Long-term follow up of childhood tuberculous meningitis

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.

Tuberculous Meningitis in Children: A Forgotten Public Health Emergency

Tuberculous meningitis (TBM) remains a major cause of morbidity and mortality in children with tuberculosis (TB), yet there are currently no estimates of the global burden of pediatric TBM. Due to frequent non-specific clinical presentation and limited and inadequate diagnostic tests, children with TBM are often diagnosed late or die undiagnosed. Even when diagnosed and treated, 20% of children with TBM die. Of survivors, the majority have substantial neurological disability with significant negative impact on children and their families. Surveillance data on this devastating form of TB can help to quantify the contribution of TBM to the overall burden, morbidity and mortality of TB in children and the epidemiology of TB more broadly. Pediatric TBM usually occurs shortly after primary infection with Mycobacterium tuberculosis and reflects ongoing TB transmission to children. In this article we explain the public health importance of pediatric TBM, discuss the epidemiology within the context of overall TB control and health system functioning and the limitations of current surveillance strategies. We provide a clear rationale for the benefit of improved surveillance of pediatric TBM using a TB care cascade framework to support monitoring and evaluation of pediatric TB, and TB control more broadly. Considering the public health implications of a diagnosis of TBM in children, we provide recommendations to strengthen pediatric TBM surveillance and outline how improved surveillance can help us identify opportunities for prevention, earlier diagnosis and improved care to minimize the impact of TBM on children globally.

Tuberculous Meningitis in Children: Reducing the Burden of Death and Disability

Tuberculous meningitis disproportionately affects young children. As the most devastating form of tuberculosis, it is associated with unacceptably high rates of mortality and morbidity even if treated. Challenging to diagnose and treat, tuberculous meningitis commonly causes long-term neurodisability in those who do survive. There remains an urgent need for strengthened surveillance, improved rapid diagnostics technology, optimised anti-tuberculosis drug therapy, investigation of new host-directed therapy, and further research on long-term functional and neurodevelopmental outcomes to allow targeted intervention. This review focuses on the neglected field of paediatric tuberculous meningitis and bridges current clinical gaps with research questions to improve outcomes from this crippling disease.

Long-term Cognitive Outcomes in Tuberculous Meningitis

Objective

Data on cognitive changes in patients with tuberculous meningitis (TBM) are sparse. We aimed to study the cognitive profiles of patients with grade I TBM and correlate them with the cytokine values.

Methods

Prospectively, 60 patients (M:F-31:29) with grade I TBM were recruited. Clinical details were collected; CSF estimation of cytokines, neuropsychological assessment, and correlation were performed.

Results

Mean age at presentation was 32.2 years (32.2 ± 10.1), and the duration of symptoms was 29.9 days (29.9 ± 25.9), respectively. Definitive evidence of mycobacterial infection was observed in 28.3% of the patients. Mean levels of tumor necrosis factor-α (TNF-α), interferon (IFN-γ), and interleukin-6 (IL-6) were 11.57 ± 30.35, 197.02 ± 186.64, and 127.03 ± 88.71 pg/mL, respectively. TNF-α levels were significantly elevated in definitive TBM (p = 0.044). Neuropsychological tests revealed an impaired auditory verbal learning test (88.3%), followed by complex figure test (50%), spatial span test (50%), clock drawing test (48.3%), digit span test (35%), color trail tests 1 and 2 (30% and 33.3%, respectively), and animal naming test (28.3%). Elevated levels of IFN-γ and IL-6 in TBM directly correlated with the number of impaired neuropsychological tests. During follow-up, significant improvement was noticed in animal naming test (p = 0.005), clock drawing test (p = 0.003), color trail test 2 (0.02), spatial span test (p = 0.012), and digit span test (0.035). Verbal learning did not show any significant change. Overall, the neuropsychological tests showed better recovery of attention, working memory, and category fluency and showed minimal recovery of verbal learning.

Conclusions

There is subclinical evidence of cognitive impairment in patients with TBM, and this correlated with elevated cytokines. Both the frontal and temporal lobes showed varying degrees of cognitive impairment.

Defeating Paediatric Tuberculous Meningitis: Applying the WHO "Defeating Meningitis by 2030: Global Roadmap"

Children affected by tuberculous meningitis (TBM), as well as their families, have needs that lie at the intersections between the tuberculosis and meningitis clinical, research, and policy spheres. There is therefore a substantial risk that these needs are not fully met by either programme. In this narrative review article, we use the World Health Organization (WHO) “Defeating Meningitis by 2030: global roadmap” as a starting point to consider key goals and activities to specifically defeat TBM in children. We apply the five pillars outlined in the roadmap to describe how this approach can be adapted to serve children affected by TBM. The pillars are (i) prevention; (ii) diagnosis and treatment; (iii) surveillance; (iv) support and care for people affected by meningitis; and (v) advocacy and engagement. We conclude by calling for greater integration between meningitis and TB programmes at WHO and at national levels.

Neurocognitive and functional impairment in adult and paediatric tuberculous meningitis

In those who survive tuberculous meningitis (TBM), the long-term outcome is uncertain; individuals may suffer neurocognitive, functional and psychiatric impairment, which may significantly affect their ability to lead their lives as they did prior to their diagnosis of TBM. In children who survive, severe illness has occurred at a crucial timepoint in their development, which can lead to behavioural and cognitive delay. The extent and nature of this impairment is poorly understood, particularly in adults. This is in part due to a lack of observational studies in this area but also inconsistent inclusion of outcome measures which can quantify these deficits in clinical studies. This leads to a paucity of appropriate rehabilitative therapies available for these individuals and their caregivers, as well as burden at a socioeconomic level. In this review, we discuss what is known about neurocognitive impairment in TBM, draw on lessons learnt from other neurological infections and discuss currently available and emerging tools to evaluate function and cognition and their value in TBM. We make recommendations on which measures should be used at what timepoints to assess for impairment, with a view to optimising and standardising assessment of neurocognitive and functional impairment in TBM research.

Delamanid Central Nervous System Pharmacokinetics in Tuberculous Meningitis in Rabbits and Humans

Central nervous system tuberculosis (TB) is devastating and affects vulnerable populations. Multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculous meningitis (TBM) specifically are nearly uniformly fatal, with little information being available to guide the treatment of these patients. Delamanid (DLM), a nitro-dihydro-imidazooxazole, is a new, well-tolerated anti-TB drug with a low MIC (1 to 12 ng/ml) against Mycobacterium tuberculosis It is used for the treatment of pulmonary MDR-TB, but pharmacokinetic (PK) data for DLM in the central nervous system (CNS) of patients with TBM are not available. In the present study, we measured DLM concentrations in the brain and cerebrospinal fluid (CSF) of six rabbits with and without experimentally induced TBM receiving single-dose DLM. We report the steady-state CSF concentrations from three patients receiving DLM as part of multidrug treatment who underwent therapeutic drug monitoring. Drug was quantified using liquid chromatography-tandem mass spectrometry. In rabbits and humans, mean concentrations in CSF (in rabbits, 1.26 ng/ml at 9 h and 0.47 ng/ml at 24 h; in humans, 48 ng/ml at 4 h) were significantly lower than those in plasma (in rabbits, 124 ng/ml at 9 h and 14.5 ng/ml at 24 h; in humans, 726 ng/ml at 4 h), but the estimated free CSF/plasma ratios were generally >1. In rabbits, DLM concentrations in the brain were 5-fold higher than those in plasma (means, 518 ng/ml at 9 h and 74.0 ng/ml at 24 h). All patients with XDR-TBM receiving DLM experienced clinical improvement and survival. Collectively, these results suggest that DLM achieves adequate concentrations in brain tissue. Despite relatively low total CSF drug levels, free drug may be sufficient and DLM may have a role in treating TBM. More studies are needed to develop a fuller understanding of its distribution over time with treatment and clinical effectiveness.

Application of Cerebrospinal Fluid Host Protein Biosignatures in the Diagnosis of Tuberculous Meningitis in Children from a High Burden Setting

Background

The diagnosis of tuberculous meningitis (TBM) especially in children is challenging. New tests are urgently needed for the diagnosis of the disease, especially in resource-limited settings.

Methods

We collected cerebrospinal fluid (CSF) samples from children presenting with symptoms requiring investigation for meningitis at a tertiary hospital in Cape Town, South Africa. Children were later classified as TBM or no TBM using published case definitions. Using a multiplex platform, we investigated the concentrations of biomarkers comprising a previously established 3-marker biosignature (VEGF, IL-13, and LL-37) and other potentially useful host biomarkers as diagnostic candidates for TBM.

Findings

Out of 47 children, age, 3 months to 13 years, 23 were diagnosed with TBM and six (16%) were HIV-infected. We validated the previously identified CSF biosignature (sensitivity of 95.7% (95% CI, 79.0-99.2%) and specificity of 37.5% (95% CI, 21.2-57.3%)). However, substitution of IL-13 and LL-37 with IFN-γ and MPO, respectively, resulted in improved accuracy (area under the ROC curve (AUC) = 0.97, 95% CI, 0.92-1.00, up to 91.3% (21/23) sensitivity and up to 100% (24/24) specificity). An alternative four-marker biosignature (sICAM-1, MPO, CXCL8, and IFN-γ) also showed potential, with an AUC of 0.97.

Conclusion

We validated a previously identified CSF biosignature and showed that refinement of this biosignature by incorporation of other biomarkers diagnosed TBM with high accuracy. Incorporation of these biomarkers into a point-of-care or bedside diagnostic test platform may result in the improved management of TBM in children.

Complementary surveillance strategies are needed to better characterise the epidemiology, care pathways and treatment outcomes of tuberculosis in children

BACKGROUND

Tuberculosis (TB) in young and HIV-infected children is frequently diagnosed at hospital level. In settings where general hospitals do not function as TB reporting units, the burden and severity of childhood TB may not be accurately reflected in routine TB surveillance data. Given the paucibacillary nature of childhood TB, microbiological surveillance alone will miss the majority of hospital-managed children. The study objective was to combine complementary hospital-based surveillance strategies to accurately report the burden, spectrum and outcomes of childhood TB managed at referral hospital-level in a high TB burden setting.

METHODS

We conducted a prospective cohort study including all children (< 13 years) managed for TB at a large referral hospital in Cape Town, South Africa during 2012. Children were identified through newly implemented clinical surveillance in addition to existing laboratory surveillance. Data were collected from clinical patient records, the National Health Laboratory Service database, and provincial electronic TB registers. Descriptive statistics were used to report overall TB disease burden, spectrum, care pathways and treatment outcomes. Univariate analysis compared characteristics between children identified through the two hospital-based surveillance strategies to characterise the group of children missed by existing laboratory surveillance.

RESULTS

During 2012, 395 children (180 [45.6%] < 2 years) were managed for TB. Clinical surveillance identified 237 (60%) children in addition to laboratory surveillance. Ninety (24.3%) children were HIV co-infected; 113 (29.5%) had weight-for-age z-scores <- 3. Extra-pulmonary TB (EPTB) was diagnosed in 188 (47.6%); 77 (19.5%) with disseminated TB. Favourable TB treatment outcomes were reported in 300/344 (87.2%) children with drug-susceptible and 50/51 (98.0%) children with drug-resistant TB. Older children (OR 1.7; 95% CI 1.0-2.8), children with EPTB (OR 2.3; 95% CI 1.5-3.6) and in-hospital deaths (OR 5.4; 95% CI 1.1-26.9) were more frequently detected by laboratory surveillance. TB/HIV co-infected children were less likely to be identified through laboratory surveillance (OR 0.3; 95% CI 0.2-0.5).

CONCLUSIONS

The burden and spectrum of childhood TB disease managed at referral hospital level in high burden settings is substantial. Hospital-based surveillance in addition to routine TB surveillance is essential to provide a complete picture of the burden, spectrum and impact of childhood TB in settings where hospitals are not TB reporting units.

Pediatric Tubercular Meningitis: A Review

Childhood tuberculosis (TB) has a high incidence and prevalence in developing countries like India with tubercular meningitis (TBM) being the most common cause of death. Most cases of TBM are diagnosed late when despite adequate therapy; morbidity and mortality continue to remain high. This review aims to provide a pragmatic approach at dealing with cases of tubercular meningitis in children including clinical features, laboratory and radiological criteria, treatment options and prognostic implications. The objective of this review is to assist in early identification, proper investigation and timely treatment of TBM in children in order to reduce neurological morbidity and mortality associated with it.

Standardized Methods for Enhanced Quality and Comparability of Tuberculous Meningitis Studies

Tuberculous meningitis (TBM) remains a major cause of death and disability in tuberculosis-endemic areas, especially in young children and immunocompromised adults. Research aimed at improving outcomes is hampered by poor standardization, which limits study comparison and the generalizability of results. We propose standardized methods for the conduct of TBM clinical research that were drafted at an international tuberculous meningitis research meeting organized by the Oxford University Clinical Research Unit in Vietnam. We propose a core dataset including demographic and clinical information to be collected at study enrollment, important aspects related to patient management and monitoring, and standardized reporting of patient outcomes. The criteria proposed for the conduct of observational and intervention TBM studies should improve the quality of future research outputs, can facilitate multicenter studies and meta-analyses of pooled data, and could provide the foundation for a global TBM data repository.

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.

Evaluating the neonatal BCG vaccination programme in Ireland

Background

The aim of this study was to compare the cost effectiveness of the current Irish programme of universal BCG vaccination of infants versus a programme which considered selectively vaccinating high risk infants using decision analytical modelling.

Methods

The efficacy of the BCG vaccine was re-evaluated to inform a decision analytical model constructed to follow a birth cohort of vaccinated and unvaccinated infants over a 15 year time horizon. The number of life years gained (LYG) was the primary outcome measure and this was compared to the net cost of the vaccination strategies.

Results

In the base case analysis, the incremental cost effectiveness ratios (ICERs) for the universal strategy and selective strategy vs no vaccination were €204,373/LYG and €143,233/LYG respectively. When comparing the incremental difference in moving from the universal to the selective strategy, the selective strategy costs €1,055,692 less per 4.8 life years lost per birth cohort. One way sensitivity analyses highlighted that a move from the universal to the selective strategy was particularly sensitive to the estimate of vaccine efficacy against deaths, the cost of administering the vaccine and the multiplier used to apportion risk of contracting tuberculosis. Probabilistic analysis suggested that a move from a universal based strategy to a selective based strategy could be deemed cost effective (probability of cost effectiveness is 76.8 %).

Conclusion

The results of the study support the protective effect of the BCG vaccine in infants and quantified the cost effectiveness of the current BCG vaccination strategy and the decremental difference in moving to a selective strategy. This analysis highlights that the additional protection offered by the universal vaccination strategy is small compared to that of the selective strategy. Consideration should therefore be given to the implementation of a selective vaccination strategy, and diverting resources to improve TB case management and control.

Electronic supplementary material

The online version of this article (doi:10.1186/s13690-016-0141-0) contains supplementary material, which is available to authorized users.

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.

Pediatric tuberculous meningitis: Model-based approach to determining optimal doses of the anti-tuberculosis drugs rifampin and levofloxacin for children

Pediatric tuberculous meningitis (TBM) is a highly morbid, often fatal disease. Standard treatment includes isoniazid, rifampin, pyrazinamide, and ethambutol. Current rifampin dosing achieves low cerebrospinal fluid (CSF) concentrations, and CSF penetration of ethambutol is poor. In adult trials, higher-dose rifampin and/or a fluoroquinolone reduced mortality and disability. To estimate optimal dosing of rifampin and levofloxacin for children, we compiled plasma and CSF pharmacokinetic (PK) and outcomes data from adult TBM trials plus plasma PK data from children. A population PK/pharmacodynamic (PD) model using adult data defined rifampin target exposures (plasma area under the curve (AUC)0-24 = 92 mg*h/L). Levofloxacin targets and rifampin pediatric drug disposition information were literature-derived. To attain target rifampin exposures, children require daily doses of at least 30 mg/kg orally or 15 mg/kg intravenously (i.v.). From our pediatric population PK model, oral levofloxacin doses needed to attain exposure targets were 19-33 mg/kg. Our results provide data-driven guidance to maximize pediatric TBM treatment while we await definitive trial results.

Uniform research case definition criteria differentiate tuberculous and bacterial meningitis in children

BACKGROUND

Tuberculous meningitis (TBM) research is hampered by low numbers of microbiologically confirmed TBM cases and the fact that they may represent a select part of the disease spectrum. A uniform TBM research case definition was developed to address these limitations, but its ability to differentiate TBM from bacterial meningitis has not been evaluated.

METHODS

We assessed all children treated for TBM from 1985 to 2005 at Tygerberg Children's Hospital, Cape Town, South Africa. For comparative purposes, a group of children with culture-confirmed bacterial meningitis, diagnosed between 2003 and 2009, was identified from the National Health Laboratory Service database. The performance of the proposed case definition was evaluated in culture-confirmed TBM and bacterial meningitis cases.

RESULTS

Of 554 children treated for TBM, 66 (11.9%) were classified as "definite TBM," 408 (73.6%) as "probable TBM," and 72 (13.0%) as "possible TBM." "Probable TBM" criteria identified culture-confirmed TBM with a sensitivity of 86% and specificity of 100%; sensitivity was increased but specificity reduced when using "possible TBM" criteria (sensitivity 100%, specificity 56%).

CONCLUSIONS

"Probable TBM" criteria accurately differentiated TBM from bacterial meningitis and could be considered for use in clinical trials; reduced sensitivity in children with early TBM (stage 1 disease) remains a concern.

Tuberculous meningitis: barriers to adherence in home treatment of children and caretaker perceptions

INTRODUCTION

In-hospital treatment of children with tuberculous meningitis (TBM) is not a feasible option in many resource-poor countries. Home-based treatment has shown to be a viable alternative. Adherence is an important factor determining success of treatment.

OBJECTIVE

Identify possible barriers to adherence of home-based treatment and caretaker perception of the disease.

METHOD

A qualitative study consisting of 11 in-depth semi-structured interviews was performed based on principles of the health belief model.

RESULTS

Barriers of adherence identified include poor understanding of the disease and transmission route, difficulty with medication administration and side effects, lack of access to the health-care facility, long waiting times and hidden costs of transportation. Caretakers showed good appreciation of the adverse effects of noncompliance and benefits obtained from taking treatment in the home environment.

CONCLUSION

Improved doctor-patient communication, information brochures, structural changes to hospital settings, provision of financial and peer support all contribute to optimal TBM home-based treatment.

Dexamethasone and long-term outcome of tuberculous meningitis in Vietnamese adults and adolescents

Background

Dexamethasone has been shown to reduce mortality in patients with tuberculous meningitis but the long-term outcome of the disease is unknown.

Methods

Vietnamese adults and adolescents with tuberculous meningitis recruited to a randomised, double-blind, placebo-controlled trial of adjunctive dexamethasone were followed-up at five years, to determine the effect of dexamethasone on long-term survival and neurological disability.

Results

545 patients were randomised to receive either dexamethasone (274 patients) or placebo (271 patients). 50 patients (9.2%) were lost to follow-up at five years. In all patients two-year survival, probabilities tended to be higher in the dexamethasone arm (0.63 versus 0.55; p = 0.07) but five-year survival rates were similar (0.54 versus 0.51, p = 0.51) in both groups. In patients with grade 1 TBM, but not with grade 2 or grade 3 TBM, the benefit of dexamethasone treatment tended to persist over time (five-year survival probabilities 0.69 versus 0.55, p = 0.07) but there was no conclusive evidence of treatment effect heterogeneity by TBM grade (p = 0.36). The dexamethasone group had a similar proportion of severely disabled patients among survivors at five years as the placebo group (17/128, 13.2% vs. 17/116, 14.7%) and there was no significant association between dexamethasone treatment and disability status at five years (p = 0.32).

Conclusions

Adjunctive dexamethasone appears to improve the probability of survival in patients with TBM, until at least two years of follow-up. We could not demonstrate a five-year survival benefit of dexamethasone treatment which may be confined to patients with grade 1 TBM.

Trial Registration

ClinicalTrials.gov NCT01317654 NCT01317654&quest;term&hairsp;&equals;&hairsp;tuberculous&plus;meningitis&amp;rank&hairsp;&equals;&hairsp;3

Tag SNP polymorphism of CCL2 and its role in clinical tuberculosis in Han Chinese pediatric population

BACKGROUND

Chemokine (C-C motif) ligand 2 CCL2/MCP-1 is among the key signaling molecules of innate immunity; in particular, it is involved in recruitment of mononuclear and other cells in response to infection, including tuberculosis (TB) and is essential for granuloma formation.

METHODOLOGY/PRINCIPAL FINDINGS

We identified a tag SNP for the CCL2/MCP-1 gene (rs4586 C/T). In order to understand whether this SNP may serve to evaluate the contribution of the CCL2 gene to the expression of TB disease, we further analysed distribution of its alleles and genotypes in 301 TB cases versus 338 non-infected controls (all BCG vaccinated) representing a high-risk pediatric population of North China. In the male TB subgroup, the C allele was identified in a higher rate (P = 0.045), and, acting dominantly, was found to be a risk factor for clinical TB (P = 0.029). Homozygous TT genotype was significantly associated with lower CSF mononuclear leukocyte (ML) counts in patients with tuberculous meningitis (TBM) (P = 0.001).

CONCLUSIONS/SIGNIFICANCE

The present study found an association of the CCL2 tag SNP rs4586 C allele and pediatric TB disease in males, suggesting that gender may affect the susceptibility to TB even in children. The association of homozygous TT genotype with decreased CSF mononuclear leukocyte (ML) count not only suggests a clinical significance of this SNP, but indicates its potential to assist in the clinical assessment of suspected TBM, where delay is critical and diagnosis is difficult.

Behaviour profiles after tuberculous meningitis

The purpose of the study was to investigate child behaviour in children who recovered from tuberculous meningitis (TBM) and to compare behaviour profiles of stage II and stage III patients. The mean age of the cohort of 74 children at the time of evaluation was 10 years and 7 months. At follow-up all patients underwent a thorough neurological examination and a psychometric test battery, which included intellectual assessment and evaluation of behaviour by means of the CBCL/6-18. Results indicated elevated mean scores (T > 60) on CBCL/6-18 scales which measure problems with anxiety, depression, attention, social relationships, disruptive and rule-breaking behaviour. Mean CBCL scores of stage III patients were significantly higher than the mean scores of stage II patients on scales which measure social problems, disruptive and rule-breaking behaviour. In addition, problems with conduct, attention, attention-deficit/hyperactivity problems, affective problems as well as the total problem scores were more pronounced in the patients with stage III TBM. We conclude that general behavioural disinhibitions as well as internalized emotional disorder probably are long-term complications in more than 10% of the survivors of TBM.

Home-based treatment of childhood neurotuberculosis

INTRODUCTION

In-hospital treatment is widely recognized as the gold standard of treatment for children with neurotuberculosis due to the complexity of care and serious consequences of non-compliance. The continuous rise in the incidence of tuberculosis (TB), fuelled by an HIV-pandemic, has resulted in severe bed shortages in tertiary, secondary and TB hospitals in the Western Cape.

OBJECTIVE

To evaluate the feasibility of home-based directly observed therapy (DOT) in TBM.

METHOD

Suitability screening by social workers, in-hospital monitoring of mother-child interaction, medication side effects and intolerance followed by a supervised outpatient surveillance program.

RESULTS

Forty of the 52 children screened were approved for home-based treatment. Thirty-four of these 40 patients (85%) completed TBM treatment successfully at home, and no patient defaulted treatment.

CONCLUSION

Home-based treatment of childhood neurotuberculosis is feasible in selected patients under close supervision. Mothers could be considered as primary DOT supporters.

Laboratory-based surveillance of patients with bacterial meningitis in Egypt (1998–2004)

Laboratory-based surveillance for bacterial meningitis was conducted in a network of infectious disease hospitals in Egypt to better understand the epidemiology of this infection. Healthcare and laboratory personnel were trained in basic surveillance and microbiologic processing of cerebrospinal fluid (CSF) specimens. All bacterial isolates from CSF were confirmed and tested for antimicrobial susceptibility. PCR testing was performed on a random subset of purulent, culture-negative CSF specimens. Of 11,070 patients who met criteria for the case definition, 843 (8%) were culture positive (42% positive for Streptococcus pneumoniae, 20% for Haemophilus influenzae serotype b, 17% for each of Neisseria meningitidis and Mycobacterium tuberculosis, and 6% for other bacteria). Of 1,784 (46%) CSF specimens tested by PCR, 232 (13%) were positive for the first three major pathogens. Of N. meningitidis isolates, 52% belonged to serogroup A, 35% to serogroup B, and 4% to serogroup W135. S. pneumoniae isolates comprised 46 different serotypes, of which 6B, 1, 19A, 23F, and 6A were the most predominant. The overall case-fatality rate for culture-positive cases was 26% and was highest among patients with M. tuberculosis (47%). Factors significantly associated with death (p < 0.05) included admission to rural hospitals, long prodromal period, referral from other hospitals, antibiotic treatment prior to admission, and clear CSF (<100 cells/mm3). Susceptibility to ampicillin and ceftriaxone was observed in 44 and 100% of H. influenzae serotype b isolates and in 52 and 94% of S. pneumoniae isolates, respectively. This surveillance highlights the significant mortality and morbidity associated with bacterial meningitis in Egypt. Decision makers need to review current treatment guidelines and introduce appropriate vaccines for prevention and control of the disease.

Paediatric tuberculosis in a Pacific Islands community in New Zealand

OBJECTIVES

To describe the demographic, clinical and management aspects of an outbreak of tuberculosis (TB) within a paediatric Pacific Island community in Auckland, New Zealand, in 2002-2003.

METHODS

The index and source case are described along with details of the extensive contact tracing that was undertaken in this community.

RESULTS

A total of 24 children were diagnosed with TB over an 11-month period. All cases were found to be epidemiologically linked to the one source case, mother of the index case. This total included 22 children with pulmonary disease, 1 case of miliary disease (index case) and 1 of cervical adenitis. Only 58% had symptoms at diagnosis and only 5 presented to medical attention with symptoms, the remainder had symptoms disclosed after contact tracing occurred. The Mycobacterium tuberculosis isolate was fully sensitive and all children (excluding the child with miliary disease) received short course directly observed therapy. One child developed hepatotoxicity requiring modification of his drug regimen.

CONCLUSIONS

Children are at high risk of developing active disease after exposure to TB. The study describes the minimal symptoms manifested in many of the children with significant radiological changes consistent with pulmonary TB. This highlights the need to consider Mantoux testing and chest X-rays for children presenting with persistent respiratory symptoms in high-risk populations. Issues of contact tracing and adherence were also a problem in this population.

Treatment of neuro-ophthalmologic manifestations of tuberculosis

In the absence of obvious pulmonary or disseminated tuberculosis, ocular and central nervous system (CNS) tuberculosis may represent a significant diagnostic challenge. Refinements in polymerase chain reaction techniques and neuroimaging have strengthened the battery of tests used to diagnose CNS and ocular tuberculosis, yet in many cases, the diagnosis remains one of exclusion; it may ultimately be determined through exacerbation by anti-inflammatory therapy with subsequent improvement by antitubercular medication treatment. Because of emerging drug resistance, at least a two-drug regimen is required for therapeutic testing and treatment of isolated ocular tuberculosis. If pulmonary or miliary disease coexists, a 6-month, four-drug regimen with isoniazid, rifampin, pyrazinamide, and ethambutol is required for treatment. Tubercular meningitis is treated with the same four-drug regimen for at least 9 to 12 months. Burden of therapeutic compliance rests on the treating physician and public health sector. Best compliance is realized with directly observed therapy.

Endoscopic third ventriculostomy in tuberculous meningitis

INTRODUCTION

We report our preliminary experience with two cases of tuberculous meningitis (TBM) in which endoscopic third ventriculostomy (ETV) was performed to treat non-communicating hydrocephalus. For many years, the insertion of ventriculoperitoneal shunts has been the standard treatment for hydrocephalus in patients with TBM, although the indications for and timing of surgery are not uniformly accepted. Shunt insertion is associated with a high incidence of complications, particularly with long-term follow-up. An alternative treatment for hydrocephalus in this group of patients would clearly be of great benefit. The indications for ETV have increased in the last decade, and there are reports of some effectiveness of the procedure in patients with hydrocephalus due to bacterial meningitis. To our knowledge, ETV has not been described in the management of TBM.

METHODS

We report the early results of our preliminary experience with ETV in two patients who presented with neurological compromise due to hydrocephalus and raised intracranial pressure. The clinical context and pre-operative investigation of these patients are presented. The emphasis is placed on the distinction between communicating and non-communicating pathologies as a guide to management options. We detail our surgical findings and the peculiar endoscopic challenges that the condition presented to us. Follow-up in these patients included clinical and investigational data suggesting early effectiveness of the procedure in converting non-communicating hydrocephalus into a communicating one, which can then be treated medically.

DISCUSSION

Endoscopic third ventriculostomy is presented as a new application of a procedure accepted for other indications in the treatment of non-communicating hydrocephalus. There are particular aspects of the use of this procedure related to the unique pathology of TBM that are significantly different. We explain our rationale for endoscopy in these patients, and suggest a protocol in which endoscopy may play a role in the management of patients with raised intracranial pressure due to tuberculous hydrocephalus.