Tuberculous meningitis: more questions, still too few answers

Tuberculosis Related Movement Disorders: A Systematic Scoping Review Highlighting Geographic Disparities, Phenotypic Patterns, Treatment Responses, and Knowledge Gaps in Global Reporting

BACKGROUND

Tuberculosis (TB) of the central nervous system (CNS) is a severe complication of TB, with movement disorders representing an under-recognized yet impactful manifestation. Despite their clinical significance, knowledge gaps persist in epidemiology, pathophysiology, and management of TB-related movement disorders (TBRMDs).

OBJECTIVE

This scoping review synthesizes evidence on TBRMDs, aiming to characterize their spectrum, evaluate diagnostic approaches, and summarize management strategies and outcomes.

METHODS

Following PRISMA-ScR guidelines, a systematic search of PubMed, EMBASE, and Scopus (final search: December 31, 2024) identified studies of all designs and languages reporting movement disorders in CNS TB. Data extraction, quality assessment (Joanna Briggs Institute tools), and thematic synthesis were conducted.

RESULTS

Of 36 included studies (91 cases), tremor (27.5%), chorea (26.4%), and dystonia (16.5%) were most prevalent. Tremor predominated in tuberculous meningitis (48.9%), while chorea was common in tuberculomas (42.3%). Lesion location correlated with phenomenology: basal ganglia lesions linked to chorea/dystonia, cerebellar involvement to ataxia. Pathogenesis included meningitis (54.9%), tuberculomas (32.9%), and vasculitis (8.8%). Treatment with anti-tubercular therapy and corticosteroids resulted in complete resolution in 43.9% of cases, but 32.9% showed no improvement. Geographically, South America (61.8%) and Asia (19.7%) reported most cases, with a temporal surge post-2000.

CONCLUSION

TBRMDs are heterogeneous in presentation, linked to lesion location and pathogenic mechanisms. Early recognition, multimodal management, and neuroimaging are critical. Significant variability in diagnostic and reporting standards highlights the need for consensus criteria and prospective studies, particularly in high-burden regions. This review underscores the need of global collaborations to optimize clinical care and advance research in this neglected domain.

Lactate-Dehydrogenase-5 May Play a Key Role in the Disturbance of Brain Energy Caused by Tuberculous Meningitis

BACKGROUND

The conversion of pyruvate to lactate is primarily catalyzed by lactate-dehydrogenase-5 (LDH-5), which comprises four lactate-dehydrogenase-A (LDHA) subunits. However, the mechanism of LDH-5 in tuberculous meningitis (TBM) remains elusive.

METHODS

Thirty-two samples of cerebrospinal fluid (CSF) were collected, including 15 from individuals without central nervous system (CNS) infectious diseases (control group) and 17 from individuals with TBM (TBM group). Based on the results of brain imaging, nine patients with TBM with meningeal enhancement were included in the meninges group. Eight patients with TBM with lesions in the brain parenchyma were included in the brain parenchyma group. The levels of adenosine triphosphatase (ATP), lactate, LDH-1, pyruvate and LDH-5 in the CSF were assessed. Subsequently, the levels of ATP, pyruvate and lactate, as well as the amplitude and frequency of action potentials (APs) in neurons overexpressing LDHA, were investigated.

RESULTS

Reduced levels of pyruvate and ATP and elevated levels of lactate and LDH-5 were observed in the CSF of individuals with TBM. The ATP level was decreased in the brain parenchyma group. In neurons with LDHA overexpression, the lactate level increased, while ATP and pyruvate levels, as well as the amplitude and frequency of APs, decreased.

CONCLUSION

Elevated levels of LDH-5 in the CNS of individuals with TBM may lead to a disturbance in brain energy and negatively affect neuronal activity.

A Case Report of Acute Ischaemic Stroke Associated with T​uberculous Meningitis

Background

Tuberculous meningitis (TBM) is a severe form of tuberculosis (TB) that affects the meninges, frequently causing major neurological problems. Timely diagnosis and care are crucial to avoid unfavourable consequences, particularly in vulnerable populations.

Purpose

This case report aims to highlight the diagnostic problems and management complications of TBM, especially when combined with rare neurological events such as acute ischaemic stroke (AIS).

Methods

An 84-year-old female presented with disorientation, seizures, aphasia and hemiparesis. The initial imaging revealed normotensive hydrocephalus and bilateral delta activity on the electroencephalogram (EEG). Despite anti-fungal treatment, CT imaging revealed widespread inflammatory alterations. Sputum and cerebrospinal fluid (CSF) tests were done and revealed the presence of Mycobacterium tuberculosis. MRI indicated several acute lesions, which are symptomatic of TBM.

Results

The patient developed AIS, a relatively rare complication of TBM. Treatment was initiated with a combination of anti-TB drugs and corticosteroids. While corticosteroids reduced inflammation and mortality risk, their potential to contribute to long-term disability was noted as an area of concern.

Conclusion

This case underscores the critical role of MRI in the early detection of TBM-related complications. Although corticosteroids improve short-term outcomes, their impact on long-term disability necessitates further research. Effective management strategies tailored to vulnerable populations are essential to improve the prognosis of TBM patients.

Tuberculous Meningitis in a Child: A Rare Presentation of Cytotoxic Lesion of the Corpus Callosum

Tuberculous meningitis (TBM) is the most severe form of tuberculosis, disproportionately affecting vulnerable populations such as young children and people living with human immunodeficiency virus (HIV). Major challenges to accurate and early diagnosis of TBM are the non-specific clinical features which overlap with other infectious syndromes and the lack of adequately sensitive tests to detect Mycobacterium tuberculosis in the cerebrospinal fluid (CSF). Diagnosis is, therefore, still dependent on clinical suspicion along with clinical features, cerebrospinal fluid (CSF) characteristics and, where facilities are available, neuroimaging. Typical neuroimaging features of TBM include hydrocephalus, infarcts, tuberculomas and basal exudates; however, less well described are very rare features such as cytotoxic lesion of the corpus callosum (CLOCC), otherwise known as transient splenic lesion. We describe the first case report of a child with confirmed TBM who had a very rare presentation of CLOCC with complete recovery and present a literature review on the pathophysiology and alternative aetiologies where CLOCC is more commonly seen.

Trojan horse strategy and TfR/ LDLR-Mediated transcytosis determine the dissemination of mycobacteria in tuberculous meningoencephalitis

Tuberculous meningoencephalitis (TBM), caused by the Mycobacterium tuberculosis complex, stands as one of the most lethal infections affecting the central nervous system (CNS). The understanding of the mechanisms underlying the neuroinvasion of Mycobacterium bovis (M. bovis) remains limited. Our findings reveal that M. bovis could exploit host transferrin receptor (TfR)- and low-density lipoprotein receptor (LDLR)-mediated transcytosis, while simultaneously utilizing infected macrophages as vectors to traverse the blood-brain barrier (BBB). Infected macrophages accelerate the M. bovis' neuroinvasion and promote its proliferation and dissemination to various organs. Persistent infection disrupts BBB integrity by degrading tight junction proteins and upregulating intercellular cell adhesion molecule-1 (iCAM-1), facilitating macrophage adhesion and migration, which contribute to the pathogen's entry into the brain. This study established a murine TBM model by administering M. bovis through carotid artery injection, accurately mimicking the interactions between the pathogen and the BBB. These findings offer insights into the mechanisms of TBM and serve as a foundation for developing targeted therapeutic strategies.

Inflammatory disorders that affect the cerebral small vessels

ABSTRACT

This comprehensive review synthesizes the latest advancements in understanding inflammatory disorders affecting cerebral small vessels, a distinct yet understudied category within cerebral small vessel diseases (SVD). Unlike classical SVD, these inflammatory conditions exhibit unique clinical presentations, imaging patterns, and pathophysiological mechanisms, posing significant diagnostic and therapeutic challenges. Highlighting their heterogeneity, this review spans primary angiitis of the central nervous system, cerebral amyloid angiopathy-related inflammation, systemic vasculitis, secondary vasculitis, and vasculitis in autoinflammatory diseases. Key discussions focus on emerging insights into immune-mediated processes, neuroimaging characteristics, and histopathological distinctions. Furthermore, this review underscores the importance of standardized diagnostic frameworks, individualized immunomodulation approaches, and novel targeted therapies to address unmet clinical demands.

Prognostic Model to Predict Outcome of Adult Patients with Tuberculous Meningitis Undergoing Ventriculoperitoneal Shunt Surgery: A Prospective Observational Study

BACKGROUND

The prognosis of adult patients with tuberculous meningitis undergoing ventriculoperitoneal (VP) surgery is not well known. Prognostic models developed to predict the prognosis might help clinicians immensely.

METHODS

This was a prospective study. Adult patients (≥18 years) with tuberculous meningitis undergoing VP shunt surgery were included in the study. Patients were followed for 6 months. The primary outcome was death and the secondary outcome was a composite outcome of death plus disability. Prognostic models were developed using binary logistic regression. The model performance was assessed using discrimination and calibration. Internal validation of the model was performed using bootstrap. The models were plotted on a nomogram and e-calculator for bedside use.

RESULTS

Of 92 patients, 28 (30.4%) died and 36 (39.1%) experienced a composite poor outcome. The final model showed Medical Research Council grade III, papilledema, seizures, and size of the temporal horn to be predictors of poor outcome. The models showed good discrimination: area under the curve of 83.7% (95% confidence interval, 75.1%-92.3%; P < 0.001) for death and area under the curve of 84.7% (95% confidence interval, 75.9%-93.5%; P < 0.001) for composite poor outcome. Both the models showed good calibration; the Hosmer-Lemeshow test P value of 0.448 for death and 0.093 for composite outcome. The model remained valid after performing a bootstrap procedure, thus signifying internal validation.

CONCLUSIONS

About 39% of adult patients with tuberculous meningitis die or remain disabled after VP shunt surgery. Medical Research Council grade III illness, papilledema, seizures, and size of hydrocephalus are the most important baseline predictors that can help in prognostication. The nomograms developed may help the treating physician with prognostication.

Post-infectious central nervous system vasculitides in adults: an underdiagnosed and treatable disease : Part I. Overview

INTRODUCTION

The differential diagnosis of Primary Central Nervous System Angiitis (PACNS) is complex and includes several inflammatory and non-inflammatory conditions. Among the first ones, post-infectious CNS vasculitides represent a relevant topic and they are often underdiagnosed.

AIMS

The main aim of this review is to summarize the clinical and neuroimaging features of post-infectious vasculitides, highlighting the diagnostic clues and the need to carefully consider them in the differential diagnosis of PACNS.

FINDINGS

Several infectious agents (viruses, bacteria, fungi and parasites) can be involved in documented post-infectious vasculitides, often with a pathological confirmation. Post-infectious vasculitides involve not only immunocompromised hosts but also immunocompetent people and the diagnosis might be complicated by the lack of close time relationship between infections and neuro-logical symptoms, as in Varicella Zoster Virus (VZV) related vasculopathy in adults. Several complications may occur, ranging from ischemic to hemorrhagic stroke, from arterial to venous thrombosis, from large to small vessel involvement, often simultaneously.

CONCLUSIONS

Post-infectious vasculitides are caused by a broad spectrum of microorganisms and they should be carefully considered in the differential diagnosis of some neurological pictures and neuroradiologicals findings in immunocompetent adults too.

Review of the aetiologies of central nervous system infections in Vietnam

Central nervous system (CNS) infections are an important cause of morbidity and mortality in Vietnam, with many studies conducted to determine the aetiology. However, the cause remains unknown in a large proportion of cases. Although a systematic review of the aetiologies of CNS infections was conducted in the Mekong region, there are no known published reviews of the studies specifically in Vietnam. Here, we review the cause of CNS infections in Vietnam while also considering the potential aetiologies where a cause was not identified, based on the literature from the region. In particular, we focus on the most common pathogens in adults and children including Streptococcus suis which is associated with the consumption of raw pig products, and Japanese encephalitis virus, a mosquito-borne pathogen. We also discuss pathogens less commonly known to cause CNS infections in Vietnam but have been detected in neighbouring countries such as Orientia tsutsugamushi, Rickettsia typhi and Leptospira species and how these may contribute to the unknown causes in Vietnam. We anticipate that this review may help guide future public health measures to reduce the burden of known pathogens and broaden testing to help identify additional aetiologies.

Stroke thrombolysis in tuberculous meningitis

A woman in her 30s presented with sudden onset right-sided weakness, speech difficulties and transient loss of consciousness. She had a medical history of migraine, hypothyroidism and cervical lymphadenopathy. On examination, her National Institutes of Health Stroke Scale (NIHSS) score was 8 due to dense right-sided hemiparesis. CT brain imaging showed no intracranial haemorrhage but revealed incidental findings of left supraclavicular and cervical lymphadenopathy. CT intracranial angiogram did not show large vessel occlusion. She received thrombolytic treatment for ischaemic stroke. NIHSS improved to 3 with no immediate complications. Following admission, she developed swinging fever, seizures and fluctuating right-sided weakness. Repeat MRI of the head showed leptomeningeal enhancement. Biopsy of the cervical lymph nodes showed histiocytic granulomatous lymphadenitis, which was suggestive of tuberculous meningitis (TBM). She was treated with quadruple antimicrobial therapy and steroids for TBM, as well as aspirin for ischaemic stroke, which resulted in good clinical improvement.

Cerebrospinal fluid-induced stable and reproducible SERS sensing for various meningitis discrimination assisted with machine learning

Cerebrospinal fluid (CSF)-based pathogen or biochemical testing is the standard approach for clinical diagnosis of various meningitis. However, misdiagnosis and missed diagnosis always occur due to the shortages of unusual clinical manifestations and time-consuming shortcomings, low sensitivity, and poor specificity. Here, for the first time, we propose a simple and reliable CSF-induced SERS platform assisted with machine learning (ML) for the diagnosis and identification of various meningitis. Stable and reproducible SERS spectra are obtained within 30 s by simply mixing the colloidal silver nanoparticles (Ag NPs) with CSF sample, and the relative standard deviation of signal intensity is achieved as low as 2.1%. In contrast to conventional salt agglomeration agent-induced irreversible aggregation for achieving Raman enhancement, a homogeneous and dispersed colloidal solution is observed within 1 h for the mixture of Ag NPs/CSF (containing 110-140 mM chloride), contributing to excellent SERS stability and reproducibility. In addition, the interaction processes and potential enhancement mechanisms of different Ag colloids-based SERS detection induced by CSF sample or conventional NaCl agglomeration agents are studied in detail through in-situ UV-vis absorption spectra, SERS analysis, SEM and optical imaging. Finally, an ML-assisted meningitis classification model is established based on the spectral feature fusion of characteristic peaks and baseline. By using an optimized KNN algorithm, the classification accuracy of autoimmune encephalitis, novel cryptococcal meningitis, viral meningitis, or tuberculous meningitis could be reached 99%, while an accuracy value of 68.74% is achieved for baseline-corrected spectral data. The CSF-induced SERS detection has the potential to provide a new type of liquid biopsy approach in the fields of diagnosis and early detection of various cerebral ailments.

Tubercular cerebellitis, identified through an expansive process: A case report

Central nervous system (CNS) tuberculosis is a postprimary form of tuberculosis with high mortality and morbidity rates, even with early diagnosis and treatment. Focal tuberculous cerebritis is extremely rare, typically occurring in patients without AIDS, and often associated with tuberculous meningitis. In endemic regions, it should be a primary consideration when encountering cerebral anomalies suggestive of granulomatous conditions. Its meningeal pseudo-tumor form poses a significant diagnostic challenge. We present the case of a 26-year-old man who arrived at the emergency room with cerebellar and pyramidal syndrome. Cerebral magnetic resonance imaging (MRI) revealed an expansive lesion in the right hemicerebellum with glove-finger edema and leptomeningeal thickening. Given the MRI findings and associated lung involvement, the diagnosis of tuberculosis was strongly suggested in our epidemiological context. Due to contraindications for lumbar puncture, high surgical risk, and strong clinical and radiological suspicion, antituberculous treatment was initiated in collaboration with neurologists and infectious disease specialists. The clinical and radiologic manifestations of CNS tuberculosis can mimic other infectious and noninfectious neurological conditions, as seen in our patient. Thus, familiarity with the imaging presentations of CNS tuberculosis among infectious disease specialists and radiologists is crucial for prompt and accurate diagnosis.

