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Shi Y, Zhang C, Pan S, Chen Y, Miao X, He G, Wu Y, Ye H, Weng C, Zhang H, Zhou W, Yang X, Liang C, Chen D, Hong L, Su F. The diagnosis of tuberculous meningitis: advancements in new technologies and machine learning algorithms. Front Microbiol 2023; 14:1290746. [PMID: 37942080 PMCID: PMC10628659 DOI: 10.3389/fmicb.2023.1290746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/09/2023] [Indexed: 11/10/2023] Open
Abstract
Tuberculous meningitis (TBM) poses a diagnostic challenge, particularly impacting vulnerable populations such as infants and those with untreated HIV. Given the diagnostic intricacies of TBM, there's a pressing need for rapid and reliable diagnostic tools. This review scrutinizes the efficacy of up-and-coming technologies like machine learning in transforming TBM diagnostics and management. Advanced diagnostic technologies like targeted gene sequencing, real-time polymerase chain reaction (RT-PCR), miRNA assays, and metagenomic next-generation sequencing (mNGS) offer promising avenues for early TBM detection. The capabilities of these technologies are further augmented when paired with mass spectrometry, metabolomics, and proteomics, enriching the pool of disease-specific biomarkers. Machine learning algorithms, adept at sifting through voluminous datasets like medical imaging, genomic profiles, and patient histories, are increasingly revealing nuanced disease pathways, thereby elevating diagnostic accuracy and guiding treatment strategies. While these burgeoning technologies offer hope for more precise TBM diagnosis, hurdles remain in terms of their clinical implementation. Future endeavors should zero in on the validation of these tools through prospective studies, critically evaluating their limitations, and outlining protocols for seamless incorporation into established healthcare frameworks. Through this review, we aim to present an exhaustive snapshot of emerging diagnostic modalities in TBM, the current standing of machine learning in meningitis diagnostics, and the challenges and future prospects of converging these domains.
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Affiliation(s)
- Yi Shi
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
- The First School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Chengxi Zhang
- School of Materials Science and Engineering, Shandong Jianzhu University, Jinan, China
| | - Shuo Pan
- The First School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Yi Chen
- The First School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Xingguo Miao
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
- Department of Infectious Diseases, Wenzhou Sixth People’s Hospital, Wenzhou, China
- Wenzhou Key Laboratory of Diagnosis and Treatment of Emerging and Recurrent Infectious Diseases, Wenzhou, China
| | - Guoqiang He
- Postgraduate Training Base Alliance of Wenzhou Medical University, Wenzhou, China
- Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, China
| | - Yanchan Wu
- School of Electrical and Information Engineering, Quzhou University, Quzhou, China
| | - Hui Ye
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
- Department of Infectious Diseases, Wenzhou Sixth People’s Hospital, Wenzhou, China
- Wenzhou Key Laboratory of Diagnosis and Treatment of Emerging and Recurrent Infectious Diseases, Wenzhou, China
| | - Chujun Weng
- The Fourth Affiliated Hospital Zhejiang University School of Medicine, Yiwu, China
| | - Huanhuan Zhang
- School and Hospital of Stomatology, Wenzhou Medical University, Wenzhou, China
| | - Wenya Zhou
- School and Hospital of Stomatology, Wenzhou Medical University, Wenzhou, China
| | - Xiaojie Yang
- Wenzhou Medical University Renji College, Wenzhou, China
| | - Chenglong Liang
- The First School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Dong Chen
- Wenzhou Key Laboratory of Diagnosis and Treatment of Emerging and Recurrent Infectious Diseases, Wenzhou, China
- Wenzhou Central Blood Station, Wenzhou, China
| | - Liang Hong
- Department of Infectious Diseases, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Feifei Su
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
- Department of Infectious Diseases, Wenzhou Sixth People’s Hospital, Wenzhou, China
- Wenzhou Key Laboratory of Diagnosis and Treatment of Emerging and Recurrent Infectious Diseases, Wenzhou, China
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Gupta S, Sinha U, Raj A. Severe Paradoxical Manifestations in an Immunocompetent Young Female With Tuberculous Meningitis. Cureus 2022; 14:e29953. [PMID: 36348841 PMCID: PMC9635577 DOI: 10.7759/cureus.29953] [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] [Accepted: 10/05/2022] [Indexed: 11/05/2022] Open
Abstract
A paradoxical reaction, in patients with tuberculous meningitis, is described as either worsening of pre-existing tuberculous lesions or the appearance of new tuberculous lesions after initial improvement with anti-tuberculosis treatment. The condition is often difficult to predict. When severe, it may also result in considerable neurological morbidity and even death. We aim to report such a rare case of severe paradoxical response in a young female with tuberculous meningitis. An 18-year-old female developed severe headache, vomiting, altered sensorium, decreased vision, and paraparesis. She was on anti-tuberculosis treatment (ATT) for tuberculous meningitis for the past two months. Radiological findings revealed tuberculomas in the left cerebral and cerebellar hemispheres, adhesive arachnoiditis in the cervical spine, and moderate communicating hydrocephalus. Visual evoked potential tests provided electrophysiological evidence of optic neuropathy in the left eye. The appearance of new (tuberculoma and adhesive arachnoiditis in the cervical spine), as well as aggravation of pre-existing tuberculous lesions (worsened hydrocephalus and worsened clinical features), were evident in the patient, suggestive of severe paradoxical response (with HIV negative serology). The patient was treated with corticosteroids, and antibiotics, and continued the ATT programme in a conservative manner. Nonetheless, as the patient had severe CNS manifestations, severe disabilities (poor vision, paraparesis, or quadriparesis) and fatalities were inevitable. Notwithstanding, it is crucial to recognize the paradoxical manifestations of tuberculous meningitis to avoid misleading diagnoses and unwarranted management strategies.
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Kiyani M, Hodges SE, Adil SM, Charalambous LT, Liu B, Lee HJ, Parente B, Perfect JR, Lad SP. Outcomes and Health Care Resource Utilization of Adult Bacterial Meningitis in the United States. Neurol Clin Pract 2021; 11:117-126. [PMID: 33842064 PMCID: PMC8032422 DOI: 10.1212/cpj.0000000000000868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 04/02/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To examine the longitudinal health care resource utilization, in-hospital mortality, and incidence of downstream complications of bacterial meningitis in the United States. METHODS Using IBM MarketScan, we retrieved data on adult patients with a diagnosis of bacterial meningitis admitted to a US hospital between 2008 and 2015. Patients were stratified into groups (1) with/without prior head trauma/neurosurgical complications, (2) nosocomial/community acquisition, and (3) Gram-negative/positive bacteria. Cost data were collected for up to 2 years and analyzed with descriptive statistics and longitudinal modeling. RESULTS Among 4,496 patients with bacterial meningitis, 16.5% and 4.6% had preceding neurosurgical complications and head injuries, respectively. Lumbar punctures were performed in 37.3% of patients without prior trauma/complications who went on to develop nosocomial meningitis, and those with prior head injuries or complications had longer initial hospital stays (17.0 days vs 8.0 days). Within a month of diagnosis, 29.2% of patients with bacterial meningitis had experienced downstream complications, most commonly hydrocephalus (12.7%). The worst 30-day mortality was due to tuberculous (12.3%) and streptococcal meningitis (7.2%). Overall, prior head trauma and complications were associated with higher costs. Community-acquired bacterial meningitis had lower median baseline costs relative to the nosocomial group (no head trauma/complication: $17,152 vs $82,778; head trauma/complication: $92,428 vs $168,309) but higher median costs within 3 months of diagnosis (no head trauma/complication: $47,911 vs $34,202; head trauma/complication: $89,207 vs $58,947). All costs demonstrated a sharp decline thereafter. CONCLUSIONS Bacterial meningitis remains costly and devastating, especially for those who experience traumatic head injuries or have a complicated progress after neurosurgery.
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Affiliation(s)
- Musa Kiyani
- Department of Neurosurgery (MK, SEH, SMA, LTC, BP, SPL), Department of Biostatistics and Bioinformatics (BL, H-JL), and Division of Infectious Diseases, Department of Medicine (JRP), Duke University Medical Center, Durham, NC
| | - Sarah E Hodges
- Department of Neurosurgery (MK, SEH, SMA, LTC, BP, SPL), Department of Biostatistics and Bioinformatics (BL, H-JL), and Division of Infectious Diseases, Department of Medicine (JRP), Duke University Medical Center, Durham, NC
| | - Syed M Adil
- Department of Neurosurgery (MK, SEH, SMA, LTC, BP, SPL), Department of Biostatistics and Bioinformatics (BL, H-JL), and Division of Infectious Diseases, Department of Medicine (JRP), Duke University Medical Center, Durham, NC
| | - Lefko T Charalambous
- Department of Neurosurgery (MK, SEH, SMA, LTC, BP, SPL), Department of Biostatistics and Bioinformatics (BL, H-JL), and Division of Infectious Diseases, Department of Medicine (JRP), Duke University Medical Center, Durham, NC
| | - Beiyu Liu
- Department of Neurosurgery (MK, SEH, SMA, LTC, BP, SPL), Department of Biostatistics and Bioinformatics (BL, H-JL), and Division of Infectious Diseases, Department of Medicine (JRP), Duke University Medical Center, Durham, NC
| | - Hui-Jie Lee
- Department of Neurosurgery (MK, SEH, SMA, LTC, BP, SPL), Department of Biostatistics and Bioinformatics (BL, H-JL), and Division of Infectious Diseases, Department of Medicine (JRP), Duke University Medical Center, Durham, NC
| | - Beth Parente
- Department of Neurosurgery (MK, SEH, SMA, LTC, BP, SPL), Department of Biostatistics and Bioinformatics (BL, H-JL), and Division of Infectious Diseases, Department of Medicine (JRP), Duke University Medical Center, Durham, NC
| | - John R Perfect
- Department of Neurosurgery (MK, SEH, SMA, LTC, BP, SPL), Department of Biostatistics and Bioinformatics (BL, H-JL), and Division of Infectious Diseases, Department of Medicine (JRP), Duke University Medical Center, Durham, NC
| | - Shivanand P Lad
- Department of Neurosurgery (MK, SEH, SMA, LTC, BP, SPL), Department of Biostatistics and Bioinformatics (BL, H-JL), and Division of Infectious Diseases, Department of Medicine (JRP), Duke University Medical Center, Durham, NC
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Spekker O, Hunt DR, Berthon W, Paja L, Molnár E, Pálfi G, Schultz M. Tracking down the White Plague. Chapter three: Revision of endocranial abnormally pronounced digital impressions as paleopathological diagnostic criteria for tuberculous meningitis. PLoS One 2021; 16:e0249020. [PMID: 33740029 PMCID: PMC7978373 DOI: 10.1371/journal.pone.0249020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/10/2021] [Indexed: 11/26/2022] Open
Abstract
Abnormally pronounced digital impressions (APDIs) on the endocranial surface develop secondary to a prolonged rise in the intracranial pressure. This can result from a number of pathological conditions, including hydrocephalus due to tuberculous meningitis (TBM). APDIs have been described with relation to TBM not only in the modern medical literature but also in several paleopathological studies. However, APDIs are not pathognomonic for TBM and their diagnostic value for identifying TBM in past human populations has not been evaluated in identified pre-antibiotic era skeletons. To assess the diagnostic value of APDIs for the first time, a macroscopic investigation was performed on skeletons from the Terry Collection (Smithsonian Institution, Washington, DC, USA). Our material consisted of 234 skeletons with tuberculosis (TB) as the cause of death (TB group) and 193 skeletons with non-tuberculous (NTB) causes of death (NTB group). The macroscopic examination focused on the stage of the prominence and frequency of APDIs in the TB group and NTB group. To determine the significance of difference (if any) in the frequency of APDIs between the two groups, χ2 testing of our data was conducted. We found that APDIs were twice as common in the TB group than in the NTB group. The χ2 comparison of the frequencies of APDIs revealed a statistically significant difference between the two groups. In addition, APDIs with more pronounced stages were recorded more frequently in the TB group. Our results indicate that APDIs can be considered as diagnostic criteria for TBM in the paleopathological practice. With suitable circumspection, their utilization provides paleopathologists with a stronger basis for identifying TB and consequently, with a more sensitive means of assessing TB frequency in past human populations.
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Affiliation(s)
- Olga Spekker
- Department of Biological Anthropology, University of Szeged, Szeged, Hungary
| | - David R. Hunt
- Department of Anthropology, National Museum of Natural History, Smithsonian Institution, Washington, District of Columbia, United States of America
| | - William Berthon
- Department of Biological Anthropology, University of Szeged, Szeged, Hungary
- Chaire d’Anthropologie Biologique Paul Broca, École Pratique des Hautes Études (EPHE), PSL University, Paris, France
| | - László Paja
- Department of Biological Anthropology, University of Szeged, Szeged, Hungary
| | - Erika Molnár
- Department of Biological Anthropology, University of Szeged, Szeged, Hungary
| | - György Pálfi
- Department of Biological Anthropology, University of Szeged, Szeged, Hungary
| | - Michael Schultz
- Institut für Anatomie und Embryologie, Zentrum Anatomie, Universitätsmedizin Göttingen, Göttingen, Germany
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Rubio-Hernandez M, Ortiz-Alvarez A, Tello-Martinez N, Vazquez-Guevara D, Rodriguez-Leyva I. Hemichorea-Hemiballism: An Uncommon Presentation of Central Nervous System Tuberculosis. Mov Disord Clin Pract 2020; 7:S77-S79. [PMID: 33015230 DOI: 10.1002/mdc3.13063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 06/22/2020] [Accepted: 07/07/2020] [Indexed: 11/07/2022] Open
Affiliation(s)
- Moises Rubio-Hernandez
- Neurology Service, Hospital Central "Dr. Ignacio Morones Prieto", Facultad de Medicina Universidad Autonoma de San Luis Potosí San Luis Potosí Mexico
| | - Arturo Ortiz-Alvarez
- Infectology Service, Hospital Central "Dr. Ignacio Morones Prieto", Facultad de Medicina Universidad Autonoma de San Luis Potosí San Luis Potosí Mexico
| | - Nallely Tello-Martinez
- Neurology Service, Hospital Central "Dr. Ignacio Morones Prieto", Facultad de Medicina Universidad Autonoma de San Luis Potosí San Luis Potosí Mexico
| | - Damaris Vazquez-Guevara
- Neurology Service, Hospital Central "Dr. Ignacio Morones Prieto", Facultad de Medicina Universidad Autonoma de San Luis Potosí San Luis Potosí Mexico
| | - Ildefonso Rodriguez-Leyva
- Neurology Service, Hospital Central "Dr. Ignacio Morones Prieto", Facultad de Medicina Universidad Autonoma de San Luis Potosí San Luis Potosí Mexico.,Infectology Service, Hospital Central "Dr. Ignacio Morones Prieto", Facultad de Medicina Universidad Autonoma de San Luis Potosí San Luis Potosí Mexico
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Spekker O, Schultz M, Paja L, Váradi OA, Molnár E, Pálfi G, Hunt DR. Tracking down the White Plague. Chapter two: The role of endocranial abnormal blood vessel impressions and periosteal appositions in the paleopathological diagnosis of tuberculous meningitis. PLoS One 2020; 15:e0238444. [PMID: 32870917 PMCID: PMC7462305 DOI: 10.1371/journal.pone.0238444] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 08/17/2020] [Indexed: 12/17/2022] Open
Abstract
Although endocranial abnormal blood vessel impressions (ABVIs) and periosteal appositions (PAs) have been considered as paleopathological diagnostic criteria for tuberculous meningitis (TBM) based on findings of previous studies, they are not pathognomonic for tuberculosis (TB). Therefore, their utilization in the paleopathological practice can be questioned, especially in consideration that most of the previous studies were not performed on identified skeletal collections but on osteoarchaeological material and did not include statistical data analysis. To fill the aforementioned research gap, for the first time, a macroscopic investigation was conducted on identified pre-antibiotic era skeletons from the Terry Collection. A sample set of 234 individuals who died of TB (TB group) and 193 individuals who died of non-tuberculous causes (NTB group) were examined. The frequency of ABVIs and PAs, as well as other probable TB-related lesions was recorded. To determine the significance of difference (if any) in the frequencies of ABVIs and PAs between the two groups, χ2 testing of our data was performed. We found that ABVIs, PAs, and their co-occurrence with each other and with other probable TB-related lesions were more common in the TB group than in the NTB group. In addition, the χ2 comparative frequencies of ABVIs and PAs revealed a statistically significant difference between individuals who died of TB and individuals who died of NTB causes. Our findings strengthen those of previous studies that ABVIs and PAs are not specific to TBM but can be of tuberculous origin. Therefore, they do have a diagnostic value in the identification of TB in human osteoarchaeological material, especially when they simultaneously occur with other probable TB-related lesions. Their prudent utilization provides paleopathologists with a stronger basis for diagnosing TB and consequently, a more sensitive means of assessing TB frequency in past human populations.
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Affiliation(s)
- Olga Spekker
- Department of Biological Anthropology, University of Szeged, Szeged, Hungary
- * E-mail:
| | - Michael Schultz
- Institut für Anatomie und Embryologie, Zentrum Anatomie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - László Paja
- Department of Biological Anthropology, University of Szeged, Szeged, Hungary
| | - Orsolya A. Váradi
- Department of Biological Anthropology, University of Szeged, Szeged, Hungary
- Department of Microbiology, University of Szeged, Szeged, Hungary
| | - Erika Molnár
- Department of Biological Anthropology, University of Szeged, Szeged, Hungary
| | - György Pálfi
- Department of Biological Anthropology, University of Szeged, Szeged, Hungary
| | - David R. Hunt
- Department of Anthropology, National Museum of Natural History, Smithsonian Institution, District of Columbia, Washington, D.C., United States of America
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Yorke E, Boima V, Dey ID, Ganu V, Nkornu N, Acquaye KS, Mate-Kole CC. Comparison of neurocognitive changes among newly diagnosed tuberculosis patients with and without dysglycaemia. BMC Psychiatry 2020; 20:143. [PMID: 32245444 PMCID: PMC7119271 DOI: 10.1186/s12888-020-02570-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 03/25/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diabetes often occurs together with tuberculosis (TB) and both may affect each other negatively. Diabetes may be associated with neurocognitive dysfunctioning in affected patients and may negatively impact treatment adherence and outcomes. This study compared the neurocognitive status between newly diagnosed smear positive tuberculosis patients with dysglycaemia and those with normoglycaemia. METHODS The current study was a cross-sectional study involving one hundred and forty-six (146) newly diagnosed smear positive TB patients. Oral glucose tolerance test (OGTT) was performed and the results were categorized as either normoglycaemia, impaired glucose tolerance (IGT), impaired fasting glucose (IFG) or diabetes. Neurocognitive functioning among study participants was assessed at the time of TB diagnosis using Cognitive Failure Questionnaire (CFQ), Montreal Cognitive Assessment tool (MoCA), California Verbal Learning Test (CVLT), Brief Symptom Inventory (BSI) and the Spitzer Quality of Life Index (QLI). RESULTS The mean age of the participants (n = 146) was 38.7 years with 78.8% being males and 21.2% females. Using the fasting blood glucose test, the prevalence of impaired fasting glucose and diabetes were 5.5 and 3.4% respectively, both representing a total of 13 out of the 146 participants; whilst the prevalence of impaired glucose tolerance and diabetes using 2-h post-glucose values were 28.8 and 11.6% respectively, both representing a total of 59 out of the 146 participants. There were no significant differences in the mean scores on the neurocognitive measures between the dysglaycaemia and normoglycamic groups using fasting plasma glucose (FPG). However, there were significant differences in the mean scores between the dysglycaemia and normal groups using 2-h postprandial (2HPP) glucose values on Phobic Anxiety (Normal, Mean = 0.38 ± 0.603; dysglycaemia, Mean = 0.23 ± 0.356; p = 0.045), and Montreal Cognitive Assessment (MoCA) scores (17.26 ± 5.981 vs. 15.04 ± 5.834, p = 0.037). CONCLUSION Newly diagnosed smear positive patients with dysglycaemia were associated with significantly lower mean cognitive scores and scores on phobic anxiety than those with normoglyacaemia. The latter finding must be further explored.
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Affiliation(s)
- Ernest Yorke
- Department of Medicine & Therapeutics, School of Medicine & Dentistry, College of Health Sciences, University of Ghana, Legon, Accra Ghana
| | - Vincent Boima
- Department of Medicine & Therapeutics, School of Medicine & Dentistry, College of Health Sciences, University of Ghana, Legon, Accra Ghana
| | - Ida Dzifa Dey
- Department of Medicine & Therapeutics, School of Medicine & Dentistry, College of Health Sciences, University of Ghana, Legon, Accra Ghana
| | - Vincent Ganu
- Department of Medicine, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Norah Nkornu
- Department of Psychology, School of Social Sciences, College of Humanities, University of Ghana, Accra, Ghana
| | - Kelvin Samuel Acquaye
- Department of Social and Behavioural Sciences, School of Public Health, University of Ghana, Accra, Ghana
| | - C. Charles Mate-Kole
- Department of Psychology, School of Social Sciences, College of Humanities, University of Ghana, Accra, Ghana
- Department of Psychiatry, School of Medicine & Dentistry, College of Health Sciences, Korle-Bu, Accra, Ghana
- Centre for Ageing Studies, College of Humanities, University of Ghana, Accra, Ghana
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Spekker O, Hunt DR, Paja L, Molnár E, Pálfi G, Schultz M. Tracking down the White Plague: The skeletal evidence of tuberculous meningitis in the Robert J. Terry Anatomical Skeletal Collection. PLoS One 2020; 15:e0230418. [PMID: 32187217 PMCID: PMC7080279 DOI: 10.1371/journal.pone.0230418] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 02/29/2020] [Indexed: 11/22/2022] Open
Abstract
Paleopathological diagnosis of tuberculosis (TB) essentially relies on the identification of macroscopic lesions in the skeleton that can be related to different manifestations of TB. Among these alterations, granular impressions (GIs) on the inner skull surface have been considered as pathognomonic features of tuberculous meningitis (TBM). GIs may be established by pressure atrophy of the tubercles formed on the outermost meningeal layer during later stages of TBM. Although GIs were used as diagnostic criteria for TBM in the paleopathological practice since the late 20th century, their diagnostic value has been questioned. To contribute to strengthening the diagnostic value of GIs, a macroscopic investigation–focusing on the macromorphological characteristics and frequency of GIs–was performed on skeletons of known cause of death from the Terry Collection. The χ2 analysis of our data revealed that GIs were significantly more common in individuals who died of TB than in individuals who died of non-TB causes. Furthermore, GIs were localized on the inner surface of the skull base and of the lower lateral skull vault. The localization pattern and distribution of GIs on the endocranial surface resemble that of the tubercles observed in the affected meninges during the pathogenesis of TBM. Our results strengthen the tuberculous origin of GIs and imply that they can be considered as specific signs of TBM. Therefore, GIs can be used as diagnostic criteria for TBM in the paleopathological practice, and the diagnosis of TBM can be established with a high certainty when GIs are present in ancient human bone remains.
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Affiliation(s)
- Olga Spekker
- Department of Biological Anthropology, University of Szeged, Szeged, Hungary
- * E-mail:
| | - David R. Hunt
- Department of Anthropology, National Museum of Natural History, Smithsonian Institution, Washington, District of Columbia, United States of America
| | - László Paja
- Department of Biological Anthropology, University of Szeged, Szeged, Hungary
| | - Erika Molnár
- Department of Biological Anthropology, University of Szeged, Szeged, Hungary
| | - György Pálfi
- Department of Biological Anthropology, University of Szeged, Szeged, Hungary
| | - Michael Schultz
- Institut für Anatomie und Embryologie, Zentrum Anatomie, Universitätsmedizin Göttingen, Göttingen, Germany
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Advances in the Diagnosis and Management of Tubercular Meningitis in Children. Indian J Pediatr 2020; 87:26-33. [PMID: 31802325 DOI: 10.1007/s12098-019-03089-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 09/24/2019] [Indexed: 10/25/2022]
Abstract
Tubercular meningitis (TBM) continues to be a common cause of neuromorbidity in children. There is no single diagnostic method that can rapidly detect Mycobacterium tuberculosis (M.tb) in TBM patients with high sensitivity and specificity. Newer diagnostic modalities like Xpert/RIF assay and Loop mediated isothermal amplification assay (LAMP) have gained an essential stand in molecular diagnostics due to their high specificity, modest sensitivity in cerebrospinal fluid (CSF) and quick availability of results. Intensified drug regimens using high dose rifampicin, fluoroquinolone and aspirin appear to be useful adjunct therapy but more pediatric clinical trials on large scale are needed to determine their appropriate place in pediatric TBM. The emergence of multi and extreme drug resistant M.tb strains further challenges the standard therapy. In this review authors summarize challenges of the currently used diagnostic methods and treatment for TBM and discuss the recent advances.
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Tan JL, Nordin S, Besari AM. Rare Clinical Presentation of Tuberculous Meningitis: A Case Report. Malays J Med Sci 2018; 24:119-123. [PMID: 29386980 DOI: 10.21315/mjms2017.24.5.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 06/14/2016] [Indexed: 10/18/2022] Open
Abstract
Introduction Tuberculosis is the second leading cause of death under the category of infectious diseases, after the human immunodeficiency virus (HIV). Tuberculous meningitis (TBM) constitutes about 5% of all extrapulmonary disease worldwide. This report describes a case of Tuberculous meningitis with rare presentation in a 28-year-old woman, who was treated based on a collection of her social background, clinical findings and Multiplex PCR of tuberculosis. Case presentation A 28-year-old Malay woman with no significant medical history presented to HUSM with one month history of on and off fever, two weeks history of generalised limbs weakness and one week history of dysphagia. She was reported to have experienced visual hallucination and significant weight loss. Her laboratory result is significant for leukocytosis, elevated ESR and hypernatremia. Non-enhanced and contrast CT scan of the brain showed severe bilateral frontal cerebral atrophy. Cerebral spinal fluid (CSF) for multiplex PCR for Mycobacterium tuberculosis complex was positive. She was promptly started on anti-TB regime combined with dexamethasone. Subsequent follow-up showed significant improvement. Conclusion This is a rare clinical manifestation of Tuberculous meningitis that demonstrates the importance of recognising and initiating the treatment early to reduce disabilities and improve clinical outcome.
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Affiliation(s)
- Jian Liang Tan
- School of Medical Sciences Universiti Sains Malaysia, Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Sudzilla Nordin
- Department of Medicine, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Alwi Muhd Besari
- Department of Medicine, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
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Qavi AH, Imran TF, Hasan Z, Ilyas F. Facial Weakness, Diplopia, and Fever in a 31-Year-Old: An Atypical Case of Tuberculous Meningitis. Cureus 2017; 9:e1918. [PMID: 29456899 PMCID: PMC5802756 DOI: 10.7759/cureus.1918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Tuberculous meningitis (TBM) is an infection of the central nervous system (CNS) meninges that carries high morbidity and mortality. It is important to recognize, as patients may present with atypical symptoms. We describe the case of a 31-year-old man with a history of diabetes who presented with a sub-acute onset of right-sided facial weakness and right gaze difficulty with diplopia. History revealed low-grade fever, right-sided headache, fatigue and moderate weight loss for the past several weeks. The patient did not report neck stiffness, rigidity, fever, chills or cough. The physical exam revealed sixth nerve palsy with a right Horner’s syndrome. Magnetic resonance imaging (MRI) of the brain showed pachymeningeal enhancement. A spinal tap revealed elevated white blood cells (WBCs), glucose and protein; cerebrospinal fluid (CSF) culture showed Mycobacterium tuberculosis. The patient was diagnosed with TBM and treated with isoniazid, rifampin, pyrazinamide, ethambutol and vitamin B6 for 12 months. The timely diagnosis of TBM can be challenging due to a nonspecific clinical presentation. In patients with a sub-acute onset of headache, fever and meningeal signs, TBM should be considered in the differential. If suspected, treatment should be initiated immediately to prevent further neurological impairment and death.
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Affiliation(s)
- Ahmed H Qavi
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York, United States
| | - Tasnim F Imran
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Zachariah Hasan
- Department of Medicine, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Fariha Ilyas
- Department of Medicine, Northwell Long Island Jewish Medical Center, New York, United States
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SHP-1 promoter 2 methylation in cerebrospinal fluid for diagnosis of leptomeningeal epithelial-derived malignancy (carcinomatous meningitis). J Neurooncol 2016; 129:395-403. [PMID: 27401153 DOI: 10.1007/s11060-016-2199-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 07/03/2016] [Indexed: 10/21/2022]
Abstract
Current diagnostic methods for leptomeningeal metastasis (LM) from epithelial-derived malignancy (EDM) have limited sensitivity. Here, we explored SHP-1 promoter 2 methylation (SHP1P2)-an epithelial-specific methylation marker previously proven as risk stratification and potential diagnostic marker in non-small cell lung cancer-for EDM with LM. We prospectively recruited 136 patients who were diagnosed EDM with LM (n = 25), EDM without LM (n = 14), non-EDM with LM (n = 8), and benign meningeal diseases (n = 89). The primary cancer sites for EDM with LM were lung (n = 17), breast (n = 5), and colon (n = 3). We performed quantitative analyses of cell-free (cfSHP1P2) and whole fraction (wSHP1P2) from cerebrospinal fluid (CSF); results were correlated with the clinicopathological data, including CSF cytology. Median cfSHP1P2 and wSHP1P2 were 3.08 [range: 0-163.5] and 9.35 [0.69-91.63] ng/ml, respectively, in EDM with LM; 0 [0-0.08] and 0.23 [0-7.84] ng/ml in EDM without LM; and were undetectable in most cases of benign meningeal diseases and non-EDM with LM. The cut-off values of 0.22 ng/ml for methylated cfSHP1P2 and 0.59 ng/ml for wSHP1P2 were the best to discriminate EDM with LM from EDM without LM (sensitivity: 79-100 %; specificity: 83-100 %), as well as from other benign conditions (sensitivity: 85-100 % specificity: 78-100 %). CSF cytology yielded 76 % sensitivity for diagnosing EDM with LM. Further validation of CSF SHP1P2 methylation detection as a role of adjunctive tool for LM from EDM should be interested based on our study.
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Kim J, Kim SE, Park BS, Shin KJ, Ha SY, Park J, Kim SE, Park KM. Procalcitonin as a Diagnostic and Prognostic Factor for Tuberculosis Meningitis. J Clin Neurol 2016; 12:332-9. [PMID: 27165424 PMCID: PMC4960218 DOI: 10.3988/jcn.2016.12.3.332] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 12/28/2015] [Accepted: 12/30/2015] [Indexed: 12/16/2022] Open
Abstract
Background and Purpose We investigated the potential role of serum procalcitonin in differentiating tuberculosis meningitis from bacterial and viral meningitis, and in predicting the prognosis of tuberculosis meningitis. Methods This was a retrospective study of 26 patients with tuberculosis meningitis. In addition, 70 patients with bacterial meningitis and 49 patients with viral meningitis were included as the disease control groups for comparison. The serum procalcitonin level was measured in all patients at admission. Differences in demographic and laboratory data, including the procalcitonin level, were analyzed among the three groups. In addition, we analyzed the predictive factors for a prognosis of tuberculosis meningitis using the Glasgow Coma Scale (GCS) at discharge, and the correlation between the level of procalcitonin and the GCS score at discharge. Results Multiple logistic regression analysis showed that a low level of procalcitonin (≤1.27 ng/mL) independently distinguished tuberculosis meningitis from bacterial meningitis. The sensitivity and specificity for distinguishing tuberculosis meningitis from bacterial meningitis were 96.2% and 62.9%, respectively. However, the level of procalcitonin in patients with tuberculosis meningitis did not differ significantly from that in patients with viral meningitis. In patients with tuberculosis meningitis, a high level of procalcitonin (>0.4 ng/mL) was a predictor of a poor prognosis, and the level of procalcitonin was negatively correlated with the GCS score at discharge (r=-0.437, p=0.026). Conclusions We found that serum procalcitonin is a useful marker for differentiating tuberculosis meningitis from bacterial meningitis and is also valuable for predicting the prognosis of tuberculosis meningitis.
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Affiliation(s)
- Jinseung Kim
- Department of Family Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Si Eun Kim
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Bong Soo Park
- Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Kyong Jin Shin
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Sam Yeol Ha
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jinse Park
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Sung Eun Kim
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Kang Min Park
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea.
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14
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Konradt G, Bassuino DM, Bianchi MV, Bandinelli MB, Driemeier D, Pavarini SP. Neurotuberculosis in cattle in southern Brazil. Trop Anim Health Prod 2016; 48:1089-94. [PMID: 27026233 DOI: 10.1007/s11250-016-1048-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 03/14/2016] [Indexed: 11/26/2022]
Abstract
Tuberculosis in cattle is a chronic infectious-contagious disease characterized by the development of nodular lesions (granulomas) in mainly the lungs and regional lymph nodes. It is caused by Mycobacterium tuberculosis complex, an acid-fast bacillus (AFB). Tuberculosis in the central nervous system is a rare condition in cattle. Herein, we describe the clinical and pathological findings of six neurotuberculosis cases in cattle diagnosed in Southern Brazil. The average age of the cattle affected was 12 months, and they varied in breed and sex. The clinical history ranged from 5 to 30 days and was characterized by motor incoordination, opisthotonus, blindness, and progression to recumbency. The cattle were euthanized, and grossly, the leptomeninges at the basilar brain showed marked and diffuse expansion, with nodular yellowish lesions ranging in size. On microscopic examination, there were multifocal granulomas located mainly in the meninges, though sometimes extending to adjacent neuropil or existing as isolated granulomas in neuropil. AFBs were observed in the cytoplasm of epithelioid macrophages and multinucleated giant cells through Ziehl-Neelsen histochemical staining and identified as Mycobacterium sp. through immunohistochemistry.
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Affiliation(s)
- Guilherme Konradt
- Setor de Patologia Veterinária, Departamