Childhood tubercular meningitis: an institutional experience and analysis of predictors of outcome

Risk Factors for Stroke in Children with Tuberculous Meningitis: A Prospective Observational Study

OBJECTIVE

The purpose of the study is to establish the prevalence of stroke as well as the clinical and radiological correlates of stroke in children with tuberculous meningitis (TBM).

METHODS AND MATERIALS

A prospective observational study was conducted at the Pediatric Department, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India. Using a computed tomography (CT) scan/brain magnetic resonance imaging (MRI), patients were divided into stroke and non-stroke groups. Demographic characteristics, clinical presentations, cerebrospinal fluid examination, basal meningeal enhancement, hydrocephalus, tuberculoma, and clinical outcome were compared between the two groups.

RESULTS

Seventy-eight TBM patients, aged between 6 months and 14 years, were included. Out of 78 enrolled patients, 3 (3.8%) had definite TBM, 73 (91%) had probable TBM, and 4 (5.1%) had possible TBM (LCS). As per the Medical Research Council (MRC) staging, 13% had Stage 1 TBM, 26% had stage 2, and 61% had stage 3 TBM. Out of 78 patients with chest X-ray findings, 42 (53%) had findings suggestive of tuberculosis (TB), which included 33 (42%) with hilar lymphadenopathy and 9 (11%) with a miliary pattern. On neuroimaging, hydrocephalous was seen in 62.8% of cases, basal meningeal enhancement in 64.1%, tuberculoma in 6.4% of cases, and infarction in 53.8% of cases. There was no statistically significant association found between the staging of TBM and the presence of infarction as the majority of cases involved were in stage 3 of the disease (61.5%). TBM patients with stroke had poor clinical outcomes.

CONCLUSION

Age, altered sensorium, focal neurological deficits, vomiting, and basal meningeal enhancement can predict the occurrence of stroke in young adults with TBM.

Surgery for Central Nervous System Tuberculosis in Children

Tuberculosis (TB) is the second most common cause of death due to a single infectious agent worldwide after COVID-19. Central nervous system tuberculosis is widely prevalent in the world, especially in the developing countries and continues to be a socioeconomic problem. It is highly devastating form of tuberculosis leading to unacceptable levels of morbidity and mortality despite appropriate antitubercular therapy. The clinical symptoms are varied and nonspecific. They can be easily overlooked. Tuberculous meningitis is the most common presentation and its sequelae viz. vasculitis, infarction and hydrocephalus can be devastating. The ensuing cognitive, intellectual, and endocrinological outcome can be a significant source of morbidity and mortality, especially in resource constrained countries. Early diagnosis and treatment of tuberculous meningitis and institution of treatment is helpful in limiting the course of disease process. The diagnosis of CNS tuberculosis remains a formidable diagnostic challenge. The microbiological methods alone cannot be relied upon. CSF diversion procedures need to be performed at the appropriate time in order to achieve good outcomes. Tuberculous pachymeningitis and arachnoiditis are morbid sequelae of tuberculous meningitis. Tuberculomas present as mass lesions in the craniospinal axis. Tuberculous abscess can mimic pyogenic abscess and requires high index of suspicion. Calvarial tuberculosis is seen in children and responds well to antituberculous chemotherapy. Tuberculosis of the spinal cord is seen similar to intracranial tuberculosis in pathogenesis but with its own unique clinical manifestations and management. Multidrug-resistant tuberculosis is a formidable problem, and alternate chemotherapy should be promptly instituted. The pathogenesis, clinical features, diagnosis, and management of central nervous system tuberculosis in children are summarized. Heightened clinical suspicion is paramount to ensure prompt investigation. Early diagnosis and treatment are essential to a gratifying outcome and prevent complications.

Isolated cerebellar tuberculoma mimicking a malignant posterior cranial fossa tumor in a healthy child: A rare case report from Tanzania

INTRODUCTION

Tuberculosis (TB) is one of the leading causes of mortality and morbidity in the world, especially in developing countries that account for 98 % deaths among TB cases. Although TB is primarily a disease of the lungs, extrapulmonary manifestations have been reported. Although CNS tuberculoma mostly affects immunocompromised people, it also affects healthy people at extremes of age. Imaging of intracranial tuberculoma may look like neurocysticercosis, and other ring-enhancing lesions hence imposing a diagnosis dilemma.

CASE PRESENTATION

A 13-year-old female presented with headache, convulsions, blurry vision, and gait disturbance for six months. Brain imaging showed a left cerebellar lesion with obstructive hydrocephalus. She underwent ventriculoperitoneal shunting on admission, then sub-occipital craniotomy with tumor resection one week later. Histology confirmed a diagnosis of tuberculoma. She was given anti-tuberculosis medications and she was discharged home healthy without any of the symptoms she had on admission.

DISCUSSION

Although only about 1 % of active tuberculosis cases presents as CNS TB, 5-10 % of intracranial space-occupying lesions in developing countries are tuberculomas. Provisional diagnosis of tuberculoma can be made through clinical history, examination, and neuroimaging. However, it is challenging because neurocysticercosis also appears as a ring-enhancing lesion in the brain and has almost similar prevalence in low-income settings. Being immunocompetent with no history of tuberculosis or constitutional symptoms, a diagnosis of tuberculoma was only confirmed by histology.

CONCLUSION

A high index of suspicion for CNS tuberculomas in TB endemic areas should be kept in patients presenting with features of intracranial space-occupying lesions regardless of the absence of risk factors.

Outcome of tuberculous meningitis in children aged 9 months to 12 years at the end of intensive phase of treatment

BACKGROUND

Tuberculous meningitis (TBM) is associated with high morbidity and mortality. Most of the literature focuses on outcomes at the end of therapy when it may be too late for intervention to improve the outcomes. So, the present study addresses outcomes by the end of intensive course of therapy.

METHODS

It was a prospective cohort observational study that enrolled 80 patients with TBM between 9 months and 12 years of age. Participants were classified into Definite, Probable and Possible TBM using Marais criteria. Survival/Mortality was evaluated at the end of hospital stay. Demographic, clinical, cerebrospinal fluid and radiological parameters were evaluated for predictors of morbidity and mortality. Standardized tools were used to assess possible impairments in different domains at the end of intensive phase of treatment, namely Gross Motor Functional Classification System for motor functional ability, Pediatric-Mini Mental score examination (MMSE), Blantyre Coma Scale (BCS) score and Vineland Social Maturity Scale (VSMS) for cognitive outcome, Auditory Brainstem Evoked Responses for hearing outcome and using Teller's/Snellen's visual acuity charts to assess visual impairment.

RESULTS

A high Mortality rate of 42.5% was seen in the enrolled patients. Out of the total 80 patients, 20% recovered completely while 36.25% survived with disability (morbidity). Motor, Hearing, Cognitive and Vision impairment was present in 33.3%, 4%, 33.3% and 48.9% of the survivors respectively. On multivariate regression, raised intracranial tension and stage III disease were significantly associated with mortality. Morbidity was significantly associated with Stage III disease on multivariate analysis.

CONCLUSIONS

Despite advances in treatment, Tuberculous meningitis is associated with high burden of deaths and devastating neurological sequelae. Timely diagnosis and intervention of neurological impairments is needed to improve the outcome of TBM in survivors.

Clinicoepidemiological Profile and Prognostic Factors in Neurotuberculosis in Children

Purpose: This study aimed to determine the clinicoepidemiological profile and prognostic factors in children with neurotuberculosis.Methods: An observational study was conducted at a tertiary care hospital on 50 children diagnosed with neurotuberculosis. The demographic profile, clinical details, and all investigations were recorded on a predetermined form and datasheet for analysis, and disability severity was graded using the modified Rankin Scale.Results: Fifty patients were enrolled (male-to-female ratio, 1.08:1). Younger children (1 to 3 years) were more commonly affected. Most patients were malnourished, and only 58% had been immunized with the Bacillus Calmette-Guerin vaccine. Fever was the most common symptom (96%) followed by headache, altered consciousness, vomiting, seizures, and abnormal posture. On cerebrospinal fluid (CSF) analysis, 87% of patients showed pleocytosis with lymphocytic predominance. More than 80% of patients had CSF protein levels >100 mg/dL and CSF glucose levels <60 mg/dL. Common findings on neuroimaging were hydrocephalus (76%), basal meningeal enhancement (60%), basal exudates (52%), and parenchymal infarcts (32%). We noted a mortality rate of 40%, of whom 87.5% had modified British Medical Research Council (BMRC) stage 3 tubercular meningitis (TBM). All patients who survived stage 3 TBM had a severe disability, and over 50% of patients with stage 2 TBM had moderate to severe disabilities.Conclusion: Young age, lower socioeconomic status, BMRC stages 2 and 3, abnormal posture, hydrocephalus, and the presence of basal exudates were associated with poor outcomes. High suspicion is needed for early diagnosis and prevention of disability and mortality.

Bacterial meningitis in Africa

Bacterial meningitis differs globally, and the incidence and case fatality rates vary by region, country, pathogen, and age group; being a life-threatening disease with a high case fatality rate and long-term complications in low-income countries. Africa has the most significant prevalence of bacterial meningitis illness, and the outbreaks typically vary with the season and the geographic location, with a high incidence in the meningitis belt of the sub-Saharan area from Senegal to Ethiopia. Streptococcus pneumoniae (pneumococcus) and Neisseria meningitidis (meningococcus) are the main etiological agents of bacterial meningitis in adults and children above the age of one. Streptococcus agalactiae (group B Streptococcus), Escherichia coli, and Staphylococcus aureus are neonatal meningitis's most common causal agents. Despite efforts to vaccinate against the most common causes of bacterial neuro-infections, bacterial meningitis remains a significant cause of mortality and morbidity in Africa, with children below 5 years bearing the heaviest disease burden. The factors attributed to this continued high disease burden include poor infrastructure, continued war, instability, and difficulty in diagnosis of bacterial neuro-infections leading to delay in treatment and hence high morbidity. Despite having the highest disease burden, there is a paucity of African data on bacterial meningitis. In this article, we discuss the common etiologies of bacterial neuroinfectious diseases, diagnosis and the interplay between microorganisms and the immune system, and the value of neuroimmune changes in diagnostics and therapeutics.

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.

Clinical Profile, Yield of Cartridge-based Nucleic Acid Amplification Test (GeneXpert), and Outcome in Children with Tubercular Meningitis

Background:

GeneXpert MTB/RIF is a test for early, rapid diagnosis of tubercular meningitis (TBM).

Aim:

The aim of this article was to study the clinical profile, radiological features, yield of GeneXpert, neurosurgical interventions, and outcome of TBM in children.

Settings and Design:

This was a retrospective and prospective observational study.

Materials and Methods:

Diagnosis was based on the uniform research definition criteria and was staged according to the British Medical Research Council. Mantoux test, analysis of cerebrospinal fluid (CSF), CSF GeneXpert, and radiological investigations were performed.

Results:

Of 36 patients, 50% were aged 1–5 years. Fever (100%), headache (82%), altered sensorium (80%), and vomiting (66%) were common features. Twelve (33%) had contact with active case of tuberculosis; 32 received Bacille Calmette Guarin vaccination. Neurological features included severe deterioration in sensorium (Glasgow Coma Scale < 8) (38%), mild and moderate deficit in sensorium (31%), hemiparesis (41%), and involvement of sixth (25%) and seventh (22%) cranial nerves. Cerebral vision impairment (25%), papilledema (25%), and dystonia (22%) were other findings. CSF GeneXpert was positive in 37% (12/33) patients. Hydrocephalus and basal exudates (75%) were noted on neuro-imaging. Surgical intervention was performed in children with hydrocephalus (13/27). Omayya reservoir was placed in seven children, of which five needed conversion to ventriculoperitoneal (VP) shunt; direct VP shunt was carried out in six (6/13). Good outcome was noted in 78% at discharge. Stage III TBM (P = 0.0001), cerebral infarcts (P = 0.0006), and motor deficits (P = 0.03) were associated with poor outcome. Sequelae included learning difficulties with poor scholastic performance (31.5%).

Conclusion:

GeneXpert has high diagnostic specificity, but negative results do not rule out TBM. CSF GeneXpert provided quick results. Placement of Ommaya reservoir in TBM stage II and III with hydrocephalus was not successful. Hydrocephalus was managed conservatively with success (53%).

Changing Clinicoradiologic Spectrum of Intracranial Neurotuberculosis in Children: A Cross-sectional Study

BACKGROUND

Neurotuberculosis is among the most severe type of tuberculosis with high mortality and morbidity in all age groups. Various sociodemographic and disease-/treatment-related factors have emerged over the years that can affect clinical and radiologic features of neurotuberculosis.

OBJECTIVE

To investigate various clinical and neuroradiologic presentations of neurotuberculosis.