Systematic review of tuberculous meningitis in high-risk populations: mortality and diagnostic disparities

Aim: Tuberculous meningitis (TBM) is one of the most severe clinical forms of tuberculosis (TB). Since epidemiological studies can contribute to TB control, we conducted a review and meta-analysis of epidemiological publications of adults TBM cases in countries with high incidence of TB.Materials & methods: The search resulted in 11,855 articles, in which 21 ultimately were included in our review and 15 in our meta-analysis.Results: TBM mortality was 25% with death rates of 70% in Africa. The review showed different and non-concordant diagnostic techniques and treatment schemes.Conclusion: Adults living in the African region are at high risk of death from TBM, highlighting an urgent need of guidelines to support diagnosis and treatment, and ultimately, to reduce mortality.

Spinal Adhesive Arachnoidopathy, the Disorder More Than Simply Adhesive Arachnoiditis: A Comprehensive Systematic Review of 510 Cases

BACKGROUND

Spinal adhesive arachnoidopathy (SAA) is a chronic pathology associated with persistent inflammatory responses in the arachnoid. Adhesive arachnoiditis (AA) is one of the major forms of SAA, with accompanying secondary complications. Therefore, we aimed to systematically review both clinical and animal model studies related to SAA to gain a deeper understanding of this unique pathology.

METHODS

A literature search was conducted in PubMed, EMBASE, and Cochrane Library databases to retrieve relevant publications up to October 2022. Clinical manifestations, etiologies, imaging modalities, treatments, and prognosis in patients with SAA were collected. Data from animal experiments related to SAA were also extracted.

RESULTS

A total of 176 studies, including 147 clinical and 29 animal model studies, with a total of 510 patients were enrolled in this study. Pain (37.5%), abnormal nerve sensations (39.58%), and abnormal motor function (78.75%) were the top three common symptoms of SAA. Major etiologies included trauma (22.7%), infection (17.73%), surgery (15.37%), and hemorrhage (13.48%). MRI was widely used to confirm the diagnosis. AA could be involved in cervical (96/606, 15.84%), thoracic (297/606, 49.01%), lumbar (174/606, 28.71%), and sacrococcygeal (39/606, 6.44%) vertebral segments. Patients with AA in cervical segments had a higher post-surgery recovery rate (p = 0.016) compared to that of other segments. The common pathological diagnoses of SAA were AA (80.82%), AA combined with arachnoid cyst (12.79%), arachnoid calcification/scars (3.43%), and arachnoid web/fibrosis (2.97%). Patients with AA were more likely to develop syringomyelia, compared with patients with other forms of SAA (p < 0.001). Animal studies mainly focused on new AA therapeutic agents (n = 14), the pathomechanism of AA (n = 14), and the development of new MRI sequences for improved diagnosis (n = 1).

CONCLUSIONS

The pathological consequences of SAA are more complex than AA and manifest in different forms, such as AA combined with arachnoid cyst, arachnoid calcification/scars, and arachnoid web/fibrosis. In many instances, AA was associated with secondary syringomyelia. Unspecific clinical manifestations of SAA may easily lead to misdiagnosis and missed diagnosis. Although SAA may result from multiple etiologies, including spinal trauma, meningitis, spinal surgery, and hemorrhage, the pathogenesis and treatment of SAA have still not been standardized.

Cerebrospinal Fluid Parameters Predicting Contralateral Isolated Lateral Ventricle in Adult Tuberculous Meningitis with Hydrocephalus Post-Ventriculoperitoneal Shunt

OBJECTIVE

Hydrocephalus, a major complication in tuberculous meningitis (TBM) patients, often necessitates treatment via ventriculoperitoneal shunt (VPS). However, post-VPS, some patients develop a complication called contralateral isolated lateral ventricle (CILV), leading to persistent hydrocephalus symptoms. This study aims to evaluate cerebrospinal fluid (CSF) parameters in predicting CILV occurrence post-VPS in adult TBM patients.

METHODS

A retrospective analysis was conducted, focusing on the relationship between preoperative CSF parameters and the development of CILV in 40 adult TBM patients who underwent VPS. The study compared CSF parameters from lumbar puncture after admission with those from ventricular CSF post-external ventricular drainage tube insertion.

RESULTS

CILV was observed in 6 of the 40 patients following VPS. Statistical analysis showed no significant difference between the CSF parameters obtained via lumbar and ventricular punctures. Notably, the mean CSF glucose level in patients with CILV was significantly lower (1.92 mmol/L) compared to the non-CILV group (3.03 mmol/L). Conversely, the median adenosine deaminase (ADA) level in the CILV group was higher (5.69 U/L) compared to the non-CILV group (3.18 U/L). The optimal cutoff values for CSF glucose and ADA levels were 1.90 mmol/L and 4.80 U/L, respectively, with a sensitivity of 66.67% and 83.33% and a specificity of 88.24% and 79.41%.

CONCLUSIONS

The study identified elevated ADA levels and decreased glucose levels in CSF as potential risk factors for CILV development in adult TBM patients post-VPS. These findings suggest the necessity for more tailored surgical approaches, in patients with altered CSF parameters to mitigate the risk of CILV.

The diagnostic potential of urine in paediatric patients undergoing initial treatment for tuberculous meningitis

Tuberculous meningitis (TBM)-the extrapulmonary form of tuberculosis, is the most severe complication associated with tuberculosis, particularly in infants and children. The gold standard for the diagnosis of TBM requires cerebrospinal fluid (CSF) through lumbar puncture-an invasive sample collection method, and currently available CSF assays are often not sufficient for a definitive TBM diagnosis. Urine is metabolite-rich and relatively unexplored in terms of its potential to diagnose neuroinfectious diseases. We used an untargeted proton magnetic resonance (1H-NMR) metabolomics approach to compare the urine from 32 patients with TBM (stratified into stages 1, 2 and 3) against that from 39 controls in a South African paediatric cohort. Significant spectral bins had to satisfy three of our four strict cut-off quantitative statistical criteria. Five significant biological metabolites were identified-1-methylnicotinamide, 3-hydroxyisovaleric acid, 5-aminolevulinic acid, N-acetylglutamine and methanol-which had no correlation with medication metabolites. ROC analysis revealed that methanol lacked diagnostic sensitivity, but the other four metabolites showed good diagnostic potential. Furthermore, we compared mild (stage 1) TBM and severe (stages 2 and 3) TBM, and our multivariate metabolic model could successfully classify severe but not mild TBM. Our results show that urine can potentially be used to diagnose severe TBM.

Prevalence, incidence, and case fatality of tuberculous meningitis in adults living with HIV: a systematic review and meta-analysis

BACKGROUND

Tuberculous meningitis (TBM) emerges as a grave complication of tuberculosis in people living with HIV (PLWH). The diagnosis and treatment of TBM pose significant challenges, leading to elevated mortality rates. To comprehensively grasp the epidemiological landscape of TBM in PLWH, a systematic review and meta-analysis were meticulously undertaken.

METHODS

We performed a comprehensive search in PubMed, Embase, and Web of Science from database inception to September 19th, 2023, with no limitations on the publication type. The search terms were HIV/AIDS terms (AIDS OR HIV OR PLWH) and TBM-related terms (tuberculous meningitis OR TBM). Studies included in this meta-analysis evaluated the incidence of TBM among PLWH, or we were able to calculate the incidence of TBM among PLWH from the research.

RESULTS

The analysis revealed that the prevalence of TBM among PLWH was 13.6% (95% CI: 6.6-25.9%), with an incidence rate of 1.5 cases per 1000 persons per year. The case fatality rate was found to be 38.1% (95% CI: 24.3-54.1%). No significant publication bias was observed. Meta-regression analysis identified the proportion of females and finance situation as factors influencing the outcomes.

CONCLUSIONS

Our study highlights TBM as a prevalent opportunistic infection that targets the central nervous system in PLWH. The elevated case fatality rate is especially prominent among PLWH in impoverished regions, underscores the pressing necessity for enhanced management strategies for PLWH suffering from TBM.

TRIAL REGISTRATION

PROSPERO; No: CRD42022338586.

LC-MS metabolomics and lipidomics in cerebrospinal fluid from viral and bacterial CNS infections: a review

There is compelling evidence that a dysregulated immune inflammatory response in neuroinfectious diseases results in modifications in metabolic processes and altered metabolites, directly or indirectly influencing lipid metabolism within the central nervous system (CNS). The challenges in differential diagnosis and the provision of effective treatment in many neuroinfectious diseases are, in part, due to limited understanding of the pathophysiology underlying the disease. Although there are numerous metabolomics studies, there remains a deficit in neurolipidomics research to provide a comprehensive understanding of the connection between altered metabolites and changes in lipid metabolism. The brain is an inherently high-lipid organ; hence, understanding neurolipidomics is the key to future breakthroughs. This review aims to provide an integrative summary of altered cerebrospinal fluid (CSF) metabolites associated with neurolipid metabolism in bacterial and viral CNS infections, with a particular focus on studies that used liquid chromatography-mass spectrometry (LC-MS). Lipid components (phospholipids) and metabolites (carnitine and tryptophan) appear to be the most significant indicators in both bacterial and viral infections. On the basis of our analysis of the literature, we recommend employing neurolipidomics in conjunction with existing neurometabolomics data as a prospective method to enhance our understanding of the cross link between dysregulated metabolites and lipid metabolism in neuroinfectious diseases.

Global Case Fatality of Bacterial Meningitis During an 80-Year Period: A Systematic Review and Meta-Analysis

Importance

The impact of vaccination, antibiotics, and anti-inflammatory treatment on pathogen distribution and outcome of bacterial meningitis over the past century is uncertain.

Objective

To describe worldwide pathogen distribution and case fatality ratios of community-acquired bacterial meningitis.

Data Sources

Google Scholar and MEDLINE were searched in January 2022 using the search terms bacterial meningitis and mortality.

Study Selection

Included studies reported at least 10 patients with bacterial meningitis and survival status. Studies that selected participants by a specific risk factor, had a mean observation period before 1940, or had more than 10% of patients with health care-associated meningitis, tuberculous meningitis, or missing outcome were excluded.

Data Extraction and Synthesis

Data were extracted by 1 author and verified by a second author. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Random-effects models stratified by age (ie, neonates, children, adults), Human Development Index (ie, low-income or high-income countries), and decade and meta-regression using the study period's year as an estimator variable were used.

Main Outcome and Measure

Case fatality ratios of bacterial meningitis.

Results

This review included 371 studies performed in 108 countries from January 1, 1935, to December 31, 2019, describing 157 656 episodes. Of the 33 295 episodes for which the patients' sex was reported, 13 452 (40%) occurred in females. Causative pathogens were reported in 104 598 episodes with Neisseria meningitidis in 26 344 (25%) episodes, Streptococcus pneumoniae in 26 035 (25%) episodes, Haemophilus influenzae in 22 722 (22%), other bacteria in 19 161 (18%) episodes, and unidentified pathogen in 10 336 (10%) episodes. The overall case fatality ratio was 18% (95% CI, 16%-19%), decreasing from 32% (95% CI, 24%-40%) before 1961 to 15% (95% CI, 12%-19%) after 2010. It was highest in meningitis caused by Listeria monocytogenes at 27% (95% CI, 24%-31%) and pneumococci at 24% (95% CI, 22%-26%), compared with meningitis caused by meningococci at 9% (95% CI, 8%-10%) or H influenzae at 11% (95% CI, 10%-13%). Meta-regression showed decreasing case fatality ratios overall and stratified by S pneumoniae, Escherichia coli, or Streptococcus agalactiae (P < .001).

Conclusions and Relevance

In this meta-analysis with meta-regression, declining case fatality ratios of community-acquired bacterial meningitis throughout the last century were observed, but a high burden of disease remained.

Posterior fossa tuberculosis: Unusual presentations of a common disease and literature review

The burden of tuberculosis is very high in our country and though the number of deaths due to tuberculosis has drastically reduced, still the associated morbidities caused by the disease can be very debilitating.1 Central nervous system tuberculosis is a rare and serious presentation of tuberculosis, the general presentation being hydrocephalus, meningitis, and disseminated miliary lesions.2 More often than not tuberculosis is associated with immunocompromised status and central nervous system tuberculosis in immunocompetent young individuals with no evidence of systemic tuberculosis is very rare.3Association of tuberculosis with ocular manifestations and even blindness is not uncommon, the causes of blindness being causes like uveitis, retinitis, interstitial keratitis, ophthalmitis, and even orbital tuberculosis.4 Classical teaching in neurosurgery is that a posterior fossa lesion unless proven otherwise is a metastasis. Therefore, here we are discussing three cases of central nervous system tuberculosis in isolation, without any systemic involvement in immunocompetent adults in the posterior fossa region as well as a literature review of cases from across the globe of posterior fossa tuberculosis in immunocompetent adults. The first case is regarding a treatable cause like tuberculoma in an immunocompetent young adult causing blindness which is rare as well as unfortunate. The other two cases highlight the need to keep tuberculosis as a differential even when the clinical features, radiological features, and blood and other investigations are not suggestive.

The diagnostic performance of GeneXpert MTB/RIF in tuberculosis meningitis: A multicentre accuracy study

OBJECTIVES

To evaluate the performance of GeneXpert MTB/RIF (Xpert) for tuberculous meningitis (TBM) and to identify additional indicators to improve diagnostic accuracy.

METHODS

An accuracy study was conducted. During 2011-2019, 243 TBM with 140 non-TBM in three TB-designated facilities in China were enrolled. Microbiological evidence of M tuberculosis (Mtb) in CSF was used as the reference. Additional indicators were identified by Boosted-Classification and Regression Tree (CART), the improvement of diagnostic performance was evaluated by ROC.

RESULTS

The diagnostic sensitivity of Xpert was 71.1 % for definite TBM, and 5.5 % for probable/possible TBM. The positive rate of Xpert was improved with cerebrospinal fluid (CSF) increasing volume and was associated with CSF color (yellow). The additional indicators obtained by CART were CSF lactate and glucose and increased the sensitivity to 96.1 % (definite TBM) and 84.6 % (probable/possible TBM).

CONCLUSIONS

The diagnostic performance of Xpert was satisfactory in definite TBM and would significantly be improved by the additional use of CSF lactate and glucose.

Efficacy of linezolid in the treatment of tuberculous meningitis: a meta-analysis

Introduction

Tuberculous meningitis (TBM) is a severe extra-pulmonary tuberculosis with high fatality. This meta-analysis aimed to assess the impact of linezolid on TBM treatment outcomes.

Methods

We searched multiple databases for studies published up to May 18, 2024 comparing the effects of linezolid on TBM. Meta-analysis was conducted using Review Manager 5.4.

Results

Our findings indicated that linezolid may reduce treatment failure risk (RR = 0.42 (0.20, 0.89), p = 0.02) and improve temperature recovery (RR = 1.56 (1.21, 2.02), p < 0.001) in TBM patients.

Conclusions

The analysis suggests a positive association between linezolid treatment and therapeutic improvements, with no significant adverse reactions reported.

Using cerebrospinal fluid nanopore sequencing assay to diagnose tuberculous meningitis: a retrospective cohort study in China

OBJECTIVE

This study aimed to evaluate the efficiency of nanopore sequencing for the early diagnosis of tuberculous meningitis (TBM) using cerebrospinal fluid and compared it with acid-fast bacilli (AFB) smear, mycobacterial growth indicator tube culture and Xpert Mycobacterium tuberculosis (MTB)/rifampicin (RIF).

DESIGN

Single-centre retrospective study.

SETTING

The Tuberculosis Diagnosis and Treatment Center of Zhejiang Chinese and Western Medicine Integrated Hospital.

PARTICIPANTS

We enrolled 64 adult patients with presumptive TBM admitted to our hospital from August 2021 to August 2023.

METHODS

We calculated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of AFB smear, culture, Xpert MTB/RIF and nanopore sequencing to evaluate their diagnostic efficacy compared with a composite reference standard for TBM.

RESULTS

Among these 64 patients, all tested negative for TBM by AFB smear. The sensitivity, specificity, PPV and NPV were 11.11%, 100%, 100% and 32.2% for culture, 13.33%, 100%, 100% and 2.76% for Xpert MTB/RIF, and 77.78%, 100%, 100% and 65.52% for nanopore sequencing, respectively.

CONCLUSION

The diagnostic accuracy of the nanopore sequencing test was significantly higher than that of conventional testing methods used to detect TBM.

Efficacy and safety of intrathecal dexamethasone combined with isoniazid in the treatment of tuberculous meningitis: a meta-analysis

BACKGROUND

The treatment regimen for tuberculous meningitis (TBM) remains unclear and requires optimization. There are some reports on successful adjunct intrathecal dexamethasone and isoniazid (IDI) treatment strategies for TBM, however, there is equivocal evidence on their efficacy and safety.

METHODS

A comprehensive search of English and Chinese databases was conducted from inception to February 2024. A meta-analysis was performed on randomized controlled trials (RCTs) estimating the effects of adjunct IDI on conventional anti-TB (C anti-TB) treatments or C anti-TB alone. Efficacy, adverse reaction rate, cerebrospinal fluid (CSF) leukocytes, and CSF protein were used as primary outcome indicators. CSF glucose, CSF chlorides, CSF pressure, recovery time for laboratory indicators and recovery time for clinical symptoms were used as secondary outcome indicators.

RESULTS

A total of 17 studies involving 1360 (IDI group vs. C anti-TB group: 392 vs. 372; higher-dose IDI group vs. lower-dose IDI group: 319 vs. 277) patients were included in our analysis. Efficacy was significantly higher (RR 1.3, 95% CI 1.2-1.4, P < 0.001) and adverse reaction rate was significantly lower in the IDI groups (RR 0.59, 95% CI 0.37-0.92, P = 0.021). Furthermore, CSF leukocytes (WMD - 29.33, 95% CI [- 40.64 to-18.02], P < 0.001) and CSF protein (WMD - 0.79, 95%CI [-0.96 to-0.61], P < 0.001) were significantly lower in the IDI groups. Recovery time indicators were all shorter in the IDI groups, fever (SMD - 2.45, 95% CI [-3.55 to-1.35], P < 0.001), coma (SMD-3.75, 95% CI [-4.33 to-3.17], P < 0.001), and headache (SMD  - 3.06, 95% CI [- 4.05 to-2.07], P < 0.001), respectively. Higher-dose IDI was more effective than lower-dose IDI (RR 1.23, 95% CI 1.14-1.33, P < 0.001), with no significant difference in adverse reaction rate between the two (RR 0.82, 95%CI 0.43-1.56, P = 0.544).

CONCLUSION

Adjunct IDI with C anti-TB can enhance therapeutic outcomes and reduce adverse reaction rate in adult TBM patients, with higher-dose IDI showing superior efficacy. These findings highlight the potential of IDI as an adjunctive therapy in TBM management. However, more high-quality RCTs from more regions should be conducted to support our results.

TRIAL REGISTRATION

Retrospectively registered in PROSPERO  https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023388860 .

Diagnosis and management of severe pulmonary and extrapulmonary tuberculosis in critically ill patients: A mini review for clinicians

Among critically ill patients, severe pulmonary and extrapulmonary tuberculosis has high morbidity and mortality. Yet, it is a diagnostic challenge given its nonspecific clinical symptoms and signs in early stages of the disease. In addition, management of severe pulmonary and extrapulmonary tuberculosis is complicated given the high risk of drug-drug interactions, drug-disease interactions, and adverse drug reactions. To help clinicians acquire an up-to-date approach to severe tuberculosis, this paper will provide a narrative review of contemporary diagnosis and management of severe pulmonary and extrapulmonary tuberculosis in critically ill patients.

Continuous evaluation of single-dose moxifloxacin concentrations in brain extracellular fluid, cerebrospinal fluid, and plasma: a novel porcine model

BACKGROUND

Knowledge regarding CNS pharmacokinetics of moxifloxacin is limited, with unknown consequences for patients with meningitis caused by bacteria resistant to beta-lactams or caused by TB.

OBJECTIVE

(i) To develop a novel porcine model for continuous investigation of moxifloxacin concentrations within brain extracellular fluid (ECF), CSF and plasma using microdialysis, and (ii) to compare these findings to the pharmacokinetic/pharmacodynamic (PK/PD) target against TB.

METHODS

Six female pigs received an intravenous single dose of moxifloxacin (6 mg/kg) similar to the current oral treatment against TB. Subsequently, moxifloxacin concentrations were determined by microdialysis within five compartments: brain ECF (cortical and subcortical) and CSF (ventricular, cisternal and lumbar) for the following 8 hours. Data were compared to simultaneously obtained plasma samples. Chemical analysis was performed by high pressure liquid chromatography with mass spectrometry. The applied PK/PD target was defined as a maximum drug concentration (Cmax):MIC ratio >8.

RESULTS

We present a novel porcine model for continuous in vivo CNS pharmacokinetics for moxifloxacin. Cmax and AUC0-8h within brain ECF were significantly lower compared to plasma and lumbar CSF, but insignificantly different compared to ventricular and cisternal CSF. Unbound Cmax:MIC ratio across all investigated compartments ranged from 1.9 to 4.3.

CONCLUSION

A single dose of weight-adjusted moxifloxacin administered intravenously did not achieve adequate target site concentrations within the uninflamed porcine brain ECF and CSF to reach the applied TB CNS target.

Disease spectrum and prognostic factors in patients treated for tuberculous meningitis in Shaanxi province, China

Background

Tuberculous meningitis (TBM) is the most severe form of tuberculosis (TB) and can be difficult to diagnose and treat. We aimed to describe the clinical presentation, diagnosis, disease spectrum, outcome, and prognostic factors of patients treated for TBM in China.

Methods

A multicenter retrospective study was conducted from 2009 to 2019 enrolling all presumptive TBM patients referred to Xijing tertiary Hospital from 27 referral centers in and around Shaanxi province, China. Patients with clinical features suggestive of TBM (abnormal CSF parameters) were included in the study if they had adequate baseline information to be classified as "confirmed," "probable," or "possible" TBM according to international consensus TBM criteria and remained in follow-up. Patients with a confirmed alternative diagnosis or severe immune compromise were excluded. Clinical presentation, central nervous system imaging, cerebrospinal fluid (CSF) results, TBM score, and outcome-assessed using the modified Barthel disability index-were recorded and compared.

Findings

A total of 341 presumptive TBM patients met selection criteria; 63 confirmed TBM (25 culture positive, 42 Xpert-MTB/RIF positive), 66 probable TBM, 163 possible TBM, and 49 "not TBM." Death was associated with BMRC grade III (OR = 5.172; 95%CI: 2.298-11.641), TBM score ≥ 15 (OR = 3.843; 95%CI: 1.372-10.761), age > 60 years (OR = 3.566; 95%CI: 1.022-12.442), and CSF neutrophil ratio ≥ 25% (OR = 2.298; 95%CI: 1.027-5.139). Among those with confirmed TBM, nearly one-third (17/63, 27.0%) had a TBM score < 12; these patients exhibited less classic meningitis symptoms and signs and had better outcomes compared with those with a TBM score ≥ 12. In this group, signs of disseminated/miliary TB (OR = 12.427; 95%CI: 1.138-135.758) and a higher TBM score (≥15, OR = 8.437; 95%CI: 1.328-53.585) were most strongly associated with death.

Conclusion

TBM patients who are older (>60 years) have higher TBM scores or CSF neutrophil ratios, have signs of disseminated/miliary TB, and are at greatest risk of death. In general, more effort needs to be done to improve early diagnosis and treatment outcome in TBM patients.

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.

Comprehensive Therapeutic Approaches to Tuberculous Meningitis: Pharmacokinetics, Combined Dosing, and Advanced Intrathecal Therapies

Tuberculous meningitis (TBM) presents a critical neurologic emergency characterized by high mortality and morbidity rates, necessitating immediate therapeutic intervention, often ahead of definitive microbiological and molecular diagnoses. The primary hurdle in effective TBM treatment is the blood-brain barrier (BBB), which significantly restricts the delivery of anti-tuberculous medications to the central nervous system (CNS), leading to subtherapeutic drug levels and poor treatment outcomes. The standard regimen for initial TBM treatment frequently falls short, followed by adverse side effects, vasculitis, and hydrocephalus, driving the condition toward a refractory state. To overcome this obstacle, intrathecal (IT) sustained release of anti-TB medication emerges as a promising approach. This method enables a steady, uninterrupted, and prolonged release of medication directly into the cerebrospinal fluid (CSF), thus preventing systemic side effects by limiting drug exposure to the rest of the body. Our review diligently investigates the existing literature and treatment methodologies, aiming to highlight their shortcomings. As part of our enhanced strategy for sustained IT anti-TB delivery, we particularly seek to explore the utilization of nanoparticle-infused hydrogels containing isoniazid (INH) and rifampicin (RIF), alongside osmotic pump usage, as innovative treatments for TBM. This comprehensive review delineates an optimized framework for the management of TBM, including an integrated approach that combines pharmacokinetic insights, concomitant drug administration strategies, and the latest advancements in IT and intraventricular (IVT) therapy for CNS infections. By proposing a multifaceted treatment strategy, this analysis aims to enhance the clinical outcomes for TBM patients, highlighting the critical role of targeted drug delivery in overcoming the formidable challenges presented by the blood-brain barrier and the complex pathophysiology of TBM.

Prolonged paradoxical reaction requiring over 5 years of corticosteroid administration in a patient with severe tuberculous meningitis

Tuberculous meningitis (TBM) is a rare disease in low-incidence countries like Japan, where general physicians have fewer experience with TBM. Despite its proper treatment and early improvement of the condition, TBM often causes paradoxical reactions (PRs), which can lead to severe complications such as stroke. As PRs in the brain are difficult to detect without regular neuroimaging surveillance and have a later onset than in other organs, delayed treatment can be fatal. We report a case of a 54-year-old, human immunodeficiency virus (HIV)-negative man who presented with TBM and miliary tuberculosis (TB) in an unconscious state. Standard anti-tuberculous therapy with adjunctive systemic high-dose dexamethasone brought rapid clinical and microbiological improvement, which allowed the dexamethasone to be tapered. However, he developed cerebral infarction with left hemiplegia due to a TBM-related PR five months after admission. Therefore, the initial high-dose dexamethasone was again added to the anti-tuberculous drugs, achieving the significant effects on the PR-related lesions. Anti-tuberculous drugs had been administered for 3 years and the dexamethasone was carefully tapered. Nevertheless, enlargement of PR-related lesions in the brain recurred 5 years later. Accordingly, the dose of corticosteroid was again increased, resulting in resolving the lesions. It is important to note that severe TBM may cause prolonged PRs, which require a long-term neuroimaging follow-up and anti-inflammatory drugs for the successful management of the TBM-related PR.

Mortality and sequelae of tuberculous meningitis in a high-resource setting: A cohort study, 1990-2017

INTRODUCTION

Tuberculous meningitis (TBM), the most serious form of tuberculosis, results in high mortality and long-term disability in low-resource countries. We investigated temporal trends in mortality and sequelae in a high-resource low-incidence country.

METHODS

We performed a retrospective cohort study of all adult patients with TBM at two third-level teaching hospitals in Barcelona (Spain), between January 1990 and December 2017, assessing temporal trends in mortality and sequelae after 12 months over four consecutive 7-year time windows. Rates observed across the four periods were adjusted for covariates.

RESULTS

Of the 135 cases included, all but one started tuberculosis (TB) treatment and 120 (89.6%) received rifampicin, isoniazid, and pyrazinamide, with or without ethambutol. The probability of being alive at month 12 was 81.8%, with no differences among the four periods: in comparison with the 1990-1996 period, the adjusted hazard ratios and 95% confidence intervals (CI) were 2.55 (0.71-9.25), 0.70 (0.13-3.85), and 1.29 (0.28-5.91) for the 1997-2003, 2004-2010, and 2011-2017 periods respectively. Sequelae were present in 28.3% at month 12, with no differences across the four periods in the adjusted analysis: in comparison with the 1990-1996 period, the odds ratios and 95% CIs were 0.80 (0.09-7.22); 1.94 (0.21-17.96), and 2.42 (0.25-23.07) for the 1997-2003, 2004-2010, and 2011-2017 periods respectively.

CONCLUSION

This study shows that TBM still causes high mortality and disability even in a high-resource low-incidence TB setting and without improvement over time.

Metagenomic next-generation sequencing on bronchoalveolar lavage fluid to contribute to diagnosis of subclinical pulmonary tuberculosis with scarce sputum and negative smear in a patient mimicking adult- onset still's disease: A case report

Extremely high serum ferritin, which is regarded as a marker of adult-onset still's disease (AOSD), has been rarely observed in patients with TB. We report a case of TB diagnose by metagenomic next-generation sequencing(mNGS) who presented with clinical criteria of AOSD and extreme hyperferritinemia, which posed a diagnostic confusion. TB presenting with major clinical criteria of AOSD should be notable. Since TB remains a potentially curable disease, an awareness of its' protean manifestations is essential. A typical or even normal outcomes of clinical, microbiochemical, and radiologic evaluation should not be overlooked and dedicated diagnostic work-up should be performed for TB diagnosis. For equivocal cases, mNGS could be helpful.

The Role of Oxidative Stress in TB Meningitis and Therapeutic Options

Meningitis is an inflammatory condition affecting the meninges surrounding the brain and spinal cord. Meningitis can be triggered by various factors, including infectious agents like viruses and bacteria and non-infectious contributors such as cancer or head injuries. The impact of meningitis on the central nervous system involves disruptions in the blood-brain barrier, cellular infiltrations, and structural alterations. The clinical features that differentiate between tuberculous meningitis (TBM) and non-tuberculous meningitis (NTM) are discussed in this review and aid in accurate diagnosis. The intricate interplay of reactive oxygen species, ferroptosis, and reactive nitrogen species within the central nervous system reveals a promising field of research for innovative therapeutic strategies tailored to TBM. This review highlights the alternative treatments targeting oxidative stress-induced TBM and ferroptosis, providing potential avenues for intervention in the pathogenesis of this complex condition.

Interactions between CNS and immune cells in tuberculous meningitis

The central nervous system (CNS) harbors its own special immune system composed of microglia in the parenchyma, CNS-associated macrophages (CAMs), dendritic cells, monocytes, and the barrier systems within the brain. Recently, advances in the immune cells in the CNS provided new insights to understand the development of tuberculous meningitis (TBM), which is the predominant form of Mycobacterium tuberculosis (M.tb) infection in the CNS and accompanied with high mortality and disability. The development of the CNS requires the protection of immune cells, including macrophages and microglia, during embryogenesis to ensure the accurate development of the CNS and immune response following pathogenic invasion. In this review, we summarize the current understanding on the CNS immune cells during the initiation and development of the TBM. We also explore the interactions of immune cells with the CNS in TBM. In the future, the combination of modern techniques should be applied to explore the role of immune cells of CNS in TBM.

Systemic and cerebrospinal fluid biomarkers for tuberculous meningitis identification and treatment monitoring

IMPORTANCE

Tuberculous meningitis is a life-threatening infection with high mortality and disability rates. Current diagnostic methods using cerebrospinal fluid (CSF) samples have limited sensitivity and lack predictive biomarkers for evaluating prognosis. This study's findings reveal excessive activation of the immune response during tuberculous meningitis (TBM) infection. Notably, a strong negative correlation was observed between CSF levels of monokine induced by interferon-γ (MIG) and the CSF/blood glucose ratio in TBM patients. MIG also exhibited the highest area under the curve with high sensitivity and specificity. This study suggests that MIG may serve as a novel biomarker for differentiating TBM infection in CSF or serum, potentially leading to improved diagnostic accuracy and better patient outcomes.

Isoniazid exposures and acetylator status in Indonesian tuberculous meningitis patients

The effect of acetylator status on the exposure to isoniazid in plasma and CSF in tuberculous meningitis (TBM) patients remains largely unexplored. Here, we describe isoniazid exposures and acetylator status of 48 subjects in the ReDEFINe study (NCT02169882). Fifty percentwere fast (half-life <130 min) or slow (half-life >130 min) acetylators. Slow acetylators had higher AUC0-24, Cmax and CSF concentrations than fast acetylators (GM AUC0-24 25.5 vs 10.6 mg/L*h, p < 0.001); plasma Cmax 5.5 vs 3.6 mg/L, p = 0.023; CSF concentration 1.9 vs 1.1 mg/L, p = 0.008). Higher isoniazid doses may benefit fast acetylators in TBM.

Advancing Diagnosis and Treatment in People Living with HIV and Tuberculosis Meningitis

PURPOSE OF REVIEW

Tuberculous meningitis (TBM) is the most severe form of tuberculosis. Inadequate diagnostic testing and treatment regimens adapted from pulmonary tuberculosis without consideration of the unique nature of TBM are among the potential drivers. This review focuses on the progress being made in relation to both diagnosis and treatment of TBM, emphasizing promising future directions.

RECENT FINDINGS

The molecular assay GeneXpert MTB/Rif Ultra has improved sensitivity but has inadequate negative predictive value to "rule-out" TBM. Evaluations of tests focused on the host response and bacterial components are ongoing. Clinical trials are in progress to explore the roles of rifampin, fluoroquinolones, linezolid, and adjunctive aspirin. Though diagnosis has improved, novel modalities are being explored to improve the rapid diagnosis of TBM. Multiple ongoing clinical trials may change current therapies for TBM in the near future.

Successful treatment of tuberculous meningitis in an Indian female under hemodialysis therapy

Hemodialysis is a well-known risk factor for severe infection by putting patients under an immunocompromised state. Such patients are prone to opportunistic pathogen and present with atypical manifestations during infection. Tuberculous meningitis is a central nervous system infection of Mycobacterium tuberculosis, accounting for the highest mortality of all forms of tuberculosis. In fact, the mortality rate of tuberculous meningitis in hemodialysis patients is extremely poor because early clinical diagnosis is difficult. Here, we report a case of tuberculous meningitis in a 61-year-old Indian hemodialysis patient, who presented with fever of unknown origin and was successfully treated with empiric treatment with standard four-drug regimen against tuberculosis. Comprehensive screening of the origin of fever revealed only the positive results of interferon-gamma release assay, which led us to initiate an empiric therapy for tuberculosis, before making a definitive diagnosis by cerebrospinal fluid nested PCR. Soon after the initiation of the treatment, the fever immediately abated. Although the patient experienced a single episode of paradoxical worsening and severe liver injury, she recovered well without any complications. This report provides a clinical course of the disease in a hemodialysis patient, highlighting the importance of early clinical diagnosis and rapid initiation of empirical tuberculosis treatment.

Ventriculoperitoneal shunt for tuberculous meningitis-associated hydrocephalus: long-term outcomes and complications

BACKGROUND

Hydrocephalus is a frequent complication of tuberculous meningitis (TBM), and ventriculoperitoneal shunt (VPS) has been shown to improve short-term prognosis for patients with TBM-associated hydrocephalus. However, questions remain about long-term prognosis and shunt-related complications. This study aims to provide a comprehensive assessment of both long-term prognosis and shunt-related complications in patients with TBM-induced hydrocephalus who have undergone VPS treatment.

METHODS

This retrospective study analyzed the clinical data of TBM patients with hydrocephalus treated with VPS at Peking Union Medical College Hospital between December 1999 and February 2023. Both short-term outcomes at discharge and long-term outcomes during follow-up were examined. Prognosis and shunt-related complications were assessed using the modified Rankin Scale (mRS) and the Activity of Daily Living (ADL) score to evaluate neurological function and autonomic living ability, respectively.

RESULTS

A total of 14 patients with TBM-associated hydrocephalus were included in this study. Of these, 92.9% (13/14) exhibited favorable short-term outcomes, while 57.1% (8/14) showed positive long-term outcomes. Initial results indicated 6 complete recoveries (CR), 7 partial recoveries (PR), and 1 treatment failure. No catheter-related complications were observed initially. Long-term results included 4 CRs, 4 PRs, and 6 treatment failures. A variety of shunt surgery-related complications were noted, including three instances of catheter obstruction, one of incision infection, one of catheter-related infection, one of acute cerebral infarction, and one of transient peritoneal irritation accompanied by diarrhea.

CONCLUSIONS

VPS appears to be an effective and well-tolerated treatment for TBM-associated hydrocephalus, efficiently alleviating acute intracranial hypertension. Nonetheless, continuous long-term monitoring and proactive management are essential to mitigate the risk of catheter-related complications.

[A case of tuberculous meningitis diagnosed early by direct Loop-Mediated Isothermal Amplification (LAMP) method using centrifuged medium of cerebrospinal fluid culture]

Tuberculous meningitis (TBM) is a central nervous system infection with a high mortality rate and requires early diagnosis and treatment. Identification of Mycobacterium tuberculosis in the cerebrospinal fluid is of primary importance in the diagnosis of TBM, however, conventional methods have some disadvantages: Rapid results tests such as smear and regular PCR method do not have sufficient diagnostic sensitivity; Nested PCR, which is one of the most sensitive tests, is not available in all facilities; Culture tests require a long period of 4-8 weeks for results. Here we report a case of TBM, diagnosed 14 days earlier than culture test by direct Loop-Mediated Isothermal Amplification (LAMP) method using centrifuged medium of cerebrospinal fluid (day 18) culture. The method we used here is simple, widely available, and considered to be useful for early detection of TBM.

Clinical characteristics of tuberculous meningitis in older patients compared with younger and middle-aged patients: a retrospective analysis

BACKGROUND

Few studies have analyzed the clinical characteristics and adverse factors affecting prognosis in older patients with tuberculous meningitis (TBM). This study aimed to compare the clinical characteristics of TBM in older patients with those in younger and middle-aged patients.

METHODS

This single-center retrospective study extracted data on the clinical features, cerebrospinal fluid changes, laboratory results, imaging features, and outcomes of patients with TBM from patient medical records and compared the findings in older patients (aged 60 years and older) with those of younger and middle-aged patients (aged 18-59 years).

RESULTS

The study included 197 patients with TBM, comprising 21 older patients aged 60-76 years at onset, and 176 younger and middle-aged patients aged 18-59 years at onset. Fever was common in both older (81%) and younger and middle-aged patients (79%). Compared with younger and middle-aged patients, older patients were more likely to have changes in awareness levels (67% vs. 40%), peripheral nerve dysfunction (57% vs. 29%), changes in cognitive function (48% vs. 20%), and focal seizures (33% vs. 6%), and less likely to have headache (71% vs. 93%), neck stiffness on meningeal stimulation (38% vs. 62%), and vomiting (47% vs. 68%). The Medical Research Council staging on admission of older patients was stage II (52%) and stage III (38%), whereas most younger and middle-aged patients had stage I (33%) and stage II (55%) disease. Neurological function evaluated on the 28th day of hospitalization was more likely to show poor prognosis in older patients than in younger and middle-aged patients (76% vs. 25%). Older patients had significantly higher red blood cell counts and blood glucose levels, and significantly lower serum albumin and sodium levels than those in younger and middle-aged patients. The cerebrospinal fluid protein levels, nucleated cell counts, glucose levels, and chloride levels did not differ significantly by age.

CONCLUSION

In patients with TBM, older patients have more severe clinical manifestations, a higher incidence of hydrocephalus and cerebral infarction, and longer hospital stays than younger and middle-aged patients. Older patients thus require special clinical attention.

Automated pupillometry and optic nerve sheath diameter ultrasound to define tuberculous meningitis disease severity and prognosis

BACKGROUND

Tuberculous meningitis (TBM) causes high mortality and morbidity, in part due to raised intracranial pressure (ICP). Automated pupillometry (NPi) and optic nerve sheath diameter (ONSD) are both low-cost, easy-to-use and non-invasive techniques that correlate with ICP and neurological status. However, it is uncertain how to apply these techniques in the management of TBM.

METHODS

We conducted a pilot study enrolling 20 adults with TBM in the Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam. Our objective was to investigate the relationships between baseline and serial measurements of NPi and ONSD and disease severity and outcome. Serial NPi and ONSD were performed for 30 days, at discharge, and at 3-months, with measurements correlated with clinical progression and outcomes.

RESULTS

ONSD and NPi measurements had an inverse relationship. Higher ONSD and lower NPi values were associated with lower Glasgow coma score. Baseline NPi was a strong predictor 3-month outcome (median NPi 4.55, interquartile range 4.35-4.65 for good outcomes versus 2.60, IQR 0.65-3.95 for poor outcomes, p = 0.002). Pupil inequality (NPi ≥0.7) was also strongly associated with poor 3-month outcomes (p = 0.006). Individual participants' serial NPi and ONSD were variable during initial treatment and correlated with clinical condition and outcome.

CONCLUSION

Pupillometry and ONSD may be used to predict clinical deterioration and outcome from TBM. Future, larger studies are need explore the optimal timing of measurements and to define how they might be used to optimise treatments and improve outcomes from TBM.

Comparative performance of microbiological methods for the detection of tuberculous meningitis pathogens in cerebrospinal fluid

The aim of this study was to comprehensively evaluate metagenomic next-generation sequencing (mNGS), Acid-fast bacillus stain (AFB), MGIT960 culture, polymerase-chain-reaction (PCR), and Xpert MTB/RIF in the diagnosis of tuberculous meningitis (TBM). A cohort of 280 patients who presented with suspected TBM (ie, headache or altered mental status with clinical signs of meningism) were analyzed. The sensitivities of the 5 assays for the diagnosis of TBM ranged from 10.0% to 70.0%. The AFB had the lowest sensitivity of 10.0% (0.5-45.9), while mNGS and PCR had the highest sensitivity, both at 70.0% (35.4-91.9). mNGS demonstrated a distinct advantage in identifying a wider array of pathogens, including viruses, in CSF samples. PCR was a cost-effective option with excellent sensitivity and specificity. However, no single method was statistically significantly better than any other in the diagnosis of TBM. New diagnostic techniques are urgently needed for the independent, rapid and accurate detection of Mycobacterium tuberculosis to guide the diagnosis of TBM.

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 clinical utility of metagenomic next-generation sequencing for the diagnosis of central nervous system infectious diseases

BACKGROUND

To evaluate the clinical utility of metagenomic next-generation sequencing (mNGS) for the diagnosis of central nervous system infections (CNSI).

METHODS

Cerebrospinal fluid (CSF) from 54 patients who were high-level clinical suspicion of CNSI was collected and sent for mNGS and conventional tests from January 2019 to March 2022.

RESULTS

Twenty out of 54 patients were diagnosed with CNSI and 34 non-CNSI. Among the 34 non-CNSI, one was false positive by mNGS. Among the 20 CNSI, 11 had presumed viral encephalitis and/or meningitis, 5 had presumed bacterial meningitis, 2 had presumed TMB, 1 had Crytococcus meningitis and 1 had neurosyphilis. The sensitivity of viral encephalitis and/or meningitis was 0.73 (8/11); 10 virus were detected; 9/10 was dsDNA; 1/10 was ssRNA. SSRN ranged from 1 to 13. The accuracy rate was 0.4, the accuracy rate was positively correlated with SSRN (r = 0.738, P = 0.015), SSRN ≥ 1, the accuracy rate was 0.4; SSRN ≥ 3, the accuracy rate was 0.66; SSRN ≥ 4, the accuracy rate was 0.75; SSRN ≥ 6, the accuracy rate was 1. The sensitivity of bacterial meningitis was 1. Seven kinds of bacteria were detected, among which 3/7 were gram positive, 3/7 were gram negative, and 1/7 was infected NTM (nontuberculous mycobacteria). The accuracy rate was 0.43 (3/7). The sensitivity of TBM was 0.66 (2/3), the accuracy rate was 1. The sensitivity of Crytococcus meningitis was 1, the accuracy rate was 0.5. PPV (positive predictive value) of mNGS was 0.94, NPV (negative predictive value) of mNGS was 0.89, specificity was 0.97 and sensitivity was 0.8. The AUG for CSF mNGS diagnosis of CNSI was 0.89 (95% CI = 0.78-0.99) Headache, meningeal irritation sign and image of meninges abnormal were correlated with the sensitivity of mNGS (r = 0.451, 0.313, 0.446; p = 0.001, 0.021, 0.001); CSF Glucose and CSF Chloride were negatively correlated with sensitivity of mNGS (r = -0.395, -0.462; p = 0.003, ＜ 0.001).

CONCLUSION

mNGS is a detection means with high sensitivity, wide coverage and strong timeliness, which can help clinicians to identify the pathogen diagnosis quickly, conduct targeted anti-infection treatment early and reduce antibiotic abuse. The pathogen which causing low CSF Glucose, low CSF Chloride or meninges infections was more likely to be detected by mNGS. It may be related to growth and structural characteristics of the pathogen and blood-brain barrier damage.

Role of Oxidative Stress in Tuberculosis Meningitis Infection in Diabetics

Tuberculosis meningitis (TBM) is a result of the invasion of the meninges with the bacilli of Mycobacterium tuberculosis (Mtb), leading to inflammation of the meninges around the brain or spinal cord. Oxidative stress occurs when the body's cells become overwhelmed with free radicals, particularly reactive oxygen species (ROS). ROS plays a significant role in the pathogenesis of TBM due to their toxic nature, resulting in impairment of the body's ability to fight off infection. ROS damages the endothelial cells and impairs the defense mechanisms of the blood-brain barrier (BBB), which contributes to CNS susceptibility to the bacteria causing TBM. Diabetes mellitus (DM) is a common condition that is characterized by the impairment of the hormone insulin, which is responsible for modulating blood glucose levels. The increased availability of glucose in individuals with diabetes results in increased cellular activity and metabolism, leading to heightened ROS production and, in turn, increased susceptibility to TBM. In this review, we summarize our current understanding of oxidative stress and its role in both TBM and DM. We further discuss how increased oxidative stress in DM can contribute to the likelihood of developing TBM and potential therapeutic approaches that may be of therapeutic value.

Recent advances in microbiological and molecular biological detection techniques of tuberculous meningitis

Tuberculous meningitis (TBM) is the most common type of central nervous system tuberculosis (TB) and has the highest mortality and disability rate. Early diagnosis is key to improving the prognosis and survival rate of patients. However, laboratory diagnosis of TBM is often difficult due to its paucibacillary nature and sub optimal sensitivity of conventional microbiology and molecular tools which often fails to detect the pathogen. The gold standard for TBM diagnosis is the presence of MTB in the CSF. The recognised methods for the identification of MTB are acid-fast bacilli (AFB) detected under CSF smear microscopy, MTB cultured in CSF, and MTB detected by polymerase chain reaction (PCR). Currently, many studies consider that all diagnostic techniques for TBM are not perfect, and no single technique is considered simple, fast, cheap, and efficient. A definite diagnosis of TBM is still difficult in current clinical practice. In this review, we summarise the current state of microbiological and molecular biological diagnostics for TBM, the latest advances in research, and discuss the advantages of these techniques, as well as the issues and challenges faced in terms of diagnostic effectiveness, laboratory infrastructure, testing costs, and clinical expertise, for clinicians to select appropriate testing methods.

Strategies to increase childhood tuberculosis case detection at the primary health care level: Lessons from an active case finding study in Zambia

INTRODUCTION

In high TB burden settings, it is estimated that 10-20% of total notifications should be children, however, currently only 6-8% of the total TB notifications in Zambia are children. We assessed whether the implementation of a multicomponent strategy, at primary healthcare facilities, that systematically targets barriers at each step of the childhood TB diagnostic cascade can increase childhood TB case detection.

METHODS

We conducted a controlled, interrupted time series analysis to compare childhood TB case notifications before (January 2018-December 2019), and during implementation (January 2020-September 2021) in two intervention and two control Level 1 hospitals in Lusaka, Zambia. At each of the intervention facilities, we implemented a multicomponent strategy constituting: (1) capacity development on childhood TB and interpretation of chest x-ray, (2) TB awareness-raising and demand creation activities, (3) setting up fast track TB services, (4) strengthening of household contact tracing, and (5) improving access to digital chest X-ray for TB screening and Xpert MTB/Rif Ultra for TB diagnosis, through strengthening sample collection in children.

FINDINGS

Among 5,150 children < 15 years screened at the two intervention facilities during the study period, 503 (9.8% yield) were diagnosed with TB. Of these, 433 (86.1%) were identified through facility-based activities (10.5% yield) and 70 (13.9%) were identified through household contact tracing (6.9% yield). Overall, 446 children (88.7%) children with TB were clinically diagnosed. Following implementation of the multicomponent strategy, the proportion children contributed to total TB notifications immediately changed by +1.5% (95%CI: -3.5, 6.6) and -4.4% (95%CI: -7.5, 1.4) at the intervention and control sites, respectively (difference 6.0% [95%CI: -0.7, 12.7]), p = 0.08); the proportion of childhood notifications increased 0.9% (95%CI: -0.7, 2.5%) each quarter at the intervention sites relative to pre-implementation trends, while declining 1.2% (-95%CI: -1.8, -0.6) at the control sites (difference 2.1% [95%CI: 0.1, 4.2] per quarter between, p = 0.046); this translated into 352 additional and 85 fewer childhood TB notifications at the intervention and control sites, respectively, compared to the pre-implementation period.

CONCLUSION

A standardized package of strategies to improve childhood TB detection at primary healthcare facilities was feasible to implement and was associated with a sustained improvement in childhood TB notifications.