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Enicker B, Aldous C. Factors associated with in-hospital mortality in HIV-infected children treated for tuberculous meningitis hydrocephalus. Childs Nerv Syst 2024; 40:695-705. [PMID: 37964056 PMCID: PMC10891234 DOI: 10.1007/s00381-023-06205-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 10/26/2023] [Indexed: 11/16/2023]
Abstract
PURPOSE The study aimed to investigate factors associated with in-hospital mortality in children diagnosed with tuberculous meningitis (TBM) hydrocephalus and HIV co-infection undergoing cerebrospinal fluid diversion procedures and their complications. METHODS Data were collected retrospectively and prospectively between 2007 and 2022. Data collected included demographics, clinical characteristics, antiretroviral therapy (ART) status, biochemistry results, CD4 count, radiology findings, CSF diversion procedures (and complications), length of hospital stay (LOHS), and in-hospital mortality. RESULTS Thirty-one children were included, with a mean age of 6.7 ± 5.3 years and 67.7% males. Median admission Glasgow Coma Scale (GCS) was 11 (IQR 9-15). Hypertonia (64.5%) and seizures (51.6%) were frequently observed clinical characteristics. Sixty-one percent of children were on ART. Cerebral infarcts and extra-meningeal TB were diagnosed in 64.5% and 19.3% of cases, respectively. The median CD4 count was 151 (IQR 70-732) cells/µL. Surgical procedures included ventriculoperitoneal shunt (VPS) in 26 cases and endoscopic third ventriculostomy (ETV) in five children. VPS complication rate was 27%. No complications were reported for ETV. Median LOHS was 7 days (IQR 4-21). Eleven children (35.5%) died during admission. Factors associated with mortality included GCS (p = 0.032), infarcts (p = 0.004), extra-meningeal TB (p = 0.003), VPS infection (p = 0.018), low CD4 count (p = 0.009), and hyponatremia (p = 0.002). No statistically significant factors were associated with VPS complications. CONCLUSION TBM hydrocephalus in HIV-infected children carries a high mortality. Clinicians in high-prevalence settings should have a high suspicion index and institute early treatment.
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Affiliation(s)
- Basil Enicker
- Department of Neurosurgery, Inkosi Albert Luthuli Central Hospital, KwaZulu-Natal, Durban, South Africa.
- Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, 719 Umbilo Road, Congella, Durban, 4001, South Africa.
| | - Colleen Aldous
- Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, 719 Umbilo Road, Congella, Durban, 4001, South Africa
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Muzumdar D, Bansal P, Rai S, Bhatia K. Surgery for Central Nervous System Tuberculosis in Children. Adv Tech Stand Neurosurg 2024; 49:255-289. [PMID: 38700688 DOI: 10.1007/978-3-031-42398-7_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Tuberculosis (TB) is the second most common cause of death due to a single infectious agent worldwide after COVID-19. Central nervous system tuberculosis is widely prevalent in the world, especially in the developing countries and continues to be a socioeconomic problem. It is highly devastating form of tuberculosis leading to unacceptable levels of morbidity and mortality despite appropriate antitubercular therapy. The clinical symptoms are varied and nonspecific. They can be easily overlooked. Tuberculous meningitis is the most common presentation and its sequelae viz. vasculitis, infarction and hydrocephalus can be devastating. The ensuing cognitive, intellectual, and endocrinological outcome can be a significant source of morbidity and mortality, especially in resource constrained countries. Early diagnosis and treatment of tuberculous meningitis and institution of treatment is helpful in limiting the course of disease process. The diagnosis of CNS tuberculosis remains a formidable diagnostic challenge. The microbiological methods alone cannot be relied upon. CSF diversion procedures need to be performed at the appropriate time in order to achieve good outcomes. Tuberculous pachymeningitis and arachnoiditis are morbid sequelae of tuberculous meningitis. Tuberculomas present as mass lesions in the craniospinal axis. Tuberculous abscess can mimic pyogenic abscess and requires high index of suspicion. Calvarial tuberculosis is seen in children and responds well to antituberculous chemotherapy. Tuberculosis of the spinal cord is seen similar to intracranial tuberculosis in pathogenesis but with its own unique clinical manifestations and management. Multidrug-resistant tuberculosis is a formidable problem, and alternate chemotherapy should be promptly instituted. The pathogenesis, clinical features, diagnosis, and management of central nervous system tuberculosis in children are summarized. Heightened clinical suspicion is paramount to ensure prompt investigation. Early diagnosis and treatment are essential to a gratifying outcome and prevent complications.
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Affiliation(s)
- Dattatraya Muzumdar
- Department of Neurosurgery, Seth Gordhandas Sunderdas Medical College and King Edward VII Memorial Hospital, Mumbai, India
| | - Puru Bansal
- Department of Neurosurgery, Seth Gordhandas Sunderdas Medical College and King Edward VII Memorial Hospital, Mumbai, India
| | - Survender Rai
- Department of Neurosurgery, Seth Gordhandas Sunderdas Medical College and King Edward VII Memorial Hospital, Mumbai, India
| | - Kushal Bhatia
- Department of Neurosurgery, Seth Gordhandas Sunderdas Medical College and King Edward VII Memorial Hospital, Mumbai, India
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Zhang X, Li P, Wen J, Chang J, Chen Y, Yin R, Xu H, Liu X, Yang L, Wei J. Ventriculoperitoneal shunt for tuberculous meningitis-associated hydrocephalus: long-term outcomes and complications. BMC Infect Dis 2023; 23:742. [PMID: 37904093 PMCID: PMC10614362 DOI: 10.1186/s12879-023-08661-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 10/02/2023] [Indexed: 11/01/2023] Open
Abstract
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.
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Affiliation(s)
- Xiao Zhang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Pengtao Li
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Junxian Wen
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jianbo Chang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yihao Chen
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Rui Yin
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Houshi Xu
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoyu Liu
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Lang Yang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Junji Wei
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
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Yiek SH, Wong ASH. Challenges and Controversies in the Management of Tuberculous Meningitis with Hydrocephalus: A Systematic Review and Sarawak Institution's Experience. Asian J Neurosurg 2022; 17:189-198. [PMID: 36120621 PMCID: PMC9473842 DOI: 10.1055/s-0042-1750781] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
Abstract
Introduction To date, there are no standard practice guidelines available and no universal consensus regarding treatment protocol in management of tuberculous meningitis (TBM) with hydrocephalus. Over the years, diverse views have existed in neurosurgical management of TBM with hydrocephalus. Some authors advocate ventriculo-peritoneal (VP) shunt, while others suggest that external ventricular drainage (EVD) may be the preferable neurosurgical procedure for a poor-grade patient.
Method We systematically reviewed published literature and presented our institution's experience. We performed a retrospective case study in our Sarawak neurosurgical center from 2018 to 2020. We tabulated the outcome according to preoperative classifications, which were Vellore Grading (VG), Modified Vellore Grading (MVG), British Medical Research Council Classification (MRC), and others: author-defined.
Result In our center, there were 20 cases of TBM with hydrocephalus treated by EVD and VP shunt from 2018 to 2020. We systematically searched published medical literature, and 23 articles were retrieved and analyzed. Poor outcomes were observed in poor-grade patients, especially VG/MVG 3/4 and MRC 3, from both institution and systemic review data. Shunt complication rate was lower in our center as compared with published literature.
Conclusion Unfortunately, morbidity and mortality were approximately twofold higher in poor-grade as compared with good-grade patients. However, about one-third of poor-grade patients achieved a good outcome. Cerebrospinal fluid (CSF) diversion would be an unavoidable treatment for hydrocephalus. Poor-grade patients tend to have cerebral infarcts in addition to hydrocephalus. An extended duration of EVD placement could be a potential measure to assess Glasgow coma scale recovery and monitor serial CSF samples.
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Affiliation(s)
- Siew-Hong Yiek
- Department of Neurosurgery, Sarawak General Hospital, Malaysia
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Chalasani R, Goonathilake MR, Waqar S, George S, Jean-Baptiste W, Yusuf Ali A, Inyang B, Koshy FS, George K, Poudel P, Mohammed L. The Outcome of Surgical Intervention (Ventriculoperitoneal Shunt and Endoscopic Third Ventriculostomy) in Patients With Hydrocephalus Secondary to Tuberculous Meningitis: A Systematic Review. Cureus 2022; 14:e25317. [PMID: 35637922 PMCID: PMC9131440 DOI: 10.7759/cureus.25317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2022] [Indexed: 11/05/2022] Open
Abstract
The objective of this study is to analyze the outcome of the safety and efficiency of the surgical interventions (ventriculoperitoneal shunt [VPS] and endoscopic third ventriculostomy [ETV]) in patients with hydrocephalus due to tuberculous (TB) meningitis. A systematic literature search has been conducted using PubMed, Google Scholar, PMC, and ScienceDirect databases from 2001 to 2022 April. A total of 16 studies have been included, irrespective of their design. These studies include patients diagnosed with hydrocephalus secondary to TB meningitis (TBM) treated with VPS or ETV. A systematic review was conducted to determine the efficiency of surgical procedures based on the outcomes and complications associated with these procedures. A total of 2207 patients (aged one month to 68 years) have been included in this study, out of which 1723 underwent VPS and 484 underwent ETV. The overall success rate in the VPS group varied from 21.1% to 77.5%. The overall success rate in the ETV group ranged from 41.1% to 77%. The overall complications rate in the VPS group varied from 10% to 43.8%, and the complications rate in the ETV group varied from 3.8% to 22.5%. After ruling out the significant differences in the average percentages of outcomes and complications followed by VPS and ETV, ETV is suggested in patients with chronic phases of illness because the chances of ETV failure are high during the initial stage. The uncertainty of the ETV gradually decreases over time. To attain favourable long-term outcomes with ETV in patients with TBM hydrocephalus (TBMH), ETV should be performed after chemotherapy, anti-tubercular treatment, and steroids. In addition, ETV is considered beneficial over VP shunt as associated long-term complications are significantly less compared to VP shunt. In contrast, VP shunt is suggested as a modified Vellore grading which shows a more favourable outcome in patients with acute illness than ETV.
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Affiliation(s)
- Roopa Chalasani
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Mastiyage R Goonathilake
- Pediatrics/Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Sara Waqar
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Sheeba George
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Wilford Jean-Baptiste
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Amina Yusuf Ali
- Pediatrics, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Bithaiah Inyang
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Feeba Sam Koshy
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Kitty George
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Prakar Poudel
- Internal Medicine, Chitwan Medical College of Medical Science, Chitwan, NPL
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Lubna Mohammed
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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Kanesen D, Kandasamy R, Wong ASH, Tharakan J, Lim CJ, Abdullah JM. Clinical Outcome of Tuberculous Meningitis with Hydrocephalus - A Retrospective Study. Malays J Med Sci 2021; 28:82-93. [PMID: 35115890 PMCID: PMC8793966 DOI: 10.21315/mjms2021.28.5.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 05/15/2021] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND To study the clinical outcome of tuberculous meningitis with hydrocephalus (TBMH) and the factors contributing to its poor clinical outcome. METHODS Clinical data of 143 adult patients diagnosed with TBM over a 6-year period in two tertiary hospitals in Malaysia were retrospectively reviewed. Relevant clinical and radiological data were studied. Patients with TBMH were further analysed based on their clinical grade and rendered treatment to identify associated factors and outcome of this subgroup of patients. The functional outcome of patients was assessed at 12 months from treatment. RESULTS The mean age of patients was 35.6 (12.4) years old, with a male gender predominance of 67.1%. Forty-four percent had TBMH, of which 42.9% had surgical intervention. In the good modified Vellore grade, 76.5% was managed medically with concurrent anti-tuberculosis treatment (ATT), steroids and osmotic agents. Four patients had surgery early in the disease as they did not respond to medical therapy and reported a good outcome subsequently. Poor outcome (65.2%) was seen in the poor modified Vellore grade despite medical and surgical intervention. Multivariate model multiple Cox regression showed significant results for seizure (adjusted hazard ratio [aHR]: 15.05; 95% CI: 3.73, 60.78), Glasgow coma scale (GCS) (aHR: 0.79; 95% CI: 0.70, 0.89) and cerebrospinal fluid (CSF) cell count (aHR: 1.11; 95% CI: 1.05, 1.17). CONCLUSION Hydrocephalus was seen in 44% of patients in this study. GCS score, seizure and high CSF cell count were factors associated with a poor prognosis in TBM. Patients with TBMH treated medically (TBMHM) had better survival function compared to TBMH patients undergoing surgical intervention (TBMHS) (P-value < 0.001). This retrospective study emphasises that TBMH is still a serious illness as 47.6% of the patients had poor outcome despite adequate treatment.
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Affiliation(s)
- Davendran Kanesen
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- Department of Neurosurgery, Hospital Umum Sarawak, Kuching, Sarawak, Malaysia
| | - Regunath Kandasamy
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | | | - John Tharakan
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Chien Joo Lim
- Clinical Research Centre, Hospital Umum Sarawak, Kuching, Sarawak, Malaysia
| | - Jafri Malin Abdullah
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- Brain and Behaviour Cluster, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
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Bhushan B, Sardana V, Shringi P, Yadav SR, Maheshwari D. Role of Surgical Procedures (VP Shunt and ETV) in Tuberculous Meningitis with Hydrocephalus (TBMH): A Systematic Review. J Pediatr Neurosci 2021; 16:106-112. [PMID: 35018177 PMCID: PMC8706600 DOI: 10.4103/jpn.jpn_286_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 10/27/2020] [Accepted: 02/11/2021] [Indexed: 11/04/2022] Open
Abstract
Objective Hydrocephalus is one of the most common complications of tuberculous meningitis. Various cerebrospinal fluid diversion procedures, endoscopic third ventriculostomy (ETV) and shunt surgery, are performed for the management of the hydrocephalus associated with tuberculous bacterial meningitis (TBM). There is decreased clarity on the type of procedure to be done. So, this study aims at generating knowledge to understand the conditions in which either of the two procedures, ETV and shunt surgery, is a better option and to develop good practice guidelines for the treatment of tubercular meningitis hydrocephalus (TBMH). Materials and Methods A systematic search of literature was performed by using PubMed and Cochrane Central Register of Controlled Trials (CENTRAL) for articles published from January 2001 to April 2020. A total of 15 studies were included irrespective of their design and having diagnosis with TBMH treated with ventriculoperitoneal shunt surgery (VPS) or ETV. Then, a systemic review was done regarding outcomes, complications, and recommendations made in different studies. Results The total number of patients diagnosed with TBMH was 603; among them, 348 patients had VPS and 255 patients had ETV. In the VPS group, the patient's good outcome varied from 25% to 68% and complication rate ranged from 10% to 43.8%. The average percentage of good outcome in the VPS group was 51.8%. In the ETV group, the patient's good outcome varied from 41% to 77% and complication rate ranged from 10% to 23.5%. The average percentage of good outcome in the ETV group was 68%. There was a significant difference in the average percentage of good outcome in the ETV versus the VPS shunt group (P-value was 0.008). Conclusion There was a significant difference in the average percentage of good outcome after ETV than VPS, and complication rate was also slightly lower after ETV than VPS during the chronic phase of illness. So during the acute phase of illness VPS placement is preferred whereas in the chronic burnout phase ETV is preferred because poor anatomy leads to more complications with ETV during the acute phase of the disease.
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Affiliation(s)
- Bharat Bhushan
- Department of Neurology, Government Medical College, Kota, Rajasthan, India
| | - Vijay Sardana
- Department of Neurology, Government Medical College, Kota, Rajasthan, India
| | - Prashant Shringi
- Department of Neurology, Government Medical College, Kota, Rajasthan, India
| | - Seeta Ram Yadav
- Department of Neurology, Government Medical College, Kota, Rajasthan, India
| | - Dilip Maheshwari
- Department of Neurology, Government Medical College, Kota, Rajasthan, India
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Rajshekhar V. Three Decades of Vellore Grading for Tuberculous Meningitis with Hydrocephalus: A Reappraisal. Neurol India 2021; 69:S569-S574. [DOI: 10.4103/0028-3886.332251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Donovan J, Rohlwink UK, Tucker EW, Hiep NTT, Thwaites GE, Figaji AA. Checklists to guide the supportive and critical care of tuberculous meningitis. Wellcome Open Res 2020. [PMID: 31984242 DOI: 10.12688/wellcomeopenres.15512.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The assessment and management of tuberculous meningitis (TBM) is often complex, yet no standardised approach exists, and evidence for the clinical care of patients, including those with critical illness, is limited. The roles of proformas and checklists are increasing in medicine; proformas provide a framework for a thorough approach to patient care, whereas checklists offer a priority-based approach that may be applied to deteriorating patients in time-critical situations. We aimed to develop a comprehensive assessment proforma and an accompanying 'priorities' checklist for patients with TBM, with the overriding goal being to improve patient outcomes. The proforma outlines what should be asked, checked, or tested at initial evaluation and daily inpatient review to assist supportive clinical care for patients, with an adapted list for patients in critical care. It is accompanied by a supporting document describing why these points are relevant to TBM. Our priorities checklist offers a useful and easy reminder of important issues to review during a time-critical period of acute patient deterioration. The benefit of these documents to patient outcomes would require investigation; however, we hope they will promote standardisation of patient assessment and care, particularly of critically unwell individuals, in whom morbidity and mortality remains unacceptably high.
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Affiliation(s)
- Joseph Donovan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ursula K Rohlwink
- Neuroscience Institute and Division of Neurosurgery, University of Cape Town, Cape Town, 7700, South Africa
| | - Elizabeth W Tucker
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA.,Division of Pediatric Critical Care, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Nguyen Thi Thu Hiep
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Anthony A Figaji
- Neuroscience Institute and Division of Neurosurgery, University of Cape Town, Cape Town, 7700, South Africa
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Paliwal VK, Das A, Anand S, Mishra P. Intravenous Steroid Days and Predictors of Early Oral Steroid Administration in Tuberculous Meningitis: A Retrospective Study. Am J Trop Med Hyg 2019; 101:1083-1086. [PMID: 31516115 PMCID: PMC6838556 DOI: 10.4269/ajtmh.19-0416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 08/16/2019] [Indexed: 11/07/2022] Open
Abstract
Intravenous (IV) dexamethasone is recommended for 14 days in stage 1 and 28 days in stage 2/3 tuberculous meningitis (TBM). We used a different steroid protocol. We shifted TBM patients to oral steroids after 48 hours of sustained improvement on IV steroids (oral group). Patients who worsened after shifting to oral steroids were reinitiated on IV steroids. Once they showed a consistent improvement for 48 hours, the IV steroids were overlapped with oral steroids for 7-10 days to taper off IV steroids (overlap group). We compared total IV steroid days in our patients with the recommended treatment and identified predictors that favored the oral group. This was a retrospective study. We included 98 patients with TBM (66 in the overlap group and 32 in the oral group) from January 2013 to July 2018. The median IV steroid days were 9 days (interquartile range of 4-12; 2-3.5 days in the oral group and 10-11.5 days in the overlap group). The mortality rate was 6.1%. The logistic regression model showed that TBM patients with basal exudate, tuberculoma, and modified Rankin scale (mRS) < 3 had a higher probability for going to the oral group. We conclude that total IV steroid days can be reduced in TBM patients by our method of steroid use. Presence of basal exudates and tuberculoma may favor early shifting from IV to oral steroid, whereas higher mRS may require a relatively longer course of IV steroid.
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Affiliation(s)
- Vimal Kumar Paliwal
- Address correspondence to Vimal Kumar Paliwal, Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Rd., Lucknow 226014, India. E-mails: or
| | - Animesh Das
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sucharita Anand
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Prabhakar Mishra
- Department of Biostatistics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Donovan J, Rohlwink UK, Tucker EW, Hiep NTT, Thwaites GE, Figaji AA. Checklists to guide the supportive and critical care of tuberculous meningitis. Wellcome Open Res 2019; 4:163. [PMID: 31984242 PMCID: PMC6964359 DOI: 10.12688/wellcomeopenres.15512.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2019] [Indexed: 12/21/2022] Open
Abstract
The assessment and management of tuberculous meningitis (TBM) is often complex, yet no standardised approach exists, and evidence for the clinical care of patients, including those with critical illness, is limited. The roles of proformas and checklists are increasing in medicine; proformas provide a framework for a thorough approach to patient care, whereas checklists offer a priority-based approach that may be applied to deteriorating patients in time-critical situations. We aimed to develop a comprehensive assessment proforma and an accompanying 'priorities' checklist for patients with TBM, with the overriding goal being to improve patient outcomes. The proforma outlines what should be asked, checked, or tested at initial evaluation and daily inpatient review to assist supportive clinical care for patients, with an adapted list for patients in critical care. It is accompanied by a supporting document describing why these points are relevant to TBM. Our priorities checklist offers a useful and easy reminder of important issues to review during a time-critical period of acute patient deterioration. The benefit of these documents to patient outcomes would require investigation; however, we hope they will promote standardisation of patient assessment and care, particularly of critically unwell individuals, in whom morbidity and mortality remains unacceptably high.
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Affiliation(s)
- Joseph Donovan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ursula K. Rohlwink
- Neuroscience Institute and Division of Neurosurgery, University of Cape Town, Cape Town, 7700, South Africa
| | - Elizabeth W. Tucker
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
- Division of Pediatric Critical Care, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, USA
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Nguyen Thi Thu Hiep
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Guy E. Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Anthony A. Figaji
- Neuroscience Institute and Division of Neurosurgery, University of Cape Town, Cape Town, 7700, South Africa
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Baghbani R. An Electrical Model of Hydrocephalus Shunt Incorporating the CSF Dynamics. Sci Rep 2019; 9:9751. [PMID: 31278327 PMCID: PMC6611941 DOI: 10.1038/s41598-019-46328-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 06/26/2019] [Indexed: 01/18/2023] Open
Abstract
The accumulation of cerebrospinal fluid (CSF) in brain ventricles and subarachnoid space is known as hydrocephalus. Hydrocephalus is a result of disturbances in the secretion or absorption process of CSF. A hydrocephalus shunt is an effective method for the treatment of hydrocephalus. In this paper, at first, the procedures of secretion, circulation, and absorption of CSF are studied and subsequently, the mathematical relations governing the pressures in different interacting compartments of the brain are considered. A mechanical-electrical model is suggested based on the brain physiology and blood circulation. In the proposed model, hydrocephalus is modeled with an incremental resistance (Ro) and hydrocephalus shunt, which is a low resistance path to drain the accumulated CSF in the brain ventricles, is modeled with a resistance in series with a diode. At the end, the simulation results are shown. The simulation results can be used to predict the shunt efficiency in reducing CSF pressure and before a real shunt implementation surgery is carried out in a patient's body.
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Affiliation(s)
- R Baghbani
- Biomedical Engineering Department, Hamedan University of Technology, Hamedan, Iran.
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13
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TB Meningitis and TB Peritonitis: Abdominal Pseudocyst and VP-Shunt Link. Case Rep Radiol 2019; 2019:4893547. [PMID: 31183240 PMCID: PMC6512015 DOI: 10.1155/2019/4893547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 01/28/2019] [Accepted: 04/16/2019] [Indexed: 11/29/2022] Open
Abstract
TB meningitis (TBM) carries high morbidity and mortality and is a relatively common extrapulmonary TB in the third world countries. TBM as thick exudative disease manifests on MRI and CT as nodular basal leptomeningitis, hydrocephalus, basal infarcts, and tuberculomas. Hydrocephalus is treated with ventriculoperitoneal shunting (VPS). Shunt malfunction and revision are common. We report a case of multidrug-resistant TBM with spinal involvement and dissemination of the disease via VPS causing TB peritonitis (TBP). TBP presented as a large abdominal pseudocyst around the catheter tip with shunt malfunction. There was no evidence for any other site of extra-CNS disease. TBP per se is relatively less common. This is the first case reporting VPS as a means of TB spread.
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14
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James J. Central Nervous System Tuberculosis - The Gray Area in Tuberculosis Treatment. J Neurosci Rural Pract 2019; 10:6-7. [PMID: 30765962 PMCID: PMC6337993 DOI: 10.4103/jnrp.jnrp_229_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Joe James
- Department of Neurology, Government Medical College, Kozhikode, Kerala, India
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15
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Outcome of Ventriculoperitoneal Shunt Surgery in Human Immunodeficiency Virus-Positive Patients on Combination Antiretroviral Therapy with Tuberculosis Meningitis and Hydrocephalus. World Neurosurg 2018; 123:e574-e580. [PMID: 30529520 DOI: 10.1016/j.wneu.2018.11.221] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND In 2000, we advised against insertion of a ventriculoperitoneal shunt (VPS) in human immunodeficiency virus (HIV)-positive patients with tuberculous meningitis (TBM) complicated by hydrocephalus. However, this was in the era when combination antiretroviral therapy (ART) was not freely available in South Africa. In this subsequent preliminary report, we describe the outcome of ventriculoperitoneal shunting in patients with TBM and hydrocephalus who are HIV positive and receiving ART. METHODS We compared a group of 15 HIV-positive patients with TBM and hydrocephalus on ART with a retrospective control group of 15 patients (demographically and clinically matched) but not on ART. All patients were otherwise managed similarly and evaluated at 1 month after VPS insertion. RESULTS In historical controls, 10 patients died (66.7%) and no patient showed any improvement 1 month after shunting. In contrast, in the current group on ART, 4 patients died (26.7%), with 11 patients (73.3%) having a good outcome. Eight of 12 patients with grade 3 TBM had a good outcome, whereas all 3 with grade 1 TBM made a good recovery. CONCLUSIONS The outcome of VP shunting in HIV-positive patients with TBM and hydrocephalus is markedly improved in patients on ART. Based on limited data from this study, we recommend that better grades of TBM (1 and 2) undergo immediate VPS surgery. Patients with grade 4 TBM should undergo a trial of external ventricular drainage and those who improve should undergo a definitive procedure. Further research is required for patients with grade 3 TBM to identify characteristics associated with better outcomes to allow for effective use of limited resources.
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16
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Muzumdar D, Vedantam R, Chandrashekhar D. Tuberculosis of the central nervous system in children. Childs Nerv Syst 2018; 34:1925-1935. [PMID: 29978252 DOI: 10.1007/s00381-018-3884-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 06/22/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Central nervous system tuberculosis (CNS TB) in children is still a socioeconomic problem in developing countries. It has varied manifestations, symptoms are nonspecific, diagnosis can be challenging, and treatment may be difficult. It is often missed or overlooked. Among the various pathological entities, tuberculous meningitis is the most common and devastating manifestation. The resultant vasculitis, infarction, and hydrocephalus can be life-threatening. It can have grave cognitive, intellectual, and endocrine sequelae if not treated in time resulting in handicap, especially in resource constraint countries. Early diagnosis and treatment of tuberculous meningitis is the single most important factor determining outcome. Tuberculous hydrocephalus needs to be recognized early, and cerebrospinal fluid diversion procedure needs to be performed in adequate time to prevent morbidity or mortality in some cases. Tuberculous pachymeningitis and arachnoiditis are rare in children. Tuberculous abscess can mimic pyogenic abscess and requires high index of suspicion. Calvarial tuberculosis is seen in children and responds well to antituberculous chemotherapy. Drug-resistant tuberculosis is a formidable problem, and alternate chemotherapy should be promptly instituted. AIM The pathogenesis, clinical features, diagnosis, and management of central nervous system tuberculosis in children are summarized. CONCLUSION Heightened clinical suspicion, early diagnosis, appropriate antituberculous treatment, and surgery in relevant situation are essential for a gratifying outcome and preventing complications.
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Affiliation(s)
- Dattatraya Muzumdar
- Department of Neurosurgery, King Edward VII Memorial Hospital, Parel, Mumbai, 400012, India.
| | - Rajshekhar Vedantam
- Department of Neurological Sciences, Christian Medical College Hospital, Vellore, India
| | - Deopujari Chandrashekhar
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Marine Lines, Mumbai, India
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17
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Abstract
Prevention and management of opportunistic infections in children is particularly relevant in an era demonstrating an increased prevalence of immunocompromising conditions. The presence of an unusual organism which results in serious infection in a child should therefore always raise the consideration of immune compromise. The more common opportunistic infections have become easier to recognize in recent times due to improved awareness and more refined diagnostic testing. Targeted treatment is usually followed by long-term prophylactic medication. The impact of these conditions on patient outcome is of clear significance and certainly warrants further discussion.
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18
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Marais BJ, Heemskerk AD, Marais SS, van Crevel R, Rohlwink U, Caws M, Meintjes G, Misra UK, Mai NTH, Ruslami R, Seddon JA, Solomons R, van Toorn R, Figaji A, McIlleron H, Aarnoutse R, Schoeman JF, Wilkinson RJ, Thwaites GE. Standardized Methods for Enhanced Quality and Comparability of Tuberculous Meningitis Studies. Clin Infect Dis 2017; 64:501-509. [PMID: 28172588 PMCID: PMC5399942 DOI: 10.1093/cid/ciw757] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 11/10/2016] [Indexed: 01/06/2023] Open
Abstract
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.
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Affiliation(s)
- Ben J Marais
- Marie Bashir Institute for Infectious Diseases and Biosecurity and the Children's Hospital at Westmead, University of Sydney, Australia
| | - Anna D Heemskerk
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Suzaan S Marais
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory, 7925, Cape Town, South Africa.,Department of Neurology, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Reinout van Crevel
- Department of Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ursula Rohlwink
- Division of Neurosurgery, University of Cape Town, South Africa
| | - Maxine Caws
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Graeme Meintjes
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory, 7925, Cape Town, South Africa
| | - Usha K Misra
- Sanjay Ghandi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Nguyen T H Mai
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - James A Seddon
- Department of Medicine, Imperial College London, United Kingdom
| | - Regan Solomons
- Tygerberg Children's Hospital and the Department of Paediatrics and Child Health, University of Stellenbosch, Tygerberg, South Africa
| | - Ronald van Toorn
- Tygerberg Children's Hospital and the Department of Paediatrics and Child Health, University of Stellenbosch, Tygerberg, South Africa
| | - Anthony Figaji
- Division of Neurosurgery, University of Cape Town, South Africa
| | - Helen McIlleron
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory, 7925, Cape Town, South Africa
| | - Robert Aarnoutse
- Department of Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johan F Schoeman
- Tygerberg Children's Hospital and the Department of Paediatrics and Child Health, University of Stellenbosch, Tygerberg, South Africa
| | - Robert J Wilkinson
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory, 7925, Cape Town, South Africa.,Department of Medicine, Imperial College London, United Kingdom.,Francis Crick Institute Mill Hill Laboratory, London, United Kingdom
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Nuffield Department of Medicine, University of Oxford, United Kingdom
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19
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Duke T, Kasa Tom S, Poka H, Welch H. Holistic care of complicated tuberculosis in healthcare settings with limited resources. Arch Dis Child 2017; 102:1161-1168. [PMID: 28912165 PMCID: PMC5754861 DOI: 10.1136/archdischild-2017-313095] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 07/28/2017] [Accepted: 07/31/2017] [Indexed: 11/03/2022]
Abstract
In recent years, most of the focus on improving the quality of paediatric care in low-income countries has been on improving primary care using the Integrated Management of Childhood Illness, and improving triage and emergency treatment in hospitals aimed at reducing deaths in the first 24 hours. There has been little attention paid to improving the quality of care for children with chronic or complex diseases. Children with complicated forms of tuberculosis (TB), including central nervous system and chronic pulmonary TB, provide examples of acute and chronic multisystem paediatric illnesses that commonly present to district-level and second-level referral hospitals in low-income countries. The care of these children requires a holistic clinical and continuous quality improvement approach. This includes timely decisions on the commencement of treatment often when diagnoses are not certain, identification and management of acute respiratory, neurological and nutritional complications, identification and treatment of comorbidities, supportive care, systematic monitoring of treatment and progress, rehabilitation, psychological support, ensuring adherence, and safe transition to community care. New diagnostics and imaging can assist this, but meticulous attention to clinical detail at the bedside and having a clear plan for all aspects of care that is communicated well to staff and families are essential for good outcomes. The care is multidimensional: biomedical, rehabilitative, social and economic, and multidisciplinary: medical, nursing and allied health. In the era of the Sustainable Development Goals, approaches to these dimensions of healthcare are needed within the reach of the poorest people who access district hospitals in low-income countries.
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Affiliation(s)
- Trevor Duke
- Centre for International Child Health, University of Melbourne, Parkville, Victoria, Australia,Intensive Care Unit, Royal Children’s Hospital, Parkville, Victoria, Australia,Discipline of Child Health, School of Medicine and Health Sciences, University of Papua New Guinea, Moresby, Papua New Guinea
| | - Sharon Kasa Tom
- Department of Paediatrics, Wabag General Hospital, Wabag, Papua New Guinea
| | - Harry Poka
- Department of Paediatrics, Sir Joseph Nombri Memorial Kundiawa General Hospital, Kundiawa, Simbu, Papua New Guinea
| | - Henry Welch
- Discipline of Child Health, School of Medicine and Health Sciences, University of Papua New Guinea, Moresby, Papua New Guinea,Department of Pediatrics, Baylor College of Medicine, Baylor International Pediatric AIDS Initiative, Houston, Texas, USA
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20
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Wilkinson RJ, Rohlwink U, Misra UK, van Crevel R, Mai NTH, Dooley KE, Caws M, Figaji A, Savic R, Solomons R, Thwaites GE. Tuberculous meningitis. Nat Rev Neurol 2017; 13:581-598. [PMID: 28884751 DOI: 10.1038/nrneurol.2017.120] [Citation(s) in RCA: 285] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Tuberculosis remains a global health problem, with an estimated 10.4 million cases and 1.8 million deaths resulting from the disease in 2015. The most lethal and disabling form of tuberculosis is tuberculous meningitis (TBM), for which more than 100,000 new cases are estimated to occur per year. In patients who are co-infected with HIV-1, TBM has a mortality approaching 50%. Study of TBM pathogenesis is hampered by a lack of experimental models that recapitulate all the features of the human disease. Diagnosis of TBM is often delayed by the insensitive and lengthy culture technique required for disease confirmation. Antibiotic regimens for TBM are based on those used to treat pulmonary tuberculosis, which probably results in suboptimal drug levels in the cerebrospinal fluid, owing to poor blood-brain barrier penetrance. The role of adjunctive anti-inflammatory, host-directed therapies - including corticosteroids, aspirin and thalidomide - has not been extensively explored. To address this deficit, two expert meetings were held in 2009 and 2015 to share findings and define research priorities. This Review summarizes historical and current research into TBM and identifies important gaps in our knowledge. We will discuss advances in the understanding of inflammation in TBM and its potential modulation; vascular and hypoxia-mediated tissue injury; the role of intensified antibiotic treatment; and the importance of rapid and accurate diagnostics and supportive care in TBM.
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Affiliation(s)
- Robert J Wilkinson
- Department of Medicine, Imperial College London, Norfolk Place, London W2 1PG, UK
- The Francis Crick Institute, Midland Road, London NW1 2AT, UK
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Republic of South Africa
| | - Ursula Rohlwink
- Division of Neurosurgery, University of Cape Town, Anzio Road, Observatory 7925, Republic of South Africa
| | - Usha Kant Misra
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae Bareli Road, Lucknow, Uttar Pradesh 226014, India
| | - Reinout van Crevel
- Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Nguyen Thi Hoang Mai
- Oxford University Clinical Research Unit, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Vietnam
| | - Kelly E Dooley
- Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, Maryland 21287, USA
| | - Maxine Caws
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Anthony Figaji
- Division of Neurosurgery, University of Cape Town, Anzio Road, Observatory 7925, Republic of South Africa
| | - Rada Savic
- UCSF School of Pharmacy, Department, Bioengineering, 1700 4th Street, San Francisco, California 94158, UA
| | - Regan Solomons
- Faculty of Health Sciences, Stellenbosch University, Tygerberg Hospital, Francie van Zijl Drive, Tygerberg 7505, Cape Town, Republic of South Africa
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Old Road, Oxford OX3 9FZ, UK
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21
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Abstract
Central nervous system tuberculosis (CNS-TB) takes three clinical forms: meningitis (TBM), intracranial tuberculoma, and spinal arachnoiditis. TBM predominates in the western world and presents as a subacute to chronic meningitis syndrome with a prodrome of malaise, fever, and headache progressing to altered mentation and focal neurologic signs, followed by stupor, coma, and death within five to eight weeks of onset. The CSF formula typically shows a lymphocytic pleocytosis, and low glucose and high protein concentrations. Diagnosis rests on serial samples of CSF for smear and culture, combined with CSF PCR. Brain CT and MRI aid in diagnosis, assessment for complications, and monitoring of the clinical course. In a patient with compatible clinical features, the combination of meningeal enhancement and any degree of hydrocephalus is strongly suggestive of TBM. Vasculitis leading to infarcts in the basal ganglia occurs commonly and is a major determinant of morbidity and mortality. Treatment is most effective when started in the early stages of disease, and should be initiated promptly on the basis of strong clinical suspicion without waiting for laboratory confirmation. The initial 4 drug regimen (isoniazid, rifampin, pyrazinamide, ethambutol) covers the possibility of infection with a resistant strain, maximizes antimicrobial impact, and reduces the likelihood of emerging resistance on therapy. Adjunctive corticosteroid therapy has been shown to reduce morbidity and mortality in all but late stage disease.
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22
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Huang HJ, Ren ZZ, Dai YN, Tong YX, Yang DH, Chen MJ, Huang YC, Wang MS, Zhang JJ, Song WY, Pan HY. Old age and hydrocephalus are associated with poor prognosis in patients with tuberculous meningitis: A retrospective study in a Chinese adult population. Medicine (Baltimore) 2017; 96:e7370. [PMID: 28658161 PMCID: PMC5500083 DOI: 10.1097/md.0000000000007370] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Tuberculous meningitis (TBM) is the most common form of central nervous system tuberculosis with a very poor prognosis. We aimed at assessing risk factors related to the prognosis of patients with TBM.Forty-five inpatients with TBM in our institution from January 2013 to December 2015 were enrolled retrospectively. The good or poor prognosis in the patients was defined, based on Glasgow Outcome Scale System at discharge. Patients with a GOS score less than 5 were defined as "poor prognosis." Univariate and multivariate logistic regression analyses were performed to assess the predictors for TBM outcome.Among 45 TBM patients, 35 (77.8%) and 10 (22.2%) were in good, poor prognoses, respectively. Old age, disturbance of consciousness, moderate to severe electroencephalogram abnormality, hydrocephalus, remarkable increase of protein (≥ 236 mg/dL) and white blood cell counts (≥ 243 /μL) in cerebral spinal fluid were associated with poor prognosis. Multivariate analysis indicated that old age (odds ratio (OR) = 18.395, P = .036) and hydrocephalus (OR = 32.995, P = .049) were independent factors for a poor outcome of TBM.In conclusion, old age and hydrocephalus are the predictors for poor prognosis of TBM. Patients with these risk factors should be treated promptly with a special care paid to improve their outcomes.
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Affiliation(s)
- Hai-Jun Huang
- Department of Infectious Diseases, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College
| | - Ze-Ze Ren
- Department of Infectious Diseases, the Second Affiliated Hospital of Zhejiang Chinese Medicinal University, Hangzhou, Zhejiang Province, China
| | - Yi-Ning Dai
- Department of Infectious Diseases, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College
| | - Yong-Xi Tong
- Department of Infectious Diseases, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College
| | - Dan-Hong Yang
- Department of Infectious Diseases, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College
| | - Mei-Juan Chen
- Department of Infectious Diseases, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College
| | - Yi-Cheng Huang
- Department of Infectious Diseases, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College
| | - Ming-Shan Wang
- Department of Infectious Diseases, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College
| | - Jia-Jie Zhang
- Department of Infectious Diseases, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College
| | - Wen-Yuan Song
- Department of Infectious Diseases, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College
| | - Hong-Ying Pan
- Department of Infectious Diseases, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College
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23
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Rizvi I, Garg RK, Malhotra HS, Kumar N, Sharma E, Srivastava C, Uniyal R. Ventriculo-peritoneal shunt surgery for tuberculous meningitis: A systematic review. J Neurol Sci 2017; 375:255-263. [DOI: 10.1016/j.jns.2017.02.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Revised: 02/02/2017] [Accepted: 02/03/2017] [Indexed: 10/20/2022]
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24
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Tai MLS, Viswanathan S, Rahmat K, Nor HM, Kadir KAA, Goh KJ, Ramli N, Bakar FKA, Zain NRM, Yap JF, Ong BH, Rafia MH, Tan CT. Cerebral infarction pattern in tuberculous meningitis. Sci Rep 2016; 6:38802. [PMID: 27958312 PMCID: PMC5153843 DOI: 10.1038/srep38802] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 11/15/2016] [Indexed: 11/10/2022] Open
Abstract
Tuberculous meningitis (TBM) causes significant morbidity and mortality. The primary objective was to re-examine the concept of “TB zone” and “ischaemic zone” in cerebral infarction in patients with tuberculous meningitis. The secondary objective was to evaluate cerebral infarction, vasculitis and vasospasm in tuberculous meningitis infections. Between 2009 and 2014, TBM patients were recruited. Neuroimaging was performed and findings of cerebral infarction, vasculitis and vasospasm were recorded. Infarcts were classified based on arterial supply and Hsieh’s classification. Fifty-one TBM patients were recruited of whom 34 patients (67%) had cerebral infarction. Based on Hsieh’s classification, 20 patients (59%) had infarcts in both “TB zone” and “ischaemic zones”. 12 patients (35%) had infarcts in “ischaemic zone” and two (6%) patients had infarcts in “TB zone”. In terms of vascular supply, almost all patients (35/36) had infarcts involving perforators and cortical branches. 25 patients (73%) and 14 patients (41%) had infarcts supplied by lateral lenticulostriate and medial lenticulostriate arteries respectively. 15 patients (37%) had vasculitis. Vasospasm was present in six patients (15%). 29 patients (85%) with cerebral infarction also had leptomeningeal enhancement (p = 0.002). In summary, infarcts involved mainly perforators and cortical branches, rather than “TB zone” versus “ischaemic zone”.
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Affiliation(s)
- Mei-Ling Sharon Tai
- Division of Neurology, Department of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Shanthi Viswanathan
- Department of Neurology, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Malaysia
| | - Kartini Rahmat
- Department of Biomedical Imaging, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Hazman Mohd Nor
- Department of Biomedical Imaging, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Khairul Azmi Abdul Kadir
- Department of Biomedical Imaging, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Khean Jin Goh
- Division of Neurology, Department of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Norlisah Ramli
- Department of Biomedical Imaging, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Fatimah Kamila Abu Bakar
- Department of Biomedical Imaging, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | | | - Jun Fai Yap
- Division of Neurology, Department of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Beng Hooi Ong
- Department of Medicine, Hospital Alor Setar. Jalan Langgar, 05460 Alor Setar, Malaysia
| | - Mohd Hanip Rafia
- Department of Neurology, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Malaysia
| | - Chong Tin Tan
- Division of Neurology, Department of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
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25
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Rohlwink UK, Kilborn T, Wieselthaler N, Banderker E, Zwane E, Figaji AA. Imaging Features of the Brain, Cerebral Vessels and Spine in Pediatric Tuberculous Meningitis With Associated Hydrocephalus. Pediatr Infect Dis J 2016; 35:e301-10. [PMID: 27213261 PMCID: PMC5024759 DOI: 10.1097/inf.0000000000001236] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric tuberculous meningitis (TBM) leads to high rates of mortality and morbidity. Prompt diagnosis and initiation of treatment are challenging; imaging findings play a key role in establishing the presumptive diagnosis. General brain imaging findings are well reported; however, specific data on cerebral vascular and spinal involvement in children are sparse. METHODS This prospective cohort study examined admission and followed up computed tomography brain scans and magnetic resonance imaging scans of the brain, cerebral vessels (magnetic resonance angiogram) and spine at 3 weeks in children treated for TBM with hydrocephalus (HCP; inclusion criteria). Exclusion criteria were no HCP on admission, treatment of HCP or commencement of antituberculosis treatment before study enrollment. Imaging findings were examined in association with outcome at 6 months. RESULTS Forty-four patients (median age 3.3 [0.3-13.1] years) with definite (54%) or probable TBM were enrolled. Good clinical outcome was reported in 72%; the mortality rate was 16%. Infarcts were reported in 66% of patients and were predictive of poor outcome. Magnetic resonance angiogram abnormalities were reported in 55% of patients. Delayed tuberculomas developed in 11% of patients (after starting treatment). Spinal pathology was more common than expected, occurring in 76% of patients. Exudate in the spinal canal increased the difficulty of lumbar puncture and correlated with high cerebrospinal fluid protein content. CONCLUSION TBM involves extensive pathology in the central nervous system. Severe infarction was predictive of poor outcome although this was not the case for angiographic abnormalities. Spinal disease occurs commonly and has important implications for diagnosis and treatment. Comprehensive imaging of the brain, spine and cerebral vessels adds insight into disease pathophysiology.
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Affiliation(s)
- Ursula K Rohlwink
- From the *Division of Neurosurgery, Pediatric Neurosurgery, †Division of Pediatric Radiology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; and ‡University of Swaziland, Kwaluseni, Swaziland
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Abstract
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.
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Affiliation(s)
- Sophie Jullien
- Jigme Dorji Wangchuck National Referral HospitalThimphuBhutan
| | - Hannah Ryan
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesLiverpoolUK
| | - Manish Modi
- Postgraduate Institute of Medical Education and ResearchDepartment of NeurologyChandigarh 160 012India
| | - Rohit Bhatia
- All India Institute of Medical SciencesDepartment of NeurologyNew DelhiIndia110029
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Kankane VK, Gupta TK, Jaiswal G. Outcome of ventriculoperitoneal shunt surgery, without prior placement of external ventricular drain in Grades III and IV patients of tubercular meningitis with hydrocephalus: A single institution's experience in the pediatric population and review of literature. J Pediatr Neurosci 2016; 11:35-41. [PMID: 27195031 PMCID: PMC4862286 DOI: 10.4103/1817-1745.181265] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Hydrocephalus is a most common complication of tubercular meningitis (TBM). Relieving hydrocephalus by ventriculoperitoneal shunt (VPS) placement has been considered beneficial in patient in Palur Grades II or III. The role of VPS placement in those of Grades III and IV is controversial, and general tendency is to avoid its use. Some authors have suggested that patient in Grades III and IV should receive a shunt only if their condition improves with a trial placement of external ventricular drain (EVD). However, recent studies suggest that VPS may be undertaken without the trial of an EVD. Our study prospectively evaluates the role of direct VPS placement in patient in Grades III and IV TBM with hydrocephalus (TBMH). MATERIALS AND METHODS This study was carried out on 50 consecutive pediatric patients of TBMH in Palur Grades III and IV from July 2013 to December 2014 in R.N.T. Medical College and M.B. Hospital, Udaipur, Rajasthan. All patients underwent direct VPS placement, without prior placement of EVD. The outcome was assessed at the end of 3 months using Glasgow Outcome Score. RESULTS The mean age of patients was 3.25 years (range, 3 months-14 years). Forty (80%) patients were in Grade III, and 10 (20%) were in Grade IV. Good outcome and mortality in Grade IV patients were 30% (3/10) and 10% (1/10), respectively; whereas in Grade III patients, it was 77.5% (31/40) and 0% (0/40), respectively. Twenty-five patients presented with focal neurological deficit at admission, which persisted in only 14 patients at 3 months follow-up. VPS-related complications were observed in 5 (10%) patients. CONCLUSIONS This study demonstrates that direct VPS surgery could improve the outcome of Grades III and IV TBMH. Despite poor grade at admission, 80% patients in Grade III and 20% patients in Grade IV had a good outcome at 3 months follow-up. Direct VPS placement is a safe and effective option even in a patient in Grades III and IV grade TBMH with a low complication rate.
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Affiliation(s)
- Vivek Kumar Kankane
- Department of Neurosurgery, R.N.T. Medical College, Udaipur, Rajasthan, India
| | - Tarun Kumar Gupta
- Department of Neurosurgery, R.N.T. Medical College, Udaipur, Rajasthan, India
| | - Gaurav Jaiswal
- Department of Neurosurgery, R.N.T. Medical College, Udaipur, Rajasthan, India
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Rajshekhar V. Surgery for brain tuberculosis: a review. Acta Neurochir (Wien) 2015; 157:1665-78. [PMID: 26170188 DOI: 10.1007/s00701-015-2501-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 06/23/2015] [Indexed: 10/23/2022]
Abstract
The two main manifestations of brain tuberculosis that require surgery are hydrocephalus associated with tuberculous meningitis (TBMH) and brain tuberculomas. TBMH most often responds to medical therapy but surgery is required promptly for those who fail medical therapy. Both ventriculoperitoneal (VP) shunt and endoscopic third ventriculostomy (ETV) are valid options although the latter is more often successful in patients with chronic hydrocephalus than in those with acute meningitis. Patients with TBMH are more prone to complications following VP shunt than other patients. The outcome of these patients is determined by the Vellore grade (I to IV) of the patients prior to surgery with those in good grades (I and II) having a better outcome and those in the worst grade (IV) having a high mortality in excess of 80 %. Patients with brain tuberculomas present clinically with features of a brain mass, indistinguishable clinically from other pathologies. CT and MR features might provide a probable diagnosis of a tuberculoma but most often a histological diagnosis is desirable. Empiric medical therapy is reserved for a small number of patients. Although the treatment of brain tuberculomas is essentially medical, surgery is required when the diagnosis is in doubt, to reduce raised intracranial pressure or local mass effect and to obtain tissue for culture and sensitivity studies. Stereotactic biopsy, stereotactic craniotomy and excision of superficial small tuberculomas and microsurgery are all procedures used to manage brain tuberculomas. The outcome in patients with brain tuberculomas is good if the tuberculous bacillus is sensitive to the anti-tuberculous therapy. The duration of therapy is debated but we suggest at least 18 months of combination therapy with three or four anti-tuberculous drugs and continue the therapy till the tuberculoma has resolved on neuro-imaging.
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Antibiotic-impregnated catheters reduce ventriculoperitoneal shunt infection rate in high-risk newborns and infants. Childs Nerv Syst 2015; 31:1129-38. [PMID: 25820704 DOI: 10.1007/s00381-015-2685-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Accepted: 03/16/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The incidence of ventriculoperitoneal (VP) shunt infection accounts for about 5-15%, but it can rise up to 70% in specific high-risk subgroups. Antibiotic-impregnated catheters (AICs) have been designed to reduce shunt infections, but reports on their efficacy are discordant, especially in young children. The aim of this study is to assess, for the first time, the efficacy of AICs in newborns and infants at very high risk for shunt infection. METHODS We reviewed the medical records of newborns and infants treated with a VP shunt for newly diagnosed hydrocephalus. Patients were divided in two groups: Group A was composed by children who received AICs, whereas Group B included children implanted with standard silicone catheters (non-AICs). We compared the shunt infection rate in both groups, and analyzed differences in specific high-risk subgroups (preterm newborns, children with posthemorrhagic or postinfective hydrocephalus, and children with a previous external ventricular drainage). RESULTS Forty eight children younger than 1 year old were included in our study. Twenty two patients were implanted with an AIC, whereas 26 patients received a standard silicone catheter. The follow-up was at least 1 year (mean 8 ± 3 years). The overall infection rate decreased from 34% in non-AIC group to 9 % in the AIC group. Moreover, AICs showed to have a protective effect against shunt infections in all the specific high-risk subgroups analyzed. CONCLUSIONS This study demonstrates for the first time that AICs are effective in reducing VP shunt infection in high-risk pediatric patients younger than 1 year old.
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Prakash M, Johnny JC. Intra cranial complications of tuberculous otitis media. J Pharm Bioallied Sci 2015; 7:S51-4. [PMID: 26015748 PMCID: PMC4439708 DOI: 10.4103/0975-7406.155795] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 10/31/2014] [Accepted: 11/09/2014] [Indexed: 11/04/2022] Open
Abstract
Tuberculosis is one of the most common infections in the world. It is seen that tuberculous otitis media (TOM) is almost secondary to pulmonary tuberculosis. In this review we have tried to deal with all the aspects of the intra cranial complications of TOM such as tuberculoma, otitic hydrocephalus, brain abscess and tuberculous meningitis. The aspects covered in this review are the pathology, clinical features, and investigations of the intra cranial manifestations.
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Affiliation(s)
- M Prakash
- Department of ENT, Sree Balaji Medical College and Hospital, Bharath University, Chromepet, Chennai, Tamil Nadu, India
| | - J Carlton Johnny
- Department of ENT, Sree Balaji Medical College and Hospital, Bharath University, Chromepet, Chennai, Tamil Nadu, India
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Ochieng' N, Okechi H, Ferson S, Albright AL. Bacteria causing ventriculoperitoneal shunt infections in a Kenyan population. J Neurosurg Pediatr 2015; 15:150-5. [PMID: 25431903 DOI: 10.3171/2014.10.peds14178] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Ventriculoperitoneal shunt (VPS) infections are a major cause of morbidity and mortality in patients with hydrocephalus. Most data about these infections come from the Western literature. Few data about infecting organisms in Africa are available, yet knowledge of these organisms is important for the prevention and treatment of infectious complications. The purpose of this study was to determine the organisms cultured from infected shunts in a rural Kenyan hospital. METHODS The authors conducted a retrospective study of patients with VPS infections recorded in the neurosurgical database of BethanyKids at Kijabe Hospital between September 2010 and July 2012. RESULTS Among 53 VPS infections confirmed by culture, 68% occurred in patients who were younger than 6 months. Seventy-nine percent of the infections occurred within 2 months after shunt insertion. Only 51% of infections were caused by Staphylococcus species (Staphylococcus aureus 25%, other Staphylococcus species 26%), whereas 40% were caused by gram-negative bacteria. All S. aureus infections and 79% of other Staphylococcus infections were sensitive to cefazolin, but only 1 of 21 gram-negative bacteria was sensitive to it. The majority of gram-negative bacterial infections were multidrug resistant, but 17 of the 20 gram-negative bacteria were sensitive to meropenem. Gram-negative bacterial infections were associated with worse outcomes. CONCLUSIONS The high proportion of gram-negative infections differs from data in the Western literature, in which Staphylococcus epidermidis is by far the most common organism. Once a patient is diagnosed with a VPS infection in Kenya, immediate treatment is recommended to cover both gram-positive and gram-negative bacterial infections. Data from other Sub-Saharan countries are needed to determine if those countries have the same increased frequency of gram-negative infections.
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Affiliation(s)
- Naomi Ochieng'
- Department of Surgery, Division of Neurosurgery, University of Nairobi; and
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Chen CH, Chang YJ, Sy HN, Chen WL, Yen HC. Risk assessment of the outcome for cerebral infarction in tuberculous meningitis. Rev Neurol (Paris) 2014; 170:512-9. [PMID: 25194476 DOI: 10.1016/j.neurol.2014.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 05/10/2014] [Accepted: 06/18/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Cerebral infarction in tuberculous meningitis is a major risk factor for permanent disability. This study assessed the clinical presentation of tuberculous meningitis and risks factors for cerebral infarction. OBSERVATION Thirty-eight adult patients with tuberculous meningitis were studied between 2002 and 2006. Clinical, radiological, and laboratory data of patients with cerebral infarction were compared with those of patients without cerebral infarction. Patients with cerebral infarction were significantly older (65.1 vs 52.1years), had higher risk assessment scores (3.7 vs 2.2), and more often had basal meningeal enhancement on imaging (92.3% vs 60.0%), mild to moderate sequelae (69.2% vs 4%), an overall poor brain outcome (69.2% vs 8%), aspirin prescription (84% vs 8%), and neurosurgical intervention for hydrocephalus (54.0% vs 16.0%). Cerebral infarction patients were also more likely to have experienced doctor-related delays in antituberculosis (61.5% vs 36%) and corticosteroid (61.5% vs 32%) therapy. DISCUSSION AND CONCLUSION The Framingham risk score would be an option for tuberculous meningitis patients to access cerebral infarction risk. Contrast-enhanced brain imaging is helpful for exploring basal meningeal enhancement, in order to obtain an early diagnosis. Antituberculosis, corticosteroid, and aspirin therapies should be started immediately when tuberculous meningitis is suspected.
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Affiliation(s)
- C-H Chen
- Division of infectious disease, department of internal medicine, Changhua-Christian hospital, 135, Nanhsiau street, Changhua, Taiwan, Republic of China; Department of Nursing, College of Medicine & Nursing, Hung Kuang University, Taichung, Republic of China.
| | - Y-J Chang
- Laboratory of epidemiology and biostatistics, Changhua-Christian hospital, 135, Nanhsiau street, Changhua, Taiwan, Republic of China
| | - H-N Sy
- Department of neurology, Changhua-Christian hospital, 135, Nanhsiau street, Changhua, Taiwan, Republic of China
| | - W L Chen
- Department of medical imaging, Changhua-Christian hospital, 135, Nanhsiau street, Changhua, Taiwan, Republic of China
| | - H-C Yen
- Department of neurosurgery, Changhua-Christian hospital, 135, Nanhsiau street, Changhua, Taiwan, Republic of China
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Allopi K, Padayachee L. An audit of the perioperative anaesthetic management of ventriculoperitoneal shunt insertion in the paediatric population at Inkosi Albert Luthuli Central Hospital. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201181.2014.979635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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A randomized study of ventriculoperitoneal shunt versus endoscopic third ventriculostomy for the management of tubercular meningitis with hydrocephalus. Childs Nerv Syst 2014; 30:851-7. [PMID: 24493368 DOI: 10.1007/s00381-014-2371-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Accepted: 01/16/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study aims at generating knowledge to understand the conditions in which either of the two procedures (endoscopic third ventriculostomy (ETV) and shunt) are better options and to develop good practice guidelines for the treatment of tubercular meningitis (TBM) hydrocephalus. METHODS This study was conducted on 48 patients in pediatric age group (less than or equal to 18 years) of TBM hydrocephalus. The patients were randomized to one of the cerebrospinal fluid diversion procedures (ETV or shunt). The two procedures were compared for their outcome, both radiologically and clinically. RESULTS Twenty-four cases underwent shunt, out of which 13 (68%) cases were successful. Twelve (70.3%) cases belonged to grade 3, while one case was of grade 1. In ETV group, 10 (42%) cases had a successful outcome, out of which 7 (38.8%) cases were in grade 3, while 1 case each belonged to grades 1, 2, and 4. Incidence of ETV failure was more in younger age group, i.e., <2 years (n = 7), while no such correlation with age was found in shunt cases. CONCLUSION Though with the present study it looks like that the relative risk of ETV failure is higher than that for shunt, but the risk becomes progressively lower with time. Therefore, if patients survive the early high-risk period, they could experience a long-term survival advantage devoid of life-long shunt-related complications. Though for definitive comparison, a long-term study is needed.
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Vadivelu S, Effendi S, Starke JR, Luerssen TG, Jea A. A review of the neurological and neurosurgical implications of tuberculosis in children. Clin Pediatr (Phila) 2013; 52:1135-43. [PMID: 23847176 DOI: 10.1177/0009922813493833] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Tuberculous involvement of the central nervous system (CNS) and vertebral column is the most lethal and disabling form of tuberculosis (TB). Several factors contribute to poor outcome, including cerebrovascular involvement with ischemia, hydrocephalus, direct parenchymal injury and formation of abscess and inflammation in the brain and spinal cord, hyponatremia, seizures, and delayed diagnosis. Spinal spondylitis from TB and associated spinal deformity is the leading cause of paraplegia in developing countries. The evidence for supportive treatment of TB infection of the CNS is limited, leading to substantial differences in management protocols. Many of the treatment approaches used in TB infection of the CNS have been extrapolated from treatment of other acute neurological disorders such as bacterial meningitis and traumatic brain injury. We review data from the available literature and highlight questions relating to the neurological and neurosurgical care of children with TB infection of the CNS and vertebral column.
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Abstract
Tuberculous meningitis is especially common in young children and people with untreated HIV infection, and it kills or disables roughly half of everyone affected. Childhood disease can be prevented by vaccination and by giving prophylactic isoniazid to children exposed to infectious adults, although improvements in worldwide tuberculosis control would lead to more effective prevention. Diagnosis is difficult because clinical features are non-specific and laboratory tests are insensitive, and treatment delay is the strongest risk factor for death. Large doses of rifampicin and fluoroquinolones might improve outcome, and the beneficial effect of adjunctive corticosteroids on survival might be augmented by aspirin and could be predicted by screening for a polymorphism in LTA4H, which encodes an enzyme involved in eicosanoid synthesis. However, these advances are insufficient in the face of drug-resistant tuberculosis and HIV co-infection. Many questions remain about the best approaches to prevent, diagnose, and treat tuberculous meningitis, and there are still too few answers.
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Proceedings of the 2013 Spring meeting of the Society of British Neurological Surgeons. Br J Neurosurg 2013. [DOI: 10.3109/02688697.2013.785202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kumar A, Singh K, Sharma V. Surgery in hydrocephalus of tubercular origin: challenges and management. Acta Neurochir (Wien) 2013; 155:869-73. [PMID: 23504056 DOI: 10.1007/s00701-013-1658-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 02/18/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hydrocephalus of tubercular origin is one of the most dreaded and difficult to manage complications of brain tuberculosis. Traditionally, the management has been ventriculoperitoneal shunting, but in recent years emerging interest is in endoscopic ventriculostomy. In this article, we discuss the management protocol of hydrocephalus in various stages of disease. METHODS A total of 424 cases of tubercular origin hydrocephalus were managed between years 2000 and 2009. Initially the cases were managed by ventriculoperitoneal shunting, which was followed by use of endoscopic third ventriculostomy. Drug-resistant cases were also encountered and managed according to drug sensitivity. RESULTS The results provided through evaluation of retrospective data showed a high mortality in cases of hydrocephalus of acute origin if endoscopic third ventriculostomy was performed. The cerebrospinal fluid protein level and neurological status of the patient determined the success or failure of the procedure. For better management, patients were divided into six groups and their management underlined. CONCLUSION The cases of tubercular meningitis with aqueductal stenosis presenting in early stages should be given a trial of endoscopic third ventriculostomy where chronic burnt-out cases or cases with communicating hydrocephalus should be managed by ventriculoperitoneal shunting.
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Affiliation(s)
- Apoorva Kumar
- Department Surgery, Era's Lucknow Medical College, Lucknow, India.
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Savardekar A, Chatterji D, Singhi S, Mohindra S, Gupta S, Chhabra R. The role of ventriculoperitoneal shunt placement in patients of tubercular meningitis with hydrocephalus in poor neurological grade: a prospective study in the pediatric population and review of literature. Childs Nerv Syst 2013; 29:719-25. [PMID: 23404292 DOI: 10.1007/s00381-013-2048-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Accepted: 01/31/2013] [Indexed: 11/28/2022]
Abstract
PURPOSE There is still no standard protocol for management of patients of tubercular meningitis (TBM) with hydrocephalus in poor neurological grade. In general, a trial of external ventricular drain (EVD) is an accepted method of treatment to decide whether a particular patient will benefit from shunt surgery. However, recent studies suggest that ventriculoperitoneal (VP) shunt may be undertaken without the trial of an EVD. Our study prospectively evaluates the role of direct VP shunt placement in poor grade patients of TBM with hydrocephalus. METHODS Twenty-six consecutive pediatric patients of TBM with hydrocephalus in Palur grades III and IV underwent direct VP shunt placement, without prior placement of EVD. Outcome was assessed at the end of 3 months using Glasgow Outcome Score. RESULTS The mean age of patients was 3.3 years (range, 4 months to 11 years). Twenty-one (80.8 %) patients were in grade III and five (19.2 %) were in grade IV. Good outcome and mortality in grade IV patients was 20 % (1/5) and 60 % (3/5) respectively; whereas in grade III patients, it was 71.4 % (15/21) and 9.5 % (2/21), respectively. Thirteen patients presented with focal neurological deficit at admission, which persisted in only three patients at 3 months follow up. VP shunt-related complications were observed in six (23.5 %) patients CONCLUSIONS Despite poor grade at admission, 71.4 % patients in grade III and 20 % patients in grade IV had a good outcome at 3 months follow-up. Direct VP shunt placement is a safe and effective option even in poor grade patients of TBM with hydrocephalus, with a low complication rate.
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Affiliation(s)
- Amey Savardekar
- Neurosurgery, Post-Graduate Institute of Medical Education and Research, Chandigarh, India
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Figaji AA, Fieggen AG. Endoscopic Challenges and Applications in Tuberculous Meningitis. World Neurosurg 2013; 79:S24.e9-14. [DOI: 10.1016/j.wneu.2012.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Accepted: 02/01/2012] [Indexed: 12/29/2022]
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Abstract
Tuberculous (TB) meningitis is common in resource-poor communities but also occurs in developed countries where the diagnosis is frequently delayed because of unfamiliarity with the disease. TB meningitis develops whenever a small intracranial tuberculoma (Rich focus) ruptures causing predominantly basal meningitis. This results in hydrocephalus, cranial nerve palsies, and ischemic brain injury secondary to tuberculous vasculitis. The primary source of TB is usually the lung. Early diagnosis is difficult because patients tend to present subacutely with nonspecific symptoms such as fever, cough, vomiting, listlessness, and failure to thrive. Lumbar puncture typically shows clear and colorless CSF with a low, predominantly lymphocytic, leukocytosis and raised protein and low glucose levels. Decision to treat is mostly clinical because of difficulty in demonstrating TB bacilli on routine smear and time needed for culture. A positive TB contact, Mantoux skin test, chest radiograph, CT/MRI brain scan, PCR for tuberculosis on CSF, and demonstration of TB bacilli from extraneural sources are invaluable in supporting a diagnosis of TB meningitis. Current World Health Organization guidelines recommend treatment with a four-drug regimen for 2 months, followed by a two-drug regimen for 10 months, the total duration of treatment being 12 months. Corticosteroids reduce mortality without changing neurological morbidity. Outcome relates closely to age and stage of disease.
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Affiliation(s)
- J F Schoeman
- Department of Paediatrics and Child Health, University of Stellenbosch, Tygerberg, South Africa.
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Lyngdoh BT, Islam MS. Ventriculocholecysto shunt: a solution to recurrent shunt complications in comorbid post-tubercular hydrocephalus with tubercular adhesive peritonitis. Acta Neurochir (Wien) 2012; 154:2267-70. [PMID: 23053281 DOI: 10.1007/s00701-012-1506-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 09/13/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tuberculosis is still a killer disease and a nightmare in developing countries. Post-tubercular hydrocephalus remains one of the most severe complications, with many diversion procedure methods. How common is the occurrence of co-morbid post tubercular hydrocephalus with tubercular peritonitis is still not known. This is a frustrating cause of repeated shunt complications and revisions. METHODS We discuss the management of two cases that were the cause of nearly 50 % of our shunt revisions due to the comorbidities of post-tubercular hydrocephalus and tubercular adhesive peritonitis. We performed the ventriculocholecysto (VC) shunt. This procedure diverts CSF from the ventricular system to the gall bladder. RESULTS The two children are disease free and did not require a revision in the 3.4-year follow-up period. CONCLUSION The VC shunt is a simple procedure. It improved the quality of life of these children who otherwise would have had a very morbid period during shunt revisions and the active disease. These children did not require further revisions and can grow normally.
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Affiliation(s)
- Bernard Trench Lyngdoh
- Department of Neurosurgery, Nazareth Hospital and Woodland Hospital, Shillong, Meghalaya, India.
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Patkar D, Narang J, Yanamandala R, Lawande M, Shah GV. Central Nervous System Tuberculosis. Neuroimaging Clin N Am 2012; 22:677-705. [DOI: 10.1016/j.nic.2012.05.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Clemente Morgado T, Kinsky M, Carrara H, Rothemeyer S, Semple P. Prognostic value of computed tomography-evident cerebral infarcts in adult patients with tuberculous meningitis and hydrocephalus treated with an external ventricular drain. World Neurosurg 2012; 80:e255-60. [PMID: 23041069 DOI: 10.1016/j.wneu.2012.09.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Revised: 08/06/2012] [Accepted: 09/27/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Tuberculous meningitis (TBM) frequently is complicated by hydrocephalus and cerebral infarction. Previous studies have shown radiologic evidence of cerebral infarction in TBM to be an indicator of poor outcome in both adults and children. Our objective was to assess short-term mortality in adult patients with TBM and hydrocephalus treated with an external ventricular drain and to assess the prognostic value of cerebral infarction on admission computed tomography imaging within this cohort. METHODS This was a retrospective case series based on an adult intensive care unit admissions database, analyzing demographic, clinical, diagnostic, and radiologic data against short-term mortality. RESULTS A total of 25 patients managed from 2005 to 2011 were identified. Three patients were excluded. Mean age was 31 years. British Medical Research Council clinical severity grading was grade I in 9.1%, grade II in 31.8%, and grade III in 59.1%. Short-term mortality was 68.2% overall. Cerebral infarction on admission scanning was seen in 10 patients (45.5%). Prevalence of infarcts was not significantly higher in HIV-positive patients (50.0% vs. 42.9%). Mortality in the group with infarcts was 100%, compared with 41.7% in the group without infarcts. Mortality in patients with an admission Glasgow Coma Scale of 8 or less was 91.7%. Mortality in the HIV-positive group was slightly greater, but this increase did not reach statistical significance (71.4% vs. 57.1% P = 0.6). Univariate analysis showed presence of infarcts at admission, Glasgow Coma Scale ≤8 at admission and age of 30 years or more to be significantly related to mortality. There was also a statistically significantly increased mortality according to British Medical Research Council grade. CONCLUSION TBM with hydrocephalus requiring cerebrospinal diversion carries a significant short-term mortality. Within this cohort, the group of patients who have computed tomography-evident cerebral infarcts at admission has an even worse outcome, with a significantly greater short-term mortality prevalence.
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Affiliation(s)
- Tiago Clemente Morgado
- Division of Neurosurgery, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa.
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Diagnosis and therapy of tuberculous meningitis in children. Tuberculosis (Edinb) 2012; 92:377-83. [DOI: 10.1016/j.tube.2012.05.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2012] [Revised: 05/22/2012] [Accepted: 05/29/2012] [Indexed: 11/22/2022]
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Lin J, Zhou H, Zhang N, Yin B, Sheng HS. Effects of the implantation of Ommaya reservoir in children with tuberculous meningitis hydrocephalus: a preliminary study. Childs Nerv Syst 2012; 28:1003-8. [PMID: 22526442 DOI: 10.1007/s00381-012-1748-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Accepted: 03/26/2012] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The role of Ommaya reservoir implantation in children with tuberculous meningitis hydrocephalus (TBMH) has been seldomly reported. Therefore, we performed this study to determine the role of the Ommaya reservoir in the treatment of children with TBMH. METHODS We retrospectively analyzed the effects of Ommaya reservoir implantation in 12 children with TBMH. Intracapsular puncture of the reservoir was performed for draining the cerebrospinal fluid and the TBM was treated by intraventricular injection of isoniazid. RESULTS The ideal treatment outcome was observed in nine (75 %) of the 12 children; two (16.7 %) children developed serious disabilities and one of them (8.3 %) eventually died. The treatment method was effective for all six (100 %) children with Palur grade II TBM but showed no effect in three (50 %) children with grade III and IV TBM. The number of leukocytes in the cerebrospinal fluid decreased to 20 × 10(6)/L (75 %) within 2 weeks after implantation of the reservoirs. Finally, the Ommaya reservoirs in eight children were removed but were retained in four children. Four children had to undergo ventriculoperitoneal shunt. CONCLUSION Ommaya reservoir implantation has been shown to be effective in treating children with TBMH. This method may be largely suitable for children with early grade II TBM or partly in children with grade III TBM who have mild or moderate hydrocephalus that can alleviate after short-term treatment. Thus, a good proportion of children who undergo Ommaya reservoir implantation can avoid ventriculoperitoneal shunt surgery.
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Affiliation(s)
- Jian Lin
- Department of Neurosurgery, Yuying Children's Hospital of Wenzhou Medical Collage, Wenzhou, China, 325027
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Torres-Corzo J, Viñas-Rios JM, Sanchez-Aguilar M, Vecchia RRD, Chalita-Williams JC, Rangel-Castilla L. Transventricular Neuroendoscopic Exploration and Biopsy of the Basal Cisterns in Patients with Basal Meningitis and Hydrocephalus. World Neurosurg 2012; 77:762-71. [DOI: 10.1016/j.wneu.2011.08.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Revised: 07/07/2011] [Accepted: 08/12/2011] [Indexed: 10/15/2022]
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Peng J, Deng X, He F, Omran A, Zhang C, Yin F, Liu J. Role of ventriculoperitoneal shunt surgery in grade IV tubercular meningitis with hydrocephalus. Childs Nerv Syst 2012; 28:209-15. [PMID: 21909965 DOI: 10.1007/s00381-011-1572-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Accepted: 08/31/2011] [Indexed: 02/07/2023]
Abstract
PURPOSE Hydrocephalus is a common complication of tuberculous meningitis (TBM) in children. The role of ventriculoperitoneal shunt (VPS) placement in grade IV patients is controversial. The aim of this study is to investigate the clinical value of VPS placement for patients with grade IV TBM with hydrocephalus (TBMH). METHODS This study was carried out on children with grade IV TBMH from January 2006 to January 2011 in Xiangya Hospital, China. All patients were given VPS placement combined with medicine treatment. External ventricular drainage (EVD) was performed only in the presence of severe biochemical derangements or brainstem dysfunction requiring correction before shunt surgery. Outcomes were divided into normal, mild sequelae, severe sequelae, death, or vegetable status. RESULTS A total of 19 children with grade IV TBMH were recruited into the study. The average follow-up period was 29 months. Three of the 19 patients expired, four patients had a full recovery, eight had slight sequelae, and four had severe sequelae. Six complications related to the shunt surgery were seen among the patients. CONCLUSIONS This study demonstrates that direct ventriculoperitoneal shunt surgery could improve the outcome of grade IV TBMH. The response to EVD is not a reliable indication for selecting patients who would benefit from shunt surgery.
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Affiliation(s)
- Jing Peng
- Department of Pediatrics, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, Hunan, People's Republic of China
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Tuberculous meningitis: diagnosis and treatment overview. Tuberc Res Treat 2011; 2011:798764. [PMID: 22567269 PMCID: PMC3335590 DOI: 10.1155/2011/798764] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2011] [Revised: 11/16/2011] [Accepted: 11/18/2011] [Indexed: 01/01/2023] Open
Abstract
Tuberculous meningitis (TBM) is the most common form of central nervous system tuberculosis (TB) and has very high morbidity and mortality. TBM is typically a subacute disease with symptoms that may persist for weeks before diagnosis. Characteristic cerebrospinal fluid (CSF) findings of TBM include a lymphocytic-predominant pleiocytosis, elevated protein, and low glucose. CSF acid-fast smear and culture have relatively low sensitivity but yield is increased with multiple, large volume samples. Nucleic acid amplification of the CSF by PCR is highly specific but suboptimal sensitivity precludes ruling out TBM with a negative test. Treatment for TBM should be initiated as soon as clinical suspicion is supported by initial CSF studies. Empiric treatment should include at least four first-line drugs, preferably isoniazid, rifampin, pyrazinamide, and streptomycin or ethambutol; the role of fluoroquinolones remains to be determined. Adjunctive treatment with corticosteroids has been shown to improve mortality with TBM. In HIV-positive individuals with TBM, important treatment considerations include drug interactions, development of immune reconstitution inflammatory syndrome, unclear benefit of adjunctive corticosteroids, and higher rates of drug-resistant TB. Testing the efficacy of second-line and new anti-TB drugs in animal models of experimental TBM is needed to help determine the optimal regimen for drug-resistant TB.
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Chatterjee S. Brain tuberculomas, tubercular meningitis, and post-tubercular hydrocephalus in children. J Pediatr Neurosci 2011; 6:S96-S100. [PMID: 22069437 PMCID: PMC3208909 DOI: 10.4103/1817-1745.85725] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Central nervous system tuberculosis in children presents commonly as tubercular meningitis, post-tubercular meningitis hydrocephalus, and much more rarely as space-occupying lesions known as tuberculomas. The occurrence of this condition, though previously reported only in the developing world, is now frequently reported in human immunodeficiency virus positive migrants in the western world. The exact pathogenesis of this condition is still incompletely understood, and the mainstay of treatment is chemotherapeutic regimes. Neurosurgical intervention is rarely necessary, and is confined to cases of hydrocephalus after tubercular meningitis and to large tubeculomas with space-occupying effects.
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Affiliation(s)
- Sandip Chatterjee
- Department of Neurosurgery, Vivekananda Institute of Medical Sciences, Kolkata, West Bengal, India
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