METHODOLOGY

This cross-sectional study was done in a tertiary care center of northern India. The patients between the ages of 3 months and 18 years with newly diagnosed neurotuberculosis were enrolled after taking informed consent.

RESULTS

A total of 78 patients (37% males) were enrolled. Fifty-six patients (72%) had tubercular meningitis (TBM) and 22 (28%) isolated tuberculomas. Very high percentage of patients in both the groups was BCG vaccinated. In the tubercular meningitis group, fever (68%), headache (59%), and vomiting (54%) were the most common complaints whereas in the tuberculoma group, seizures (95.5%) were the main complaint and systemic symptoms were rare. In tubercular meningitis patients, cerebrospinal fluid-based studies showed cartridge-based nucleic acid amplification test (Xpert MTB/RIF) positivity for Mycobacterium tuberculosis in 17.6% cases, whereas on gastric aspirate and sputum examination, acid-fast bacilli were seen in 30.7% and cartridge-based nucleic acid amplification test was positive in 19% patients. On neuroimaging, hydrocephalus was seen in 44.6% of tubercular meningitis patients, infarcts in 32%, and basal exudates in 12% patients only; coexistent tuberculomas were seen in 53%.

CONCLUSION

Compared with the available literature, the present study showed a smaller percentage of children <5 years of age, stage III tubercular meningitis cases, and typical neuroradiologic findings like hydrocephalus and basal exudates and more tuberculomas associated with tubercular meningitis.

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.

The prevalence, characteristics and outcome of seizure in tuberculous meningitis

Seizures are a common finding in patients with tuberculous meningitis (TBM), and associate with four times increased risk of death and neurological disability, especially in children. It has been reported that brain inflammation, diffuse neuronal injury, and reactive gliosis may all contribute to the pathogenesis of seizures in TBM. Early seizure onset may be associated with meningeal irritation and cerebral oedema; while, the late seizures are usually due to infarction, hydrocephalus, tuberculoma and paradoxical response. Moreover, recurrent uncontrolled seizures can evolve to status epileptics resulting in an increased risk of chronic epilepsy and poor prognosis. Therefore, this review aimed to assess the frequency of seizures in patients with TBM, and discuss the etiologies, mechanisms, and characteristics of seizures in TBM. Besides, we have searched the literature to identify the prognostic factors for chronic epilepsy after TBM.

Tuberculous meningitis in children: Clinical management & outcome

Although the occurrence of tuberculous meningitis (TBM) in children is relatively rare, but it is associated with higher rates of mortality and severe morbidity. The peak incidence of TBM occurs in younger children who are less than five years of age, and most children present with late-stage disease. Confirmation of diagnosis is often difficult, and other infectious causes such as bacterial, viral and fungal causes must be ruled out. Bacteriological confirmation of diagnosis is ideal but is often difficult because of its paucibacillary nature as well as decreased sensitivity and specificity of diagnostic tests. Early diagnosis and management of the disease, though difficult, is essential to avoid death or neurologic disability. Hence, a high degree of suspicion and a combined battery of tests including clinical, bacteriological and neuroimaging help in diagnosis of TBM. Children diagnosed with TBM should be managed with antituberculosis therapy (ATT) and steroids. There are studies reporting low concentrations of ATT, especially of rifampicin and ethambutol in cerebrospinal fluid (CSF), and very young children are at higher risk of low ATT drug concentrations. Further studies are needed to identify appropriate regimens with adequate dosing of ATT for the management of paediatric TBM to improve treatment outcomes. This review describes the clinical presentation, investigations, management and outcome of TBM in children and also discusses various studies conducted among children with TBM.

Tuberculosis of the central nervous system in children

BACKGROUND

Central nervous system tuberculosis (CNS TB) in children is still a socioeconomic problem in developing countries. It has varied manifestations, symptoms are nonspecific, diagnosis can be challenging, and treatment may be difficult. It is often missed or overlooked. Among the various pathological entities, tuberculous meningitis is the most common and devastating manifestation. The resultant vasculitis, infarction, and hydrocephalus can be life-threatening. It can have grave cognitive, intellectual, and endocrine sequelae if not treated in time resulting in handicap, especially in resource constraint countries. Early diagnosis and treatment of tuberculous meningitis is the single most important factor determining outcome. Tuberculous hydrocephalus needs to be recognized early, and cerebrospinal fluid diversion procedure needs to be performed in adequate time to prevent morbidity or mortality in some cases. Tuberculous pachymeningitis and arachnoiditis are rare in children. Tuberculous abscess can mimic pyogenic abscess and requires high index of suspicion. Calvarial tuberculosis is seen in children and responds well to antituberculous chemotherapy. Drug-resistant tuberculosis is a formidable problem, and alternate chemotherapy should be promptly instituted.

AIM

The pathogenesis, clinical features, diagnosis, and management of central nervous system tuberculosis in children are summarized.

CONCLUSION

Heightened clinical suspicion, early diagnosis, appropriate antituberculous treatment, and surgery in relevant situation are essential for a gratifying outcome and preventing complications.

Biomarkers of Cerebral Injury and Inflammation in Pediatric Tuberculous Meningitis

Background

Tuberculous meningitis (TBM) leads to death or disability in half the affected individuals. Tools to assess severity and predict outcome are lacking. Neurospecific biomarkers could serve as markers of the severity and evolution of brain injury, but have not been widely explored in TBM. We examined biomarkers of neurological injury (neuromarkers) and inflammation in pediatric TBM and their association with outcome.

Methods

Blood and cerebrospinal fluid (CSF) of children with TBM and hydrocephalus taken on admission and over 3 weeks were analyzed for the neuromarkers S100B, neuron-specific enolase (NSE), and glial fibrillary acidic protein (GFAP), in addition to multiple inflammatory markers. Results were compared with 2 control groups: patients with (1) a fatty filum (abnormal filum terminale of the spinal cord); and (2) pulmonary tuberculosis (PTB). Imaging was conducted on admission and at 3 weeks. Outcome was assessed at 6 months.

Results

Data were collected from 44 patients with TBM (cases; median age, 3.3 [min-max 0.3-13.1] years), 11 fatty filum controls (median age, 2.8 [min-max 0.8-8] years) and 9 PTB controls (median age, 3.7 [min-max 1.3-11.8] years). Seven cases (16%) died and 16 (36%) had disabilities. Neuromarkers and inflammatory markers were elevated in CSF on admission and for up to 3 weeks, but not in serum. Initial and highest concentrations in week 1 of S100B and NSE were associated with poor outcome, as were highest concentration overall and an increasing profile over time in S100B, NSE, and GFAP. Combined neuromarker concentrations increased over time in patients who died, whereas inflammatory markers decreased. Cerebral infarcts were associated with highest overall neuromarker concentrations and an increasing profile over time. Tuberculomas were associated with elevated interleukin (IL) 12p40, interferon-inducible protein 10, and monocyte chemoattractant protein 1 concentrations, whereas infarcts were associated with elevated tumor necrosis factor α, macrophage inflammatory protein 1α, IL-6, and IL-8.

Conclusions

CSF neuromarkers are promising biomarkers of injury severity and are predictive of mortality. An increasing trend suggested ongoing brain injury, even though markers of inflammation declined with treatment. These findings could offer novel insight into the pathophysiology of TBM.

Imaging Features of the Brain, Cerebral Vessels and Spine in Pediatric Tuberculous Meningitis With Associated Hydrocephalus

BACKGROUND

Pediatric tuberculous meningitis (TBM) leads to high rates of mortality and morbidity. Prompt diagnosis and initiation of treatment are challenging; imaging findings play a key role in establishing the presumptive diagnosis. General brain imaging findings are well reported; however, specific data on cerebral vascular and spinal involvement in children are sparse.

METHODS

This prospective cohort study examined admission and followed up computed tomography brain scans and magnetic resonance imaging scans of the brain, cerebral vessels (magnetic resonance angiogram) and spine at 3 weeks in children treated for TBM with hydrocephalus (HCP; inclusion criteria). Exclusion criteria were no HCP on admission, treatment of HCP or commencement of antituberculosis treatment before study enrollment. Imaging findings were examined in association with outcome at 6 months.

RESULTS

Forty-four patients (median age 3.3 [0.3-13.1] years) with definite (54%) or probable TBM were enrolled. Good clinical outcome was reported in 72%; the mortality rate was 16%. Infarcts were reported in 66% of patients and were predictive of poor outcome. Magnetic resonance angiogram abnormalities were reported in 55% of patients. Delayed tuberculomas developed in 11% of patients (after starting treatment). Spinal pathology was more common than expected, occurring in 76% of patients. Exudate in the spinal canal increased the difficulty of lumbar puncture and correlated with high cerebrospinal fluid protein content.

CONCLUSION

TBM involves extensive pathology in the central nervous system. Severe infarction was predictive of poor outcome although this was not the case for angiographic abnormalities. Spinal disease occurs commonly and has important implications for diagnosis and treatment. Comprehensive imaging of the brain, spine and cerebral vessels adds insight into disease pathophysiology.

Six months therapy for tuberculous meningitis

BACKGROUND

Tuberculous meningitis (TBM) is the main form of tuberculosis that affects the central nervous system and is associated with high rates of death and disability. Most international guidelines recommend longer antituberculous treatment (ATT) regimens for TBM than for pulmonary tuberculosis disease to prevent relapse. However, longer regimens are associated with poor adherence, which could contribute to increased relapse, development of drug resistance, and increased costs to patients and healthcare systems.

OBJECTIVES

To compare the effects of short-course (six months) regimens versus prolonged-course regimens for people with tuberculous meningitis (TBM).

SEARCH METHODS

We searched the following databases up to 31 March 2016: the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library; MEDLINE; EMBASE; LILACS; INDMED; and the South Asian Database of Controlled Clinical Trials. We searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov for ongoing trials. We also checked article reference lists and contacted researchers in the field.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and prospective cohort studies of adults and children with TBM treated with antituberculous regimens that included rifampicin for six months or longer than six months. The primary outcome was relapse, and included studies required a minimum of six months follow-up after completion of treatment.

DATA COLLECTION AND ANALYSIS

Two review authors (SJ and HR) independently assessed the literature search results for eligibility, and performed data extraction and 'Risk of bias' assessments of the included studies. We contacted study authors for additional information when necessary. Most data came from single arm cohort studies without a direct comparison so we pooled the findings for each group of cohorts and presented them separately using a complete-case analysis. We assessed the quality of the evidence narratively, as using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was inappropriate with no direct comparisons between short- and prolonged-course regimens.

MAIN RESULTS

Four RCTs and 12 prospective cohort studies met our inclusion criteria, and included a total of 1881 participants with TBM. None of the included RCTs directly compared six months versus longer regimens, so we analysed all data as individual cohorts to obtain relapse rates in each set of cohorts.We included seven cohorts of participants treated for six months, with a total of 458 participants. Three studies were conducted in Thailand, two in South Africa, and one each in Ecuador and Papua New Guinea between the 1980s and 2009. We included 12 cohorts of participants treated for longer than six months (ranging from eight to 16 months), with a total of 1423 participants. Four studies were conducted in India, three in Thailand and one each in China, South Africa, Romania, Turkey and Vietnam, between the late 1970s and 2011.The proportion of participants classified as having stage III disease (severe) was higher in the cohorts treated for six months (33.2% versus 16.9%), but the proportion with known concurrent HIV was higher in the cohorts treated for longer (0/458 versus 122/1423). Although there were variations in the treatment regimens, most cohorts received isoniazid, rifampicin, and pyrazinamide during the intensive phase.Investigators achieved follow-up beyond 18 months after completing treatment in three out of the seven cohorts treated for six months, and five out of the 12 cohorts treated for eight to 16 months. All studies had potential sources of bias in their estimation of the relapse rate, and comparisons between the cohorts could be confounded.Relapse was an uncommon event across both groups of cohorts (3/369 (0.8%) with six months treatment versus 7/915 (0.8%) with longer), with only one death attributed to relapse in each group.Overall, the proportion of participants who died was higher in the cohorts treated for longer than six months (447/1423 (31.4%) versus 58/458 (12.7%)). However, most deaths occurred during the first six months in both treatment cohorts, which suggested that the difference in death rate was not directly related to duration of ATT but was due to confounding. Clinical cure was higher in the group of cohorts treated for six months (408/458 (89.1%) versus longer than six months (984/1336 (73.7%)), consistent with the observations for deaths.Few participants defaulted from treatment with six months treatment (4/370 (1.1%)) versus longer treatment (8/355 (2.3%)), and adherence was not well reported.

AUTHORS' CONCLUSIONS

In all cohorts most deaths occurred in the first six months; and relapse was uncommon in all participants irrespective of the regimen. Further inferences are probably inappropriate given this is observational data and confounding is likely. These data are almost all from participants who are HIV-negative, and thus the inferences will not apply to the efficacy and safety of the six months regimens in HIV-positive people. Well-designed RCTs, or large prospective cohort studies, comparing six months with longer treatment regimens with long follow-up periods established at initiation of ATT are needed to resolve the uncertainty regarding the safety and efficacy of six months regimens for TBM.

Tubercular meningitis in children: Clinical, pathological, and radiological profile and factors associated with mortality

CONTEXT

Childhood tuberculosis is a major public health problem in developing countries with tubercular meningitis being a serious complication with high mortality and morbidity.

AIM

To study the clinicopathological as well as radiological profile of childhood tuberculous meningitis (TBM) cases.

SETTINGS AND DESIGN

Prospective, observational study including children <14 years of age with TBM admitted in a tertiary care hospital from Western India.

SUBJECTS AND METHODS

TBM was diagnosed based on predefined criteria. Glassgow coma scale (GCS) and intracranial pressure (ICP) was recorded. Staging was done as per British Medical Council Staging System. Mantoux test, chest X-ray, cerebrospinal fluid (CSF) examination, neuroimaging, and other investigations were done to confirm TB.

STATISTICAL ANALYSIS USED

STATA software (version 9.0) was used for data analysis. Various risk factors were determined using Chi-square tests, and a P< 0.05 was considered significant.

RESULTS

Forty-seven children were included, of which 11 (24.3%) died. Fever was the most common presenting symptom, and meningismus was the most common sign. Twenty-nine (62%) children presented with Stage III disease. Stage III disease, low GCS, and raised ICP were predictors of mortality. Findings on neuroimaging or CSF examination did not predict mortality.

CONCLUSIONS

Childhood TBM presents with nonspecific clinical features. Stage III disease, low GCS, lack of Bacillus Calmette-Guérin vaccination at birth and raised ICP seem to the most important adverse prognostic factors.

Clinical characteristics and neurodevelopmental outcomes of children with tuberculous meningitis and hydrocephalus

AIM

Tuberculous meningitis (TBM) is a lethal and commonly occurring form of extra-pulmonary tuberculosis in children, often complicated by hydrocephalus which worsens outcome. Despite high mortality and morbidity, little data on the impact on neurodevelopment exists. We examined the clinical characteristics, and clinical and neurodevelopmental outcomes of TBM and hydrocephalus.

METHOD

Demographic and clinical data (laboratory and radiological findings) were prospectively collected on children treated for probable and definite TBM with hydrocephalus. At 6 months, clinical outcome was assessed using the Paediatric Cerebral Performance Category Scale and neurodevelopmental outcome was assessed with the Griffiths Mental Development Scale - Extended Version.

RESULTS

Forty-four patients (median age 3y 3mo, range 3mo-13y 1mo, [SD 3y 5mo]) were enrolled. The mortality rate was 16%, three patients (6.8%) were in a persistent vegetative state, two were severely disabled (4.5%), and 11 (25%) suffered mild-moderate disability. All cases demonstrated neurodevelopmental deficits relative to controls. Multiple or large infarcts were prognostic of poor outcome.

INTERPRETATION

Neurological and neurodevelopmental deficits are common after paediatric TBM with hydrocephalus, and appear to be related to ongoing cerebral ischaemia and consequent infarction. The impact of TBM on these children is multidimensional and presents short- and long-term challenges.

Central Nervous System Tuberculosis: Challenges and Advances in Diagnosis and Treatment

Mycobacterium tuberculosis is one of the most prevalent human infections. Although the largest share of the burden of disease is in Africa and Asia, tuberculosis has a global footprint due to travel and migration. Resource constraints in many low- and middle-income countries are hampering efforts to control new infections and to prevent drug resistance. Infection of the central nervous system by Mycobacterium tuberculosis includes meningitis, tuberculoma, and abscess and carries a high morbidity and mortality. High clinical suspicion, combined with cerebrospinal fluid analysis and brain imaging studies, can improve the diagnostic certainty. The recent scale-up of nucleic acid amplification technology may allow earlier diagnosis of tuberculous meningitis in many regions of the world. Treatment of tuberculous infection of the central nervous system is usually empirical and follows conventional regimens for pulmonary tuberculosis. The optimal treatment regimen is still being elucidated and has been the subject of recent clinical trials.