced stage of disease (OR = 6.06, 95% CI 4.31-8.53), hydrocephalus (OR = 5.27, 95% CI 2.25-12.37), altered consciousness (OR 3.33, 95% CI 1.51-7.36), altered sensorium (OR 3.31, 95% CI 2.20-4.98), advanced age (> 60 years; OR = 2.64, 95% CI 1.27-5.51), and cerebral infarction (OR = 2.35, 95% CI 1.63-3.38). The clinical features and diagnostic findings present in more than four-fifths of the patients were fever (86.3%, 95% CI 82.4-89.8) and low CSF/serum glucose ratio (80.6%, 95% CI 64.8-92.6).

CONCLUSIONS

Adults with TBM have high rates of mortality. Clinicians should maintain a high clinical suspicion for patients who present with certain clinical features, and should pay more attention to prognostic factors.

TB Meningitis and TB Peritonitis: Abdominal Pseudocyst and VP-Shunt Link

TB meningitis (TBM) carries high morbidity and mortality and is a relatively common extrapulmonary TB in the third world countries. TBM as thick exudative disease manifests on MRI and CT as nodular basal leptomeningitis, hydrocephalus, basal infarcts, and tuberculomas. Hydrocephalus is treated with ventriculoperitoneal shunting (VPS). Shunt malfunction and revision are common. We report a case of multidrug-resistant TBM with spinal involvement and dissemination of the disease via VPS causing TB peritonitis (TBP). TBP presented as a large abdominal pseudocyst around the catheter tip with shunt malfunction. There was no evidence for any other site of extra-CNS disease. TBP per se is relatively less common. This is the first case reporting VPS as a means of TB spread.

Ophthalmological manifestation in patients of tuberculous meningitis

BACKGROUND

Vision impairment, blindness in particular is a devastating complication in patients with tuberculous meningitis. However, information regarding ophthalmological manifestation and its impact on vision is sparse in the literature. This study evaluated the spectrum of ophthalmological manifestations in tuberculous meningitis, including retinal nerve fiber layer thickness assessment by optic coherence tomography and its correlation with visual and clinical outcome.

METHODS

This was a prospective observational study done from October 2015 to March 2017. Consecutive patients of tuberculous meningitis, diagnosed as per consensus case definition were included in the study. The patients were divided into two categories: uncomplicated and complicated tuberculous meningitis. Clinical evaluation, cerebrospinal fluid examination and contrast enhanced MRI of brain was done. Detailed ophthalmological evaluation including optic coherence tomography was done in all patients. All the patients were followed for 6 months. The primary outcome was blindness or low vision after 6 months. The secondary outcome was death or severe disability after 6 months. It was defined as modified Barthel index (MBI) ≤ 12 at 6 months (including disability plus death). Appropriate statistical analysis was done.

RESULTS

Out of 101 patients of tuberculous meningitis, 47 patients of TBM belonged to uncomplicated category, while 54 patients were of complicated group. The visual impairment was present in 24 out of 101 (23.76%) patients out of which 20 (19.8%) patients had low vision while 4 (3.96%) had blindness. The visual impairment was more evident in complicated group, low vision 0.03 (1.2-31.5). The most common abnormality on fundus examination was papilledema (22.8%). The complicated group had more incidence <0.0001 (19.6-48). Optic atrophy was found in three patients while choroid tubercles were found in eight patients (all complicated TBM group). RNFL thinning was noted in 10 patients in both the eyes. On univariate analysis, presence of diplopia at baseline, impairment of color vision at baseline, visual impairment at baseline, cranial nerve VIth involvement, optic atrophy and papilledema at baseline, RNFL thinning, abnormal VEP and baseline MBI were associated with poor visual outcome. On multivariate analysis, none of the factors were found to be independently associated with poor visual outcome. On univariate analysis, many factors including baseline MRC staging, altered sensorium, seizure, hemiparesis, basal exudates, infarcts, optochiasmaticarachnoiditis, visual impairment at baseline were found to be associated with poor clinical outcome at 6 months. On multivariate analysis, presence of seizure (P = 0.047, odds ratio = 78.59, 95% confidence interval (1.07-578.72)) was the only factor found to be independently associated with poor outcome.

CONCLUSION

Wide spectrum of ophthalmological manifestation was observed in patients of tuberculous meningitis. The visual impairment was more evident in complicated tuberculous meningitis. Ophthalmological findings like optic atrophy, papilledema and RNFL thinning were associated with poor visual outcome on univariate but not multivariate analysis. Visual impairment at baseline, among other factors was associated with poor clinical outcome on univariate analysis, whereas seizure was the only factor independently associated with poor outcome on multivariate analysis.

The neurocritical care of tuberculous meningitis

Tuberculous meningitis is the most severe form of tuberculosis and often causes critical illness with high mortality. Two primary management objectives are reducing intracranial pressure, and optimising cerebral perfusion, while killing the bacteria and controlling intracerebral inflammation. However, the evidence base guiding the care of critically ill patients with tuberculous meningitis is poor and many patients do not have access to neurocritical care units. Invasive intracranial pressure monitoring is often unavailable and although new non-invasive monitoring techniques show promise, further evidence for their use is required. Optimal management regimens of neurological complications (eg, hydrocephalus and paradoxical reactions) and of hyponatraemia, which frequently accompanies tuberculous meningitis, remain to be elucidated. Advances in the field of tuberculous meningitis predominantly focus on diagnosis, inflammatory processes, and antituberculosis chemotherapy. However, clinical trials are required to provide robust evidence guiding the most effective supportive, therapeutic, and neurosurgical interventions for tuberculous meningitis that will improve morbidity and mortality.

Age-specific global epidemiology of hydrocephalus: Systematic review, metanalysis and global birth surveillance

Background

Hydrocephalus is a debilitating disorder, affecting all age groups. Evaluation of its global epidemiology is required for healthcare planning and resource allocation.

Objectives

To define age-specific global prevalence and incidence of hydrocephalus.

Methods

Population-based studies reporting prevalence of hydrocephalus were identified (MEDLINE, EMBASE, Cochrane, and Google Scholar (1985–2017)). Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Two authors reviewed abstracts, full text articles and abstracted data. Metanalysis and meta-regressions were used to assess associations between key variables. Heterogeneity and publication bias were assessed. Main outcome of interest was hydrocephalus prevalence among pediatric (≤ 18 years), adults (19–64 years), and elderly (≥ 65) patients. Annual hydrocephalus incidence stratified by country income level and folate fortification requirements were obtained (2003–2014) from the International Clearinghouse for Birth Defects Surveillance and Research (ICBDSR).

Results

Of 2,460 abstracts, 52 met review eligibility criteria (aggregate population 171,558,651). Mean hydrocephalus prevalence was 85/100,000 [95% CI 62, 116]. The prevalence was 88/100,000 [95% CI 72, 107] in pediatrics; 11/100,000 [95% CI 5, 25] in adults; and 175/100,000 [95% CI 67, 458] in the elderly. The ICBDSR-based incidence of hydrocephalus diagnosed at birth remained stable over 11 years: 81/100,000 [95% CI 69, 96]. A significantly lower incidence was identified in high-income countries.

Conclusion

This systematic review established age-specific global hydrocephalus prevalence. While high-income countries had a lower hydrocephalus incidence according to the ICBDSR registry, folate fortification status was not associated with incidence. Our findings may inform future healthcare resource allocation and study.

Central Nervous System Tuberculosis : Etiology, Clinical Manifestations and Neuroradiological Features

PURPOSE

As a result of multilateral migration and globalization in times of humanitarian crises, western countries face a possible increase in the incidence of central nervous system tuberculosis (CNS TB). The diagnosis of CNS TB is challenging and often delayed due to the manifold and often non-specific presentation of the disease. The aim of this review is to analyze and summarize imaging features and correlated clinical findings of CNS TB.

METHODS

The different manifestations of CNS TB are explained and illustrated by characteristic neuroradiological as well as neuropathological findings. An overview on diagnostic and therapeutic approaches is provided. For clarity, tables summarizing the lesion patterns, differential diagnoses and diagnostic hints are added.

RESULTS

The CNS TB can be manifested (1) diffuse as tuberculous meningitis (TBM), (2) localized as tuberculoma or (3) tuberculous abscess or (4) in extradural and intradural spinal infections. Information on clinical presentation, underlying pathology and the distinguishing features is demonstrated. The TBM is further described, which may lead to cranial nerve palsy, hydrocephalus and infarction due to associated arteritis of the basal perforators. The differential diagnoses are vast and include other infections, such as bacterial, viral or fungal meningoencephalitis, malignant causes or systemic inflammation with CNS. Complicating factors of diagnosis and treatment are HIV coinfection, multi-drug resistance and TB-associated immune reconstitution inflammatory syndrome (IRIS).

CONCLUSIONS

Neurologists and (neuro-)radiologists should be familiar with the neuroradiological presentation and the clinical course of CNS TB to ensure timely diagnosis and treatment.

Functional outcomes in adults with tuberculous meningitis admitted to the ICU: a multicenter cohort study

BACKGROUND

Tuberculous meningitis (TBM) is a devastating infection in tuberculosis endemic areas with limited access to intensive care. Functional outcomes of severe adult TBM patients admitted to the ICU in nonendemic areas are not known.

METHODS

We conducted a retrospective multicenter cohort study (2004-2016) of consecutive TBM patients admitted to 12 ICUs in the Paris area, France. Clinical, biological, and brain magnetic resonance imaging (MRI) findings at admission associated with a poor functional outcome (i.e., a score of 3-6 on the modified Rankin scale (mRS) at 90 days) were identified by logistic regression. Factors associated with 1-year mortality were investigated by Cox proportional hazards modeling.

RESULTS

We studied 90 patients, of whom 61 (68%) had a score on the Glasgow Coma Scale ≤ 10 at presentation and 63 (70%) required invasive mechanical ventilation. Brain MRI revealed infarction and hydrocephalus in 38/75 (51%) and 25/75 (33%) cases, respectively. A poor functional outcome was observed in 55 (61%) patients and was independently associated with older age (adjusted odds ratio (aOR) 1.03, 95% CI 1.0-1.07), cerebrospinal fluid protein level ≥ 2 g/L (aOR 5.31, 95% CI 1.67-16.85), and hydrocephalus on brain MRI (aOR 17.2, 95% CI 2.57-115.14). By contrast, adjunctive steroids were protective (aOR 0.13, 95% CI 0.03-0.56). The multivariable adjusted hazard ratio of adjunctive steroids for 1-year mortality (47%, 95% CI 37%-59%) was 0.23 (95% CI 0.11-0.44). Among survivors at 1 year, functional independence (mRS of 0-2) was observed in 27/37 (73%, 95% CI 59%-87%) cases.

CONCLUSIONS

A poor functional outcome in adult TBM patients admitted to the ICU in a nonendemic area is observed in 60% of cases and is independently associated with elevated cerebrospinal fluid protein level and hydrocephalus. Our data also suggest a protective effect of adjunctive steroids, with reduced disability and mortality, irrespective of immune status and severity of disease at presentation. One-year follow-up revealed functional independence in most survivors.

Multifaceted progressive neurotuberculosis in a single patient: from miliary tuberculomas to cortical venous infarct

Neurotuberculosis is a potentially fatal disease which requires prompt diagnosis and immediate multidrug antitubercular treatment as per international guidelines. There is evidence that the bacterial spread can continue even during therapy at least in its initial stages. We monitored our patient not only with chest X-rays but with brain MRI during the first 6 weeks. To our surprise on serial MRI, during treatment, we found several new localization of the disease in a pauci-symptomatic patient. These included vessel wall inflammation (vasculitis), arachnoiditis and hypophysitis. At 4 weeks of treatment, the patient complained of dizziness and vomiting which were first dismissed as treatment side-effects but MRI revealed multiple cortical venous hemorrhagic infarcts. We report this case to emphasize the importance of neuroimaging even in case of the most subtle symptoms and that disease can continue to progress in the initial phase of treatment which may require additional therapeutic intervention.

Central nervous system infections in immunocompromised patients

PURPOSE OF REVIEW

Although rare, central nervous system (CNS) infections are increasingly being recognized in immunocompromised patients. The goal of the present review is to provide a practical diagnostic approach for the intensivist, and to briefly discuss some of the most prevalent conditions.

RECENT FINDINGS

Immunocompromised patients presenting with new neurological symptoms should always be suspected of a CNS infection. These infections carry a poor prognosis, especially if intracranial hypertension, severely altered mental status or seizures are present. Clinical examination and serum blood tests should be followed by brain imaging, and when no contra-indications are present, a lumbar puncture including cerebrospinal fluid PCR to identify causative organisms. Empirical therapy depends on the type of immunodeficiency. In HIV-infected patients, the most common CNS infection is cerebral toxoplasmosis, whereas in other immunocompromised patients, aspergillosis, cryptococcal meningitis and tuberculous meningitis are more prevalent. Multiple pathogens can be detected in up to 15% of patients. The diagnostic value of fast multiplex PCR has yet to be evaluated in this setting.

SUMMARY

CNS infections represent a rare but severe complication in immunocompromised patients. A systematic approach including early diagnosis, appropriate antimicrobial treatment, early ICU admission and aggressive measures to reduce intracranial pressure may improve outcome.

Atypical Cerebral Manifestations of Disseminated Mycobacterium tuberculosis

Background

We investigated the patterns of cerebral manifestations in patients with underlying pulmonary or extrapulmonary tuberculosis or disseminated tuberculosis.

Materials and methods

From January 2010 to September 2016, brain magnetic resonance imaging (MRI) scans were obtained to evaluate cerebral manifestations in patients with underlying pulmonary or extrapulmonary tuberculosis. We also included patients with drug-resistant tuberculosis or disseminated tuberculosis. MRI findings of tuberculous meningitis and tuberculoma were classified as typical; other MRI findings were classified as atypical. Demographic data, risk factors, and drug regimens were collected and analyzed.

Results

Twenty-two patients were diagnosed with cerebral tuberculosis. Cerebral tuberculosis was due to hematogenous spread from pulmonary tuberculosis (10 patients), spinal tuberculosis (8 patients), disseminated tuberculosis (3 patients), and unknown causes (1 patient). There were six patients with typical MRI findings (three patients with typical meningitis involving the basal cistern and supratentorium, one patient with tuberculomas, and two patients with both) and seven patients with atypical MRI findings [five patients with evidence of early meningitis, such as high signal intensity on fluid-attenuated inversion recovery (FLAIR) along the cerebellar folia, and two patients with only hydrocephalus].

Conclusion

Besides the typical sites of meningeal involvement, overlooked findings such as FLAIR abnormalities along the cerebellar folia or hydrocephalus should be checked for early detection of cerebral tuberculosis and initiation of the appropriate treatment against disseminated tuberculosis.

Tuberculous Meningitis in Children and Adults: New Insights for an Ancient Foe

PURPOSE OF REVIEW

Tuberculous meningitis is the most devastating manifestation of infection with Mycobacterium tuberculosis and represents a medical emergency. Approximately one half of tuberculous meningitis patients die or suffer severe neurologic disability. The goal of this review will be to review the pathogenic, clinical, and radiologic features of tuberculous meningitis and to highlight recent advancements in translational and clinical science.

RECENT FINDINGS

Pharmacologic therapy includes combination anti-tuberculosis drug regimens and adjunctive corticosteroids. It is becoming clear that a successful treatment outcome depends on an immune response that is neither too weak nor overly robust, and genetic determinants of this immune response may identify which patients will benefit from adjunctive corticosteroids. Recent clinical trials of intensified anti-tuberculosis treatment regimens conducted in Indonesia and Vietnam, motivated by the pharmacologic challenges of treating M. tuberculosis infections of the central nervous system, have yielded conflicting results regarding the survival benefit of intensified treatment regimens. More consistent findings have been observed regarding the relationship between initial anti-tuberculosis drug resistance and mortality among tuberculous meningitis patients. Prompt initiation of anti-tuberculosis treatment for all suspected cases remains a key aspect of management. Priorities for research include the improvement of diagnostic testing strategies and the optimization of host-directed and anti-tuberculosis therapies.

Old age and hydrocephalus are associated with poor prognosis in patients with tuberculous meningitis: A retrospective study in a Chinese adult population

Tuberculous meningitis (TBM) is the most common form of central nervous system tuberculosis with a very poor prognosis. We aimed at assessing risk factors related to the prognosis of patients with TBM.Forty-five inpatients with TBM in our institution from January 2013 to December 2015 were enrolled retrospectively. The good or poor prognosis in the patients was defined, based on Glasgow Outcome Scale System at discharge. Patients with a GOS score less than 5 were defined as "poor prognosis." Univariate and multivariate logistic regression analyses were performed to assess the predictors for TBM outcome.Among 45 TBM patients, 35 (77.8%) and 10 (22.2%) were in good, poor prognoses, respectively. Old age, disturbance of consciousness, moderate to severe electroencephalogram abnormality, hydrocephalus, remarkable increase of protein (≥ 236 mg/dL) and white blood cell counts (≥ 243 /μL) in cerebral spinal fluid were associated with poor prognosis. Multivariate analysis indicated that old age (odds ratio (OR) = 18.395, P = .036) and hydrocephalus (OR = 32.995, P = .049) were independent factors for a poor outcome of TBM.In conclusion, old age and hydrocephalus are the predictors for poor prognosis of TBM. Patients with these risk factors should be treated promptly with a special care paid to improve their outcomes.