1
|
Grasso EA, Pozzilli V, Tomassini V. Transverse myelitis in children and adults. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:101-117. [PMID: 37620065 DOI: 10.1016/b978-0-323-98817-9.00020-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Transverse myelitis is a noncompressive myelopathy of inflammatory origin. The causes are broad, ranging from infective or toxic to immuno-mediated etiology. They can be manifestations of systemic diseases, such as sarcoidosis and systemic lupus erythematous, or phenotypes of neuroinflammation; in a portion of cases, the etiology remains unknown, leading to the designation idiopathic. The clinical presentation of transverse myelitis depends on the level of spinal cord damage and may include sensorimotor deficits and autonomic dysfunction. The age of onset of the disorder can impact the symptoms and outcomes of affected patients, with differences in manifestation and prognosis between children and adults. Spinal cord magnetic resonance imaging and cerebrospinal fluid examination are the main diagnostic tools that can guide clinicians in the diagnostic process, even though the search for antibodies that target the structural components of the neural tissue (anti-aquaporin4 antibodies and anti-myelin-oligodendrocyte antibodies) helps in the distinction among the immune-mediated phenotypes. Management and outcomes depend on the underlying cause, with different probabilities of relapse according to the phenotypes. Hence, immunosuppression is often recommended for the immune-mediated diseases that may have a higher risk of recurrence. Age at onset has implications for the choice of treatment.
Collapse
Affiliation(s)
- Eleonora Agata Grasso
- Department of Neurosciences, Imaging and Clinical Sciences, Institute of Advanced Biomedical Technologies (ITAB), University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Valeria Pozzilli
- Department of Neurosciences, Imaging and Clinical Sciences, Institute of Advanced Biomedical Technologies (ITAB), University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Valentina Tomassini
- Department of Neurosciences, Imaging and Clinical Sciences, Institute of Advanced Biomedical Technologies (ITAB), University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.
| |
Collapse
|
2
|
Palackdkharry CS, Wottrich S, Dienes E, Bydon M, Steinmetz MP, Traynelis VC. The leptomeninges as a critical organ for normal CNS development and function: First patient and public involved systematic review of arachnoiditis (chronic meningitis). PLoS One 2022; 17:e0274634. [PMID: 36178925 PMCID: PMC9524710 DOI: 10.1371/journal.pone.0274634] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 08/31/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND & IMPORTANCE This patient and public-involved systematic review originally focused on arachnoiditis, a supposedly rare "iatrogenic chronic meningitis" causing permanent neurologic damage and intractable pain. We sought to prove disease existence, causation, symptoms, and inform future directions. After 63 terms for the same pathology were found, the study was renamed Diseases of the Leptomeninges (DLMs). We present results that nullify traditional clinical thinking about DLMs, answer study questions, and create a unified path forward. METHODS The prospective PRISMA protocol is published at Arcsology.org. We used four platforms, 10 sources, extraction software, and critical review with ≥2 researchers at each phase. All human sources to 12/6/2020 were eligible for qualitative synthesis utilizing R. Weekly updates since cutoff strengthen conclusions. RESULTS Included were 887/14286 sources containing 12721 DLMs patients. Pathology involves the subarachnoid space (SAS) and pia. DLMs occurred in all countries as a contributor to the top 10 causes of disability-adjusted life years lost, with communicable diseases (CDs) predominating. In the USA, the ratio of CDs to iatrogenic causes is 2.4:1, contradicting arachnoiditis literature. Spinal fusion surgery comprised 54.7% of the iatrogenic category, with rhBMP-2 resulting in 2.4x more DLMs than no use (p<0.0001). Spinal injections and neuraxial anesthesia procedures cause 1.1%, and 0.2% permanent DLMs, respectively. Syringomyelia, hydrocephalus, and arachnoid cysts are complications caused by blocked CSF flow. CNS neuron death occurs due to insufficient arterial supply from compromised vasculature and nerves traversing the SAS. Contrast MRI is currently the diagnostic test of choice. Lack of radiologist recognition is problematic. DISCUSSION & CONCLUSION DLMs are common. The LM clinically functions as an organ with critical CNS-sustaining roles involving the SAS-pia structure, enclosed cells, lymphatics, and biologic pathways. Cases involve all specialties. Causes are numerous, symptoms predictable, and outcomes dependent on time to treatment and extent of residual SAS damage. An international disease classification and possible treatment trials are proposed.
Collapse
Affiliation(s)
| | - Stephanie Wottrich
- Case Western Reserve School of Medicine, Cleveland, Ohio, United States of America
| | - Erin Dienes
- Arcsology®, Mead, Colorado, United States of America
| | - Mohamad Bydon
- Department of Neurologic Surgery, Orthopedic Surgery, and Health Services Research, Mayo Clinic School of Medicine, Rochester, Minnesota, United States of America
| | - Michael P. Steinmetz
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine Neurologic Institute, Cleveland, Ohio, United States of America
| | - Vincent C. Traynelis
- Department of Neurosurgery, Rush University School of Medicine, Chicago, Illinois, United States of America
| |
Collapse
|
3
|
Vishnevetsky A, Anand P. Approach to Neurologic Complications in the Immunocompromised Patient. Semin Neurol 2021; 41:554-571. [PMID: 34619781 DOI: 10.1055/s-0041-1733795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Neurologic complications are common in immunocompromised patients, including those with advanced human immunodeficiency virus, transplant recipients, and patients on immunomodulatory medications. In addition to the standard differential diagnosis, specific pathogens and other conditions unique to the immunocompromised state should be considered in the evaluation of neurologic complaints in this patient population. A thorough understanding of these considerations is critical to the inpatient neurologist in contemporary practice, as increasing numbers of patients are exposed to immunomodulatory therapies. In this review, we provide a chief complaint-based approach to the clinical presentations and diagnosis of both infectious and noninfectious complications particular to immunocompromised patients.
Collapse
Affiliation(s)
- Anastasia Vishnevetsky
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pria Anand
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| |
Collapse
|
4
|
LoRusso S. Infections of the Peripheral Nervous System. Continuum (Minneap Minn) 2021; 27:921-942. [PMID: 34623098 DOI: 10.1212/con.0000000000000981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article describes infections that affect the peripheral nervous system, including their clinical features, differential diagnoses, and treatments. RECENT FINDINGS Rates of pyomyositis have increased recently in the United States, possibly because of an increase in risk factors such as IV drug use, obesity, and diabetes. Other peripheral nervous system infections, such as diphtheria, have become more common in older patients secondary to a lack of revaccination or waning immunity. Although recommended treatment regimens for most infections remain unchanged over recent years, debate over the ideal dosing and route of administration continues for some infections such as tetanus and leprosy (Hansen disease). SUMMARY Infections of the peripheral nervous system are varied in terms of the type of infection, localization, and potential treatment. Nerve conduction studies and EMG can help determine localization, which is key to determining an initial differential diagnosis. It is important to recognize infections quickly to minimize diagnostic delays that could lead to patient morbidity and mortality.
Collapse
|
5
|
Saxena D, Pinto DS, Tandon AS, Hoisala R. MRI findings in tubercular radiculomyelitis. eNeurologicalSci 2021; 22:100316. [PMID: 33604460 PMCID: PMC7875821 DOI: 10.1016/j.ensci.2021.100316] [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: 09/02/2020] [Revised: 12/02/2020] [Accepted: 01/17/2021] [Indexed: 11/29/2022] Open
Abstract
This article aims to familiarize the reader with the MR imaging findings of tubercular radiculomyelitis (TBRM) and to identify the sources of infection. We evaluated 29 patients on a 1.5 T GE MRI in a cross-sectional study. MRI of the spine with contrast and lumbar puncture were performed in all patients. MRI brain was performed for 13 patients. The typical and atypical manifestations enlisted in this article, will enable early detection of TBRM when the clinical history is ambiguous, as TBRM can present with low backache in both retrovirus positive and negative patients.
Collapse
Affiliation(s)
- Deepali Saxena
- Department of Radiodiagnosis, St. John's Medical College Hospital, Sarjapur Road, Koramangala, Bangalore 560034, India
| | - Denver Steven Pinto
- Department of Radiodiagnosis, St. John's Medical College Hospital, Sarjapur Road, Koramangala, Bangalore 560034, India
| | - Anisha S. Tandon
- Department of Radiodiagnosis, St. John's Medical College Hospital, Sarjapur Road, Koramangala, Bangalore 560034, India
| | - Ravi Hoisala
- Department of Radiodiagnosis, St. John's Medical College Hospital, Sarjapur Road, Koramangala, Bangalore 560034, India
| |
Collapse
|
6
|
Jurga S, Szymańska-Adamcewicz O, Wierzchołowski W, Pilchowska-Ujma E, Urbaniak Ł. Spinal adhesive arachnoiditis: three case reports and review of literature. Acta Neurol Belg 2021; 121:47-53. [PMID: 32833147 PMCID: PMC7937595 DOI: 10.1007/s13760-020-01431-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 07/03/2020] [Indexed: 01/30/2023]
Abstract
Spinal adhesive arachnoiditis is a rare pathology involving pia mater of the spinal cord and nerve roots. It can potentially lead to disability—many patients end up wheelchair-bound due to subsequent paraparesis. It is an infrequent but possible cause of lower extremities weakness in patients with a history of spinal surgery, epidural anaesthesia, myelography or spinal tumors. Three patients, one male and two females, admitted to our unit due to paraparesis presented at least one of the above mentioned risk factors. Each of them had a severe course of illness—progressive paresis of lower extremities. All above cases were diagnosed with spinal adhesive arachnoiditis confirmed with Magnetic Resonance Imaging (MRI) scan—the most sensitive and specific diagnostic tool. Despite conservative treatment and intensive rehabilitation none of the presented patients preserved the ability to mobilise independently. Considering spinal adhesive arachnoiditis in patients with paraparesis and history of typical risk factors should be included in clinical diagnostic procedure.
Collapse
Affiliation(s)
- Szymon Jurga
- Department of Neurology, University Hospital, Zielona Góra, Poland
| | | | | | | | - Łukasz Urbaniak
- Department of Neurology, University Hospital, Zielona Góra, Poland
| |
Collapse
|
7
|
Abstract
Background: Meningitis caused by Streptococcus pneumoniae is associated with devastating clinical outcomes. A considerable number of patients will develop long-term neurologic complications. Hearing loss, diffuse brain edema, and hydrocephalus are frequently encountered. Acute spinal cord dysfunction and polyradiculopathy can develop in some patients. Case Report: A 63-year-old female was admitted to our hospital with sudden-onset bilateral lower extremity weakness. On admission, the patient had evidence of spinal cord dysfunction given the abnormal motor and sensory physical examination findings and the absent sensation with a sensory level at dermatome T4 on neurologic examination. Computed tomography myelography did not show evidence of spinal cord compression or transverse myelitis. Cerebrospinal fluid examination was positive for pneumococcal meningitis. The patient was treated with antibiotics and steroids. Nerve conduction studies demonstrated the absence of response, suggesting damage to the peripheral nerves and polyradiculopathy. The patient was treated with plasmapheresis for possible Guillain-Barré syndrome; however, she did not improve despite appropriate antibiotics, steroids, and plasmapheresis. She developed persistent quadriparesis, sensory impairments in upper and lower extremities, and bowel and bladder sphincter dysfunction. Conclusion: Our case demonstrates the development of spinal cord dysfunction (supported by the sudden onset of paraplegia and the presence of a sensory level) and polyradiculopathy (flaccid paralysis, ascending weakness, and absence of response in neurophysiologic studies suggesting severe damage to the peripheral nerves). The appearance of either complication is unusual, and the simultaneous occurrence of both complications is even more uncommon.
Collapse
|
8
|
Le Guennec L. Manifestazioni neurologiche delle infezioni. Neurologia 2020. [DOI: 10.1016/s1634-7072(20)43298-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
9
|
Marais S, Roos I, Mitha A, Mabusha SJ, Patel V, Bhigjee AI. Spinal Tuberculosis: Clinicoradiological Findings in 274 Patients. Clin Infect Dis 2019; 67:89-98. [PMID: 29340585 DOI: 10.1093/cid/ciy020] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 01/10/2018] [Indexed: 12/14/2022] Open
Abstract
Background Mycobacterium tuberculosis is a major cause of myelopathy and radiculopathy in settings with a high prevalence of tuberculosis/human immunodeficiency virus (HIV) coinfection. However, a paucity of publications exists on the spectrum of neurological and magnetic resonance (MR) imaging findings of spinal tuberculosis in these populations. Methods We conducted a retrospective study of adults with spinal tuberculosis at a referral center in South Africa for patients with spinal disease without bony involvement seen at plain film radiography. We report the clinical, laboratory and spinal MR imaging findings, compare HIV-infected and HIV-uninfected patients, and correlate clinical and cerebrospinal fluid findings with those of MR imaging. Results Of 274 patients, 209 (76%) were HIV infected and 49 (18%) were HIV uninfected. Radiculomyelitis occurred in 77% (n = 210), and spondylitis in 39% (n = 106). Subdural abscess (n = 42) and intramedullary tuberculoma (n = 33) were common. In 24% of HIV-infected and 14% of HIV-uninfected patients, spinal disease manifested as a paradoxical tuberculosis reaction, frequently following tuberculous meningitis. The triad of neurological deficit, fever, and back pain was similar in patients with spondylitis (24%), epi/subdural abscess without bony disease (14%), meningoradiculitis (17%), and isolated myelitis (17%) . Conclusions Radiculomyelitis is a common manifestation of spinal tuberculosis in settings with high tuberculosis/HIV prevalence, often presenting as a paradoxical reaction. We describe a high frequency of rarely reported spinal tuberculosis manifestations, suggesting that these are more common than implied by the literature.
Collapse
Affiliation(s)
- Suzaan Marais
- Department of Neurology, Inkosi Albert Luthuli Central Hospital, Durban, South Africa.,Department of Neurology, University of KwaZulu-Natal, Durban, South Africa
| | - Izanne Roos
- Department of Neurology, Inkosi Albert Luthuli Central Hospital, Durban, South Africa.,Department of Neurology, University of KwaZulu-Natal, Durban, South Africa
| | - Ayesha Mitha
- Department of Radiology, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | | | - Vinod Patel
- Department of Neurology, Inkosi Albert Luthuli Central Hospital, Durban, South Africa.,Department of Neurology, University of KwaZulu-Natal, Durban, South Africa
| | - Ahmed I Bhigjee
- Department of Neurology, Inkosi Albert Luthuli Central Hospital, Durban, South Africa.,Department of Neurology, University of KwaZulu-Natal, Durban, South Africa
| |
Collapse
|
10
|
Abstract
Tuberculous meningomyelitis is a relatively rare but serious type of nervous system tuberculosis. This disease is caused by invasion of the spinal cord or the spinal meninges tuberculosis. The early symptoms are not typical and lack specificity. It can cause early changes in the MRI. Analysis of the MRI manifestations combined with the clinical manifestations and cere- brospinal fluid examination can facilitate accurate diagnosis of the disease. Early treatment has a clear effect, we want to increase knowledge of the dis- ease by sharing this case in order to reduce clinical misdiagnosis and allow more patients to be treated in time.
Collapse
|
11
|
Abstract
PURPOSE OF REVIEW This article details the epidemiology and clinical manifestations of central nervous system (CNS) tuberculosis (TB), provides guidance for diagnostic imaging and CSF testing, and recommends treatment strategies for tuberculous meningitis and other forms of CNS TB, illustrating key aspects of diagnosis and management with case presentations. RECENT FINDINGS Although improvements in our understanding of the pathogenesis and management of CNS TB have occurred over the past 50 years, the emergence of multidrug-resistant and extensively drug-resistant TB, the advent of acquired immunodeficiency syndrome (AIDS), and the subsequent availability of highly active antiretroviral therapy that can produce the immune reconstitution inflammatory syndrome have complicated the diagnosis and treatment of CNS TB. Advances in diagnostic assays promise to increase the speed of diagnosis as well as the percentage of people with a confirmed rather than a presumptive diagnosis. Advances in precision medicine have identified polymorphisms in the LTA4H gene that influence the risk for inflammation in patients with tuberculous meningitis. SUMMARY CNS TB continues to be a major cause of morbidity and mortality, with the majority of people affected living in low-income and middle-income countries. Newer diagnostic assays promise to increase the speed of diagnosis and improve appropriate selection of antituberculous therapy and anti-inflammatory medications. Despite these advances, CNS TB remains difficult to diagnose, and clinicians should have a low threshold for initiating empiric therapy in patients with presumptive infection.
Collapse
|
12
|
Beck ES, Ramachandran PS, Khan LM, Sample HA, Zorn KC, O'Connell EM, Nash T, Reich DS, Venkatesan A, DeRisi JL, Nath A, Wilson MR. Clinicopathology conference: 41-year-old woman with chronic relapsing meningitis. Ann Neurol 2019; 85:161-169. [PMID: 30565288 PMCID: PMC6370480 DOI: 10.1002/ana.25400] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/11/2018] [Accepted: 12/13/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Erin S Beck
- National Institute of Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Prashanth S Ramachandran
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA.,Department of Neurology, University of California, San Francisco, San Francisco, CA
| | - Lillian M Khan
- Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, CA
| | - Hannah A Sample
- Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, CA
| | - Kelsey C Zorn
- Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, CA
| | - Elise M O'Connell
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Theodore Nash
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Daniel S Reich
- National Institute of Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Arun Venkatesan
- Department of Neurology, Johns Hopkins University, Baltimore, MD
| | - Joseph L DeRisi
- Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, CA.,Chan Zuckerberg Biohub, San Francisco, CA
| | - Avindra Nath
- National Institute of Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Michael R Wilson
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA.,Department of Neurology, University of California, San Francisco, San Francisco, CA
| |
Collapse
|
13
|
Marais S, Roos I, Mitha A, Patel V, Bhigjee AI. Posttubercular syringomyelia in HIV-infected patients: A report of 10 cases and literature review. J Neurol Sci 2018; 395:54-61. [PMID: 30292964 DOI: 10.1016/j.jns.2018.09.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 09/03/2018] [Accepted: 09/26/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To describe the clinical presentation, spinal magnetic resonance imaging (MRI) findings and outcome of HIV-infected patients with tuberculosis (TB)-associated syringomyelia and to compare these findings between all HIV-infected and -uninfected cases published in the literature. METHODS A retrospective observational study conducted over a 12.5-year period at a public-sector referral hospital in South Africa. HIV-infected adults with neurological TB in whom MRI confirmed a syrinx were included. We searched PubMed to identify all published syringomyelia cases. RESULTS Ten patients were enrolled. Syringomyelia complicated neurological TB within four years of initial diagnosis in all patients (median: 21 months, range: 0-39) after initial diagnosis. Six patients were treated conservatively (TB treatment = 5, no treatment = 1); four improved, but only one was ambulant during follow-up. Four patients underwent syringoperitoneal shunting; three improved and one died three months later. Our literature review identified 50 additional cases (HIV-infected = 2, HIV-uninfected = 9, HIV status not documented = 39 [presumed HIV-uninfected]). Clinical and imaging findings and outcomes were similar between HIV-infected and -uninfected cases, except for time of presentation following neurological TB diagnosis, which was delayed (>4 years) in 46% of HIV-uninfected cases, compared to 8% of HIV-infected cases. Conclusions Syringomyelia is a disabling complication of neurological TB that usually presents early after neurological TB diagnosis in HIV coinfected patients.
Collapse
Affiliation(s)
- Suzaan Marais
- Department of Neurology, Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal, 800 Vusi Mzimela Road, Durban 4901, South Africa.
| | - Izanne Roos
- Department of Neurology, Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal, 800 Vusi Mzimela Road, Durban 4901, South Africa
| | - Ayesha Mitha
- Department of Radiology, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Vinod Patel
- Department of Neurology, Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal, 800 Vusi Mzimela Road, Durban 4901, South Africa
| | - Ahmed I Bhigjee
- Department of Neurology, Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal, 800 Vusi Mzimela Road, Durban 4901, South Africa
| |
Collapse
|
14
|
Abstract
The epidemiology of spinal cord disease in human immunodeficiency virus (HIV) infection is largely unknown due to a paucity of data since combination antiretroviral therapy (cART). HIV mediates spinal cord injury indirectly, by immune modulation, degeneration, or associated infections and neoplasms. The pathologies vary and range from cytotoxic necrosis to demyelination and vasculitis. Control of HIV determines the differential for all neurologic presentations in infected individuals. Primary HIV-associated acute transverse myelitis, an acute inflammatory condition with pathologic similarities to HIV encephalitis, arises in early infection and at seroconversion. In contrast, HIV vacuolar myelopathy and opportunistic infections predominate in uncontrolled disease. There is systemic immune dysregulation as early as primary infection due to initial depletion of gut-associated lymphoid tissue CD4 cells and allowance of microbial translocation across the gut that never fully recovers throughout the course of HIV infection, regardless of how well controlled. The subsequent proinflammatory state may contribute to spinal cord diseases observed even after cART initiation. This chapter will highlight an array of spinal cord pathologies classified by stage of HIV infection and immune status.
Collapse
Affiliation(s)
- Seth N Levin
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Jennifer L Lyons
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| |
Collapse
|
15
|
David WS, Bowley MP, Mehan WA, Shin JH, Gerstner ER, DeWitt JC. Case 19-2017 - A 53-Year-Old Woman with Leg Numbness and Weakness. N Engl J Med 2017. [PMID: 28636859 DOI: 10.1056/nejmcpc1701762] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- William S David
- From the Departments of Neurology (W.S.D., M.P.B., E.R.G.), Radiology (W.A.M.), Neurosurgery (J.H.S.), and Pathology (J.C.D.), Massachusetts General Hospital, and the Departments of Neurology (W.S.D., M.P.B., E.R.G.), Radiology (W.A.M.), Neurosurgery (J.H.S.), and Pathology (J.C.D.), Harvard Medical School - both in Boston
| | - Michael P Bowley
- From the Departments of Neurology (W.S.D., M.P.B., E.R.G.), Radiology (W.A.M.), Neurosurgery (J.H.S.), and Pathology (J.C.D.), Massachusetts General Hospital, and the Departments of Neurology (W.S.D., M.P.B., E.R.G.), Radiology (W.A.M.), Neurosurgery (J.H.S.), and Pathology (J.C.D.), Harvard Medical School - both in Boston
| | - William A Mehan
- From the Departments of Neurology (W.S.D., M.P.B., E.R.G.), Radiology (W.A.M.), Neurosurgery (J.H.S.), and Pathology (J.C.D.), Massachusetts General Hospital, and the Departments of Neurology (W.S.D., M.P.B., E.R.G.), Radiology (W.A.M.), Neurosurgery (J.H.S.), and Pathology (J.C.D.), Harvard Medical School - both in Boston
| | - John H Shin
- From the Departments of Neurology (W.S.D., M.P.B., E.R.G.), Radiology (W.A.M.), Neurosurgery (J.H.S.), and Pathology (J.C.D.), Massachusetts General Hospital, and the Departments of Neurology (W.S.D., M.P.B., E.R.G.), Radiology (W.A.M.), Neurosurgery (J.H.S.), and Pathology (J.C.D.), Harvard Medical School - both in Boston
| | - Elizabeth R Gerstner
- From the Departments of Neurology (W.S.D., M.P.B., E.R.G.), Radiology (W.A.M.), Neurosurgery (J.H.S.), and Pathology (J.C.D.), Massachusetts General Hospital, and the Departments of Neurology (W.S.D., M.P.B., E.R.G.), Radiology (W.A.M.), Neurosurgery (J.H.S.), and Pathology (J.C.D.), Harvard Medical School - both in Boston
| | - John C DeWitt
- From the Departments of Neurology (W.S.D., M.P.B., E.R.G.), Radiology (W.A.M.), Neurosurgery (J.H.S.), and Pathology (J.C.D.), Massachusetts General Hospital, and the Departments of Neurology (W.S.D., M.P.B., E.R.G.), Radiology (W.A.M.), Neurosurgery (J.H.S.), and Pathology (J.C.D.), Harvard Medical School - both in Boston
| |
Collapse
|
16
|
Aydın T, Taşpınar Ö, Keskin Y, Kepekçi M, Güneşer M, Çamlı A, Seyithanoğlu H, Kızıltan H, Eriş AH. A Rare Complication of Tuberculosis: Acute Paraplegia. Ethiop J Health Sci 2016; 26:405-7. [PMID: 27587940 PMCID: PMC4992782 DOI: 10.4314/ejhs.v26i4.14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Tuberculous radiculomyelitis(TBRM) is one of the complications of neurological tuberculosis and includes cases of arachnoiditis, intradural spinal tuberculoma or granuloma, and spinal cord complications of tuberculous meningitis (TBM). Here, we report a case of TBRM which presented with acute paraplegia. Case Details Neurological examination on admission revealed flaccid paralysis, bilateral extensor plantar responses, and exaggerated deep tendon reflexes. Cerebrospinal fluid analysis showed xanthochromic fluid that contained 600 cells/mm3, 98% lymphocytes, protein 318 mg/dl and glucose 51 mg/dl (blood glucose 118 mg/dl). On thorax CT, calcified lymph nodes that were sequelae of primary tuberculosis infection was detected. Antituberculosis and intravenous corticosteroids treatment was started. Seven weeks from the onset, on-control spinal MRI myelomalacia was determined, and there was no leptomeningeal enhancement. After six weeks of rehabilitation, lower limb total motor score was increased from 0/50 to 15/50. Conclusions Tuberculous radiculomyelitis is a complication of TBM. It is rarely seen.
Collapse
Affiliation(s)
- Teoman Aydın
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Bezmi Alem Vakıf University, İstanbul
| | - Özgür Taşpınar
- Department of Physical Medicine and Rehabilitation, Cınarcik State Hospital, Yalova
| | - Yasar Keskin
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Bezmi Alem Vakıf University, İstanbul
| | - Müge Kepekçi
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Bezmi Alem Vakıf University, İstanbul
| | - Meryem Güneşer
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Bezmi Alem Vakıf University, İstanbul
| | - Adil Çamlı
- Department of Internal Medicine, Faculty of Medicine, Bezmi Alem Vakıf University, İstanbul
| | - Hakan Seyithanoğlu
- Department of Neurosurgery, Faculty of Medicine, Bezmi Alem Vakıf University, İstanbul
| | - Huriye Kızıltan
- Department of Radiation Oncology, Faculty of Medicine, Bezmi Alem Vakıf University, İstanbul
| | - Ali Hikmet Eriş
- Department of Radiation Oncology, Faculty of Medicine, Bezmi Alem Vakıf University, İstanbul
| |
Collapse
|
17
|
Panos G, Watson DC, Karydis I, Velissaris D, Andreou M, Karamouzos V, Sargianou M, Masdrakis A, Chra P, Roussos L. Differential diagnosis and treatment of acute cauda equina syndrome in the human immunodeficiency virus positive patient: a case report and review of the literature. J Med Case Rep 2016; 10:165. [PMID: 27268102 PMCID: PMC4895963 DOI: 10.1186/s13256-016-0902-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 04/17/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Acute cauda equina syndrome is an uncommon but significant neurologic presentation due to a variety of underlying diseases. Anatomical compression of nerve roots, usually by a lumbar disk hernia is a common cause in the general population, while inflammatory, neoplastic, and ischemic causes have also been recognized. Among human immunodeficiency virus (HIV) infected patients with acquired immunodeficiency syndrome, infectious causes are encountered more frequently, the most prevalent of which are: cytomegalovirus, herpes simplex virus 1/2, varicella zoster virus, and Mycobacterium tuberculosis infections. Studies of cauda equina syndrome in well-controlled HIV infection are lacking. We describe such a case of cauda equina syndrome in a well-controlled HIV-infected patient, along with a brief review of the literature regarding the syndrome's diagnosis and treatment in individuals with HIV infection. CASE PRESENTATION A 36-year-old Greek male, HIV-positive patient presented with perineal and left hemiscrotal numbness, lumbar pain, left-sided sciatica, and urinary incontinence. Magnetic resonance imaging of the patient's lumbar spine revealed intrathecal migration of a fragment from an intervertebral lumbar disk exerting pressure on the cauda equina. A cerebrospinal fluid examination, brain computed tomography scan, spine magnetic resonance imaging, and serological test results were negative for central nervous system infections. Our patient underwent emergency neurosurgical spinal decompression, which resolved most symptoms, except for mild urinary incontinence. CONCLUSIONS Noninfectious etiologies may also cause cauda equina syndrome in HIV-infected individuals, especially in well-controlled disease under antiretroviral therapy. Prompt recognition and treatment of the underlying cause is important to minimize residual symptoms. Targeted antimicrobial chemotherapy is used to treat infectious causes, while prompt surgical decompression is favored for anatomical causes of cauda equina syndrome in the HIV-infected patient.
Collapse
Affiliation(s)
- George Panos
- Special Infections Unit, 2nd Internal Medicine Clinic, 1st Ι.Κ.Α. Penteli General Hospital, Melissia, Athens, Greece. .,Department of Infectious Diseases, Patras University General Hospital, 26504, Rion, Patras, Greece.
| | - Dionysios C Watson
- Department of Infectious Diseases, Patras University General Hospital, 26504, Rion, Patras, Greece
| | - Ioannis Karydis
- Special Infections Unit, 2nd Internal Medicine Clinic, 1st Ι.Κ.Α. Penteli General Hospital, Melissia, Athens, Greece
| | - Dimitrios Velissaris
- Internal Medicine Department, University Hospital of Patras, 26504, Rion, Patras, Greece
| | - Marina Andreou
- Internal Medicine Department, University Hospital of Patras, 26504, Rion, Patras, Greece
| | - Vasilis Karamouzos
- Internal Medicine Department, University Hospital of Patras, 26504, Rion, Patras, Greece
| | - Maria Sargianou
- Department of Infectious Diseases, Patras University General Hospital, 26504, Rion, Patras, Greece
| | - Antonios Masdrakis
- Special Infections Unit, 2nd Internal Medicine Clinic, 1st Ι.Κ.Α. Penteli General Hospital, Melissia, Athens, Greece
| | - Paraskevi Chra
- Department of Microbiology, Benakio-Korgialenio Hospital, 1 Erythrou Staurou Street, 11526, Athens, Greece
| | - Lavrentios Roussos
- Neurosurgery Clinic, Κ.Α.Τ. Hospital, 2 Nikis Street, 14561, Kifissia, Athens, Greece
| |
Collapse
|
18
|
Suto Y, Ito S, Nomura T, Watanabe Y, Kitao S, Nakayasu H, Nakashima K. [A case of tuberculous myeloradiculitis with abdominal lymphadenitis presenting with symptoms of radiculomyelopathy]. Rinsho Shinkeigaku 2015; 55:816-22. [PMID: 26369375 DOI: 10.5692/clinicalneurol.cn-000717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 30-year old man was admitted with right hip pain and gait disturbances. Neurological findings revealed muscular weakness in the lower limbs, hyporeflexia, dysesthesia in the sacral region, and bowel and bladder disturbances. Cerebrospinal fluid (CSF) examination indicated a white blood cell count of 371/μl (lymphocyte:polymorphonuclear leukocyte = 97:3), protein levels of 463 mg/dl and sugar of 20 mg/dl. Although CSF culture was negative, tuberculous infection was presumed. Magnetic resonance imaging revealed areas of enhancement in the intramedullary region surrounding the spinal cord and cauda equina. Enhanced computed tomography (CT) of the abdomen revealed lymph node swelling around the head of the pancreas. Biopsy of the lymph node swelling was culture-positive for Mycobacterium tuberculosis. Hence, assuming a diagnosis of tuberculous lymphadenitis of the abdomen, antitubercular drugs were started. Since antitubercular therapy had beneficial effects on the neurological symptoms and CSF findings, we diagnosed the patient with tuberculous myeloradiculitis. Systematic examinations including lymph node biopsy and cultures were useful for the diagnosis of tuberculous myeloradiculitis.
Collapse
Affiliation(s)
- Yutaka Suto
- Division of Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University
| | | | | | | | | | | | | |
Collapse
|
19
|
Garg RK, Malhotra HS, Gupta R. Spinal cord involvement in tuberculous meningitis. Spinal Cord 2015; 53:649-57. [PMID: 25896347 DOI: 10.1038/sc.2015.58] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 02/24/2015] [Accepted: 03/04/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To summarize the incidence and spectrum of spinal cord-related complications in patients of tuberculous meningitis. SETTING Reports from multiple countries were included. METHODS An extensive review of the literature, published in English, was carried out using Scopus, PubMed and Google Scholar databases. RESULTS Tuberculous meningitis frequently affects the spinal cord and nerve roots. Initial evidence of spinal cord involvement came from post-mortem examination. Subsequent advancement in neuroimaging like conventional lumbar myelography, computed tomographic myelography and gadolinium-enhanced magnetic resonance-myelography have contributed immensely. Spinal involvement manifests in several forms, like tuberculous radiculomyelitis, spinal tuberculoma, myelitis, syringomyelia, vertebral tuberculosis and very rarely spinal tuberculous abscess. Frequently, tuberculous spinal arachnoiditis develops paradoxically. Infrequently, spinal cord involvement may even be asymptomatic. Spinal cord and spinal nerve involvement is demonstrated by diffuse enhancement of cord parenchyma, nerve roots and meninges on contrast-enhanced magnetic resonance imaging. High cerebrospinal fluid protein content is often a risk factor for arachnoiditis. The most important differential diagnosis of tuberculous arachnoiditis is meningeal carcinomatosis. Anti-tuberculosis therapy is the main stay of treatment for tuberculous meningitis. Higher doses of corticosteroids have been found effective. Surgery should be considered only when pathological confirmation is needed or there is significant spinal cord compression. The outcome in these patients has been unpredictable. Some reports observed excellent recovery and some reported unfavorable outcomes after surgical decompression and debridement. CONCLUSIONS Tuberculous meningitis is frequently associated with disabling spinal cord and radicular complications. Available treatment options are far from satisfactory.
Collapse
Affiliation(s)
- R K Garg
- Department of Neurology, King George Medical University, Uttar Pradesh, India
| | - H S Malhotra
- Department of Neurology, King George Medical University, Uttar Pradesh, India
| | - R Gupta
- Department of Neurology, King George Medical University, Uttar Pradesh, India
| |
Collapse
|
20
|
Abstract
INTRODUCTION Tuberculous meningitis (TBM) is the most severe form of infection caused by Mycobacterium tuberculosis, causing death or disability in more than half of those affected. The aim of this review is to examine recent advances in our understanding of TBM, focussing on the diagnosis and treatment of this devastating condition. SOURCES OF DATA Papers on TBM published between 1891 and 2014 and indexed in the NCBI Pubmed. The following search terms were used: TBM, diagnosis, treatment and outcome. AREAS OF AGREEMENT The diagnosis of TBM remains difficult as its presentation is non-specific and may mimic other causes of chronic meningoencephalitis. Rapid recognition of TBM is crucial, however, as delays in initiating treatment are associated with poor outcome. The laboratory diagnosis of TBM is hampered by the low sensitivity of cerebrospinal fluid microscopy and the slow growth of M. tuberculosis in conventional culture systems. The current therapy of TBM is based on the treatment of pulmonary tuberculosis, which may not be ideal. The combination of TBM and HIV infection poses additional management challenges because of the need to treat both infections and the complications associated with them. AREAS OF CONTROVERSY The pathogenesis of TBM remains incompletely understood limiting the development of interventions to improve outcome. The optimal therapy of TBM has not been established in clinical trials, and increasing antimicrobial resistance threatens successful treatment of this condition. The use of adjunctive anti-inflammatory agents remains controversial, and their mechanism of action remains incompletely understood. The role of surgical intervention is uncertain and may not be available in areas where TBM is common. GROWING POINTS Laboratory methods to improve the rapid diagnosis of TBM are urgently required. Clinical trials of examining the use of high-dose rifampicin and/or fluoroquinolones are likely to report in the near future. AREAS TIMELY FOR DEVELOPING RESEARCH The use of biomarkers to improve the rapid diagnosis of TBM warrants further investigation. The role of novel antituberculosis drugs, such as bedaquiline and PA-824, in the treatment of TBM remains to be explored. Human genetic polymorphisms may explain the heterogeneity of response to anti-inflammatory therapies and could potentially be used to tailor therapy.
Collapse
Affiliation(s)
- M E Török
- Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Box 157, Hills Road, Cambridge CB2 0QQ, UK Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK Public Health England, Clinical Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| |
Collapse
|
21
|
Gupta R, Garg RK, Jain A, Malhotra HS, Verma R, Sharma PK. Spinal cord and spinal nerve root involvement (myeloradiculopathy) in tuberculous meningitis. Medicine (Baltimore) 2015; 94:e404. [PMID: 25621686 PMCID: PMC4602633 DOI: 10.1097/md.0000000000000404] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Most of the information about spinal cord and nerve root involvement in tuberculous meningitis is available in the form of isolated case reports or case series. In this article, we evaluated the incidence, predictors, and prognostic impact of spinal cord and spinal nerve root involvement in tuberculous meningitis.In this prospective study, 71 consecutive patients of newly diagnosed tuberculous meningitis were enrolled. In addition to clinical evaluation, patients were subjected to magnetic resonance imaging (MRI) of brain and spine. Patients were followed up for at least 6 months.Out of 71 patients, 33 (46.4%) had symptoms/signs of spinal cord and spinal nerve root involvement, 22 (30.9%) of whom had symptoms/signs at enrolment. Eleven (15.4%) patients had paradoxical involvement. Paraparesis was present in 22 (31%) patients, which was of upper motor neuron type in 6 (8.4%) patients, lower motor neuron type in 10 (14%) patients, and mixed type in 6 (8.4%) patients. Quadriparesis was present in 3 (4.2%) patients. The most common finding on spinal MRI was meningeal enhancement, seen in 40 (56.3%) patients; in 22 (30.9%), enhancement was present in the lumbosacral region. Other MRI abnormalities included myelitis in 16 (22.5%), tuberculoma in 4 (5.6%), cerebrospinal fluid (CSF) loculations in 4 (5.6%), cord atrophy in 3 (4.2%), and syrinx in 2 (2.8%) patients. The significant predictor associated with myeloradiculopathy was raised CSF protein (>250 mg/dL). Myeloradiculopathy was significantly associated with poor outcome.In conclusion, spinal cord and spinal nerve root involvement in tuberculous meningitis is common. Markedly raised CSF protein is an important predictor. Patients with myeloradiculopathy have poor outcome.
Collapse
Affiliation(s)
- Rahul Gupta
- From the Department of Neurology (RG, RKG, HSM, RV, PKS); and Department of Microbiology (AJ), King George Medical University, Lucknow, Uttar Pradesh, India
| | | | | | | | | | | |
Collapse
|
22
|
Yu HY, Hu FS, Xiang DR, Sheng JF. Clinical management of tuberculous meningitis: experiences of 42 cases and literature review. Neurol Sci 2013; 35:303-5. [DOI: 10.1007/s10072-013-1606-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 12/10/2013] [Indexed: 10/25/2022]
|
23
|
Abstract
Distal symmetric polyneuropathy (DSP) related to human immunodeficiency virus (HIV) is one of the most common neurologic complications of HIV, possibly affecting as many as 50% of all individuals infected with HIV. Two potentially neurotoxic mechanisms have been proposed to play a crucial role in the pathogenesis of HIV DSP: neurotoxicity resulting from the virus and its products; as well as adverse neurotoxic effects of medications used in the treatment of HIV. Clinically, HIV DSP is characterized by a combination of signs and symptoms that include decreased deep tendon reflexes at the ankles and decreased sensation in the distal extremities as well as paresthesias, dysesthesias, and pain in a symmetric stocking-glove distribution. These symptoms are generally static or slowly progressive over time, and depending on the severity, may interfere significantly with the patient's daily activities. In addition to the clinical picture, nerve conduction studies and skin biopsies are often pursued to support the diagnosis of HIV DSP. Anticonvulsants, antidepressants, topical agents, and nonspecific analgesics may help relieve neuropathic pain. Specifically, gabapentin, lamotrigine, pregabalin, amitriptyline, duloxetine, and high-dose topical capsaicin patches have been used in research and clinical practice. Further research is needed to elucidate the pathogenesis of HIV DSP, thus facilitating the development of novel treatment strategies. This review discusses the epidemiology, pathophysiology, clinical findings, diagnosis, and management of DSP in the setting of HIV.
Collapse
Affiliation(s)
- Sonja G Schütz
- Department of Neurology, Mount Sinai School of Medicine, New York, NY, USA
| | | |
Collapse
|
24
|
Abstract
Tuberculous radiculomyelitis is an uncommon but serious complication of tuberculosis that can lead to considerable morbidity and mortality. We present the case of a 21-month-old male Congolese refugee diagnosed with tuberculous radiculomyelitis who presented with gradual motor and speech regression, and likely an infection-related seizure 2 months before diagnosis.
Collapse
|
25
|
Abstract
Peripheral nerve disorders are associated with all stages of HIV infection. Distal sensory polyneuropathy is characterised by often-disabling pain that is difficult to treat. It is prevalent in both high-income and low-income settings. In low-income settings, use of potentially neurotoxic antiretrovirals, which are inexpensive and widely available, contributes substantially to incidence. Research has focused on identification of factors that predict risk of distal sensory polyneuropathy and elucidation of the multifactorial mechanisms behind pathogenesis. Sensorimotor polyneuropathies and polyradiculopathies are less frequent than distal sensory polyneuropathy, but still occur in low-income settings and have potentially devastating consequences. However, many of these diseases can be treated successfully with a combination of antiretroviral and immune-modulating therapies. To distinguish between peripheral nerve disorders that have diverse, overlapping, and frequently atypical presentations can be challenging; a framework based on a clinicoanatomical approach might assist in the diagnosis and management of such disorders.
Collapse
|
26
|
Gupta A, Garg RK, Singh MK, Verma R, Malhotra HS, Sankhwar SN, Jain A, Singh R, Parihar A. Bladder dysfunction and urodynamic study in tuberculous meningitis. J Neurol Sci 2013; 327:46-54. [PMID: 23472924 DOI: 10.1016/j.jns.2013.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 01/11/2013] [Accepted: 02/12/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Micturitional disturbances in tuberculous meningitis have been reported infrequently and that too without urodynamic studies. Bladder dysfunction in tuberculous meningitis is often considered secondary to tuberculous radiculomyelopathy. We, in this study, evaluated the incidence and pattern of bladder dysfunction in tuberculous meningitis. MATERIALS AND METHOD In this prospective study, 51 patients were included. In addition to clinical evaluation, patients were subjected to a urodynamic study along with magnetic resonance imaging (MRI) of brain and spine. Patients were followed up for 6 months. A follow-up urodynamic study was performed after 6 months. RESULTS Out of 51 patients, urinary symptoms were present in one-third of the patients. Approximately, 70% (36) of the patients had urodynamic abnormalities. The commonest (22/51) urodynamic abnormality was detrusor hyporeflexia/areflexia. Other urodynamic abnormalities were neurogenic detrusor overactivity in 10, detrusor sphincter dyssynergia in 6, normal detrusor activity in 19, reduced bladder sensation in 12, raised cystometric capacity in 9, and larger volumes of post-void residual urine in 12 patients. Six patients were unable to void on command. Three patients with neurogenic detrusor overactivity had leak during study. MRI showed spinal meningeal enhancement in 37, lumbosacral arachnoiditis in 25, myelitis in 12 patients, CSF loculations in 6, and cord atrophy in 5 patients. Spinal arachnoiditis and urinary symptoms showed significant association with urodynamic abnormalities. Follow-up urodynamic study showed resolution of urodynamic abnormalities in 72.6% of the patients with treatment. Seven (28%) patients, with normal baseline urodynamic findings, paradoxically developed new abnormalities. CONCLUSION Bladder dysfunctions, in tuberculous meningitis, are frequently encountered. A significant association exists between urodynamic abnormalities and tuberculous lumbosacral arachnoiditis and myeloradiculopathy.
Collapse
Affiliation(s)
- Arvind Gupta
- Department of Neurology, King George Medical University, Uttar Pradesh, Lucknow, India
| | | | | | | | | | | | | | | | | |
Collapse
|
27
|
|
28
|
|
29
|
Sridhar A, Bhandari JK, Lewis G, Ganesan S, Parepalli S, Abulhoul L. Tuberculous radiculomyelitis presenting as urinary retention in a child with Down's syndrome. BMJ Case Rep 2012; 2012:bcr.10.2011.5005. [PMID: 22602831 DOI: 10.1136/bcr.10.2011.5005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Tuberculous radiculomyelitis (TBRM) is an uncommon complication of TB meningitis. The authors report the case of a 10-year-old Asian girl with trisomy 21, who presented with acute urinary retention and fever. She was initially treated for a urinary tract infection. After an acute neurological deterioration she was found to have evidence of TB meningitis with TBRM. She developed acute hydrocephalus requiring ventriculo-peritoneal shunt. She was treated with quadruple antituberculous therapy and high dose intravenous dexamethasone. She needed tracheostomy with continuous positive airway pressure (CPAP) support. Although she showed gradual neurological improvement in her cognitive functions, she persisted to have quadriparesis with the need for tracheostomy and CPAP support overnight and gastrostomy feeding. Acute urinary retention in children is uncommon, and should serve as a 'red flag' to consideration of further underlying neurological problems. This presentation and subsequent events should serve as a learning point to clinicians.
Collapse
Affiliation(s)
- Arani Sridhar
- Children's Hospital, Leicester Royal Infirmary, Leicester, UK.
| | | | | | | | | | | |
Collapse
|
30
|
Zanin A, Sartori S, Salandin M, Laverda AM, Fenicia L, Anniballi F, Cogo PE. A descending cranial nerve palsy during the christmas holidays. Neurohospitalist 2012; 2:66-70. [PMID: 23983866 DOI: 10.1177/1941874412438903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Anna Zanin
- Department of Pediatrics Salus Pueri, University of Padua, Italy
| | | | | | | | | | | | | |
Collapse
|
31
|
Sethi D, Gupta M, Sood S. Cauda equina syndrome after spinal anaesthesia in a patient with asymptomatic tubercular arachnoiditis. Indian J Anaesth 2011; 55:375-7. [PMID: 22013254 PMCID: PMC3190512 DOI: 10.4103/0019-5049.84864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 14-year-old boy underwent emergency debridement surgery of right foot under spinal anaesthesia. Four hours after the surgery, the patient developed symptoms of cauda equina syndrome (CES). Postoperative magnetic resonance imaging of the patient's spine suggested underlying tubercular arachnoiditis. The boy was started on intravenous methylprednisolone and antitubercular therapy. He responded to the therapy and recovered completely in 2 weeks without any residual neurological deficits. We suggest that underlying pathological changes in the subarachnoid space due to tubercular arachnoiditis contributed to maldistribution of the local anaesthetic drug leading to CES.
Collapse
Affiliation(s)
- Divya Sethi
- Department of Anaesthesia and Intensive Care, Employees' State Insurance Postgraduate Institute of Medical Sciences and Research (ESIC PGIMSR), Basaidarapur, New Delhi, India
| | | | | |
Collapse
|
32
|
Nelson CA, Zunt JR. Tuberculosis of the central nervous system in immunocompromised patients: HIV infection and solid organ transplant recipients. Clin Infect Dis 2011; 53:915-26. [PMID: 21960714 DOI: 10.1093/cid/cir508] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Central nervous system (CNS) tuberculosis (TB) is a devastating infection with high rates of morbidity and mortality worldwide and may manifest as meningitis, tuberculoma, abscess, or other forms of disease. Immunosuppression, due to either human immunodeficiency virus infection or solid organ transplantation, increases susceptibility for acquiring or reactivating TB and complicates the management of underlying immunosuppression and CNS TB infection. This article reviews how immunosuppression alters the clinical presentation, diagnosis, treatment, and outcome of TB infections of the CNS.
Collapse
Affiliation(s)
- Christina A Nelson
- Department of Neurology, Global Health, Medicine, and Epidemiology, University of Washington School of Medicine, Seattle, Washington, USA
| | | |
Collapse
|
33
|
Konar SK, Rao KN, Mahadevan A, Devi BI. Tuberculous lumbar arachnoiditis mimicking conus cauda tumor: A case report and review of literature. J Neurosci Rural Pract 2011; 2:93-6. [PMID: 21716842 PMCID: PMC3123009 DOI: 10.4103/0976-3147.80098] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Tuberculous spinal arachnoiditis involving cauda equina is rare. A patient with lumbar tuberculous arachnoiditis in the absence of both vertebral and meningeal tuberculosis, which was mimicking spinal intradural extramedullary tumor is described here. Diagnosis was made based on intraoperative findings and was confirmed by histopathology. Surgical decompression along with a combination of steroid and antitubercular therapy resulted in a good outcome. At 3 months follow-up, the patient regained bladder control and was able to walk with support. Clinical features, magnetic resonance imaging, and intraoperative findings are described. Pathology and the relevant literature are discussed. Based on the patient's clinical and radiologic findings, it was believed that the patient had a conus cauda tumor and was operated on. Histologic examination of the mass revealed tuberculoma. Surgical decompression followed by antituberculosis medication resulted in good outcome. Hence tuberculous arachnoiditis should be considered in differential diagnosis of conus cauda tumors.
Collapse
Affiliation(s)
- Subhas K Konar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | | | | | | |
Collapse
|
34
|
Marais S, Pepper DJ, Marais BJ, Török ME. HIV-associated tuberculous meningitis--diagnostic and therapeutic challenges. Tuberculosis (Edinb) 2010; 90:367-74. [PMID: 20880749 DOI: 10.1016/j.tube.2010.08.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Revised: 06/15/2010] [Accepted: 08/29/2010] [Indexed: 10/19/2022]
Abstract
HIV-associated tuberculous meningitis (TBM) poses significant diagnostic and therapeutic challenges and carries a dismal prognosis. In this review, we present the clinical features and management of HIV-associated TBM, and compare this to disease in HIV-uninfected individuals. Although the clinical presentation, laboratory findings and radiological features of TBM are similar in HIV-infected and HIV-uninfected patients, some important differences exist. HIV-infected patients present more frequently with extra-meningeal tuberculosis and systemic features of HIV infection. In HIV-associated TBM, clinical course and outcome are influenced by profound immunosuppression at presentation, emphasising the need for earlier diagnosis of HIV infection and initiation of antiretroviral treatment.
Collapse
Affiliation(s)
- Suzaan Marais
- Department of Medicine, GF Jooste Hospital, Manenberg 7764, South Africa.
| | | | | | | |
Collapse
|
35
|
Anderson N, Somaratne J, Mason D, Holland D, Thomas M. Neurological and systemic complications of tuberculous meningitis and its treatment at Auckland City Hospital, New Zealand. J Clin Neurosci 2010; 17:1114-8. [DOI: 10.1016/j.jocn.2010.01.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Accepted: 01/03/2010] [Indexed: 02/08/2023]
|
36
|
Abstract
Tuberculous meningitis is a severe form of extrapulmonary tuberculosis. The exact incidence and prevalence are not known. In countries with high burden of pulmonary tuberculosis, the incidence is expected to be proportionately high. Children are much more vulnerable. Human immunodeficiency virus-infected patients have a high incidence of tuberculous meningitis. The hallmark pathological processes are meningeal inflammation, basal exudates, vasculitis and hydrocephalus. Headache, vomiting, meningeal signs, focal deficits, vision loss, cranial nerve palsies and raised intracranial pressure are dominant clinical features. Diagnosis is based on the characteristic clinical picture, neuroimaging abnormalities and cerebrospinal fluid changes (increased protein, low glucose and mononuclear cell pleocytosis). Cerebrospinal fluid smear examination, mycobacterial culture or polymerase chain reaction is mandatory for bacteriological confirmation. The mortality and morbidity of tuberculous meningitis are exceptionally high. Prompt diagnosis and early treatment are crucial. Decision to start antituberculous treatment is often empirical. WHO guidelines recommend a 6 months course of antituberculous treatment; however, other guidelines recommend a prolonged treatment extended to 9 or 12 months. Corticosteroids reduce the number of deaths. Resistance to antituberculous drugs is associated with a high mortality. Patients with hydrocephalus may need ventriculo-peritoneal shunting. Bacillus Calmette-Guérin vaccination protects to some degree against tuberculous meningitis in children.
Collapse
Affiliation(s)
- R K Garg
- Department of Neurology, Chhatrapati Shahuji Maharaj Medical University, Uttar Pradesh, Lucknow, India.
| |
Collapse
|
37
|
|
38
|
Paraplegia due to non-osseous spinal tuberculosis: report of three cases and review of the literature. Int J Infect Dis 2008; 12:425-9. [DOI: 10.1016/j.ijid.2007.12.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2007] [Revised: 09/23/2007] [Accepted: 12/11/2007] [Indexed: 11/20/2022] Open
|
39
|
Lunn MPT, Clarke C, Aldeen T. Acute paraplegia in a patient with AIDS and a normal CSF examination. J Hosp Med 2008; 3:279-80. [PMID: 18571806 DOI: 10.1002/jhm.303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We report a case of tuberculous myeloradiculitis in a patient with AIDS. The case highlights the difficulty in reaching a diagnosis for the neurological symptoms of a patient with a normal CSF examination and the need for HIV screening of immune-compromised patients with myeloradiculitis.
Collapse
Affiliation(s)
- M P T Lunn
- National Hospital for Neurology and Neurosurgery, London, UK
| | | | | |
Collapse
|
40
|
Abdelmalek R, Kanoun F, Kilani B, Tiouiri H, Zouiten F, Ghoubantini A, Chaabane TB. Tuberculous meningitis in adults: MRI contribution to the diagnosis in 29 patients. Int J Infect Dis 2006; 10:372-7. [PMID: 16839793 DOI: 10.1016/j.ijid.2005.07.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2004] [Revised: 05/09/2005] [Accepted: 07/12/2005] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Tuberculous meningitis (TBM) is a life-threatening disease and is difficult to diagnose. We aim to promote the role of magnetic resonance imaging (MRI) in TBM diagnosis and survey. DESIGN AND METHODS This was a retrospective study undertaken between 1996 and 2003 in which we reviewed all cases of TBM that had undergone cerebral computed tomography (CT) and MRI performed with and without contrast. RESULTS We reviewed 29 patients; all had had subacute lymphocytic meningitis. Diagnosis was definite in only 11 cases and presumptive in 18 cases. MRI was performed showing one or more abnormalities in 26 cases. The use of MRI allowed the detection of CNS lesions in both brain and spine. CONCLUSION Cerebrospinal MRI performed when TBM is suspected aids in its diagnosis and is also a useful means of monitoring the course of the disease under treatment.
Collapse
Affiliation(s)
- Rim Abdelmalek
- Infectious Diseases Department, La Rabta Hospital, 1007, Jebari, Tunis, Tunisia
| | | | | | | | | | | | | |
Collapse
|
41
|
Wasay M, Arif H, Khealani B, Ahsan H. Neuroimaging of Tuberculous Myelitis: Analysis of Ten Cases and Review of Literature. J Neuroimaging 2006; 16:197-205. [PMID: 16808820 DOI: 10.1111/j.1552-6569.2006.00032.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
We retrospectively reviewed the clinical and neuroimaging features of 10 patients with tuberculous myelitis. The most common presenting symptoms were fever (70%) and paraplegia (60%). Bladder and bowel symptoms were present in 90% patients. On MRI, the involvement of the cervical/thoracic segment of the spinal cord was most commonly seen (90%). The most consistent finding was hyperintense signals on T2-weighted MRI. T1-weighted images showed isointense (n= 5) and hypointense (n= 4) signals in the spinal cord lesions. Post-contrast enhancement was present in 6 patients, epidural enhancement in 4 patients, and cord swelling in 2 patients. We reviewed more than 250 published cases with the diagnosis of tuberculous myelitis and radiculomyelitis with special attention to MRI findings. It is predominantly a disease of the thoracic spinal cord. Most spinal cord lesions appear as hyperintense on T2 and iso- or hypointense on T1-weighted images. MRI findings in patients with spinal cord tuberculosis have both diagnostic and prognostic significance. Cord atrophy or cavitation and the presence of syrinx on MRI may be associated with poor outcome.
Collapse
Affiliation(s)
- Mohammad Wasay
- Department of Neurology, The Aga Khan University, Stadium Road, Karachi 74800, Pakistan.
| | | | | | | |
Collapse
|
42
|
Arméstar F, Coll-Cantí J, Capellades J, Batlle M. [Tuberculous myelitis with paraplegia]. Med Clin (Barc) 2006; 126:556-7. [PMID: 16756912 DOI: 10.1157/13087147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
43
|
Sree Harsha CK, Shetty AP, Rajasekaran S. Intradural spinal tuberculosis in the absence of vertebral or meningeal tuberculosis: a case report. J Orthop Surg (Hong Kong) 2006; 14:71-5. [PMID: 16598092 DOI: 10.1177/230949900601400116] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We present a patient with spinal intradural tuberculosis in the absence of both vertebral and meningeal tuberculosis. Diagnosis was made based on intra-operative findings and was confirmed by histopathology. Early surgical decompression along with a combination of steroid and antitubercular therapy resulted in a good outcome. At 26-month follow-up, the patient regained bladder control and was able to walk with support. Clinical features, magnetic resonance imaging, and intra-operative findings are described. Pathology and the relevant literature are discussed.
Collapse
Affiliation(s)
- C K Sree Harsha
- Department of Orthopaedics and Spinal Surgery, Ganga Hospital, Coimbatore, South India
| | | | | |
Collapse
|
44
|
Estanislao LB, Morgello S, Simpson DM. Peripheral neuropathies associated with HIV and hepatitis C co-infection: a review. AIDS 2005; 19 Suppl 3:S135-9. [PMID: 16251810 DOI: 10.1097/01.aids.0000192082.41561.49] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Co-infection with HIV and hepatitis C has become increasingly prevalent. It is a major source of morbidity in HIV-infected populations. Distal symmetric polyneuropathy is the most common form of peripheral neuropathy in HIV as well as hepatitis C mono-infection. There is considerable overlap in the symptoms and signs of HIV and hepatitis C neuropathy. It is not known whether there are additive or synergistic effects on the peripheral nerve by these two viruses. There is a need for studies to further elucidate the mechanisms involved.
Collapse
Affiliation(s)
- Lydia B Estanislao
- Department of Neurology (NeuroAIDS Research Program), Mount Sinai Medical Center, New York, NY 10029, USA
| | | | | |
Collapse
|
45
|
Roca B. Intradural extramedullary tuberculoma of the spinal cord: a review of reported cases. J Infect 2005; 50:425-31. [PMID: 15907551 DOI: 10.1016/j.jinf.2004.07.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2004] [Accepted: 07/19/2004] [Indexed: 10/26/2022]
Abstract
Intradural extramedullary tuberculoma of the spinal cord (IETSC) is a rare modality of tuberculosis, with only a few cases described so far. Here we review 22 reports of the disease found in the literature of the last 25 years. IETSC is closely associated with tuberculous meningitis (TM). Both conditions may occur simultaneously, but more frequently IETSC is preceded by TM. IETSC has been described in a predominantly young population of both genders. The pathogenesis is unknown, although a paradoxical reaction to antituberculous medication is a reasonable possibility. The disease presents insidiously with paraparesis, hypoesthesia with a sensory level, and bladder dysfunction, due to cord involvement or compression by the inflammatory process. Permanent paraparesis is a common sequela. MRI is the diagnostic technique of choice in IETSC. Prompt surgical excision of the tuberculoma is the cornerstone of therapy. Antituberculous treatment is also indicated; unless resistance is present, conventional chemotherapy is probably enough. Corticosteroids are also generally recommended. In conclusion, IETSC is a rare complication of TM, which presents insidiously, despite adequate antituberculous treatment. To avoid the permanent disability that this condition may provoke, an early diagnosis and prompt treatment is critical.
Collapse
Affiliation(s)
- Bernardino Roca
- Infectious Disease Division, Department of Medicine, Hospital General of Castellon, Castellon, Spain.
| |
Collapse
|
46
|
Rabar D, Issartel B, Petiot P, Boibieux A, Chidiac C, Peyramond D. Tuberculomes et méningoradiculite tuberculeuse d’évolution paradoxale sous traitement. Presse Med 2005; 34:32-4. [PMID: 15685096 DOI: 10.1016/s0755-4982(05)83881-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Neuromeningeal tuberculosis of deleterious, paradoxical, progression despite appropriate antibiotic therapy is rare. OBSERVATION An immunocompetent woman exhibited an immediately disseminated form of tuberculosis with progressive neurological involvement associating expanding intracranial tuberculomas and meningeal-radiculitis despite adapted anti-tuberculosis quadritherapy. DISCUSSION During anti-tuberculosis therapy clinical worsening is rare, particularly when 2 different manifestations are associated and the worsening occurs in an immunocompetent patient. This possibility should be systematically evoked in such cases. The explanation of this phenomenon is still unclear.
Collapse
Affiliation(s)
- D Rabar
- Service de maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Lyon
| | | | | | | | | | | |
Collapse
|
47
|
Abstract
PURPOSE Central nervous system (CNS) tuberculosis remains a public health problem, particularly in developing countries. The aim of this study is to characterize neuroradiologic findings of various intracranial lesions. METHODS We retrospectively reviewed data of 122 patients with CNS tuberculosis, without immunosuppression. CT scan was performed in all patients, whereas 17 patients had CT scan and MRI. RESULTS We included 74 women (61%) and 48 men (39%) with a mean age of 37 years (17 -88y). 18 patients (14,7%) had a history of tuberculosis. Tuberculous meningitis was the most frequent clinical presentation (119 cases). Mycobacterium tuberculosis was isolated in cerebrospinal fluid of 18 patients (15%). Several types of lesions were identified : hydrocephalus (35 cases), tuberculomas (29 cases), leptomeningitis (26 cases), infarction (15 cases), abcesses (2 cases). Hydrocephalus was associated to other lesions in 26 cases. Communication hydrocephalus was present in 28 cases. Multiple tuberculomas were seen in 23 cases (80%), with miliary aspects in some cases. In 3 cases, tuberculoma was present without meningitis. Patients with leptomeningitis showed thick meningeal contrast enhancement involving all basal cisterns. Infarction resulted from arterial englobement or embols, and involved the area of middle cerebral artery (12 cases). CONCLUSION Central nervous system tuberculosis has different appearences, mostly hydrocephalus and tuberculomas. MR with contrast is necessary for diagnosis and for follow-up during treatment.
Collapse
|
48
|
Eroles Vega G, Castro Vilanova MD, Mendivil Ferrer M, Gómez Rodrigo J, Lacambra Calvet C, Ruiz-Capillas JJ, Quiñones D. [Arachnoiditis and intraspinal lesion. Complications of tuberculous meningitis in 2 patients with human immunodeficiency virus infection]. Rev Clin Esp 2001; 201:575-8. [PMID: 11817224 DOI: 10.1016/s0014-2565(01)70917-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Radiculomyelitis (arachnoiditis) (RMA) is a severe complication of tuberculous meningitis (TM). Two patients with HIV infection and TM are here reported. These patients developed RMA. In Spain only four cases of RMA have previously been reported (only one of them was HIV-positive). Clinical manifestations (subacute paraplegia, radicular pain, sensitive level and neurogenic bladder) are reported. Cerebrospinal fluid had inflammatory features, wit predominance of mononuclear cells and remarkable increase in protein content. Magnetic resonance imaging (MRI) is the most suitable diagnostic method. The therapeutic possibilities of this complication are discussed.
Collapse
Affiliation(s)
- G Eroles Vega
- Servicio de Medicina Interna, Hospital Severo Ochoa, Avenida de Orellana, s/n. 28911 Leganés, Madrid
| | | | | | | | | | | | | |
Collapse
|
49
|
Wendel KA, Alwood KS, Gachuhi R, Chaisson RE, Bishai WR, Sterling TR. Paradoxical worsening of tuberculosis in HIV-infected persons. Chest 2001; 120:193-7. [PMID: 11451837 DOI: 10.1378/chest.120.1.193] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE To determine the incidence of paradoxical worsening of tuberculosis (TB) in HIV-infected persons. DESIGN Observational cohort study. SETTING Public, urban TB clinic. PATIENTS HIV-infected persons treated for TB between January 1, 1996, and December 31, 1999, and followed through June 30, 2000. INTERVENTION Patients received standard anti-TB therapy. Antiretroviral therapy was provided by primary medical providers. Patients receiving antiretroviral therapy were given nucleoside reverse transcriptase inhibitors alone or highly active antiretroviral therapy (HAART; nucleoside reverse transcriptase inhibitors in combination with a protease inhibitor or a nonnucleoside reverse transcriptase inhibitor). MAIN OUTCOME MEASURE Paradoxical worsening of TB. RESULTS There were 82 TB cases in 76 patients. Paradoxical worsening was identified in 6 of 82 cases (7%; 95% confidence interval, 3 to 15%). Paradoxical worsening occurred in 3 of 28 cases (11%) in patients receiving HAART and in 3 of 44 cases (7%) in patients not receiving antiretroviral therapy (p = 0.67). Cases complicated by paradoxical worsening were more likely to have both pulmonary and extrapulmonary disease at initial diagnosis than cases without paradoxical worsening (83% vs 24%; p = 0.006). TB relapse occurred in 2 of 6 cases (33%) in patients with paradoxical worsening and in 4 of 76 cases (5%) in patients without paradoxical worsening (p = 0.06). CONCLUSIONS Paradoxical worsening of TB occurred less frequently than in previous reports and was not associated with HAART. Paradoxical worsening also appeared to be associated with an increased risk of TB relapse. Further studies are warranted to better characterize the risk factors for paradoxical worsening and the appropriate duration of anti-TB therapy in patients in whom it occurs.
Collapse
Affiliation(s)
- K A Wendel
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore 21287, USA.
| | | | | | | | | | | |
Collapse
|
50
|
Cheng VCC, Yuen KY. Reply. Clin Infect Dis 2001. [DOI: 10.1086/319233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
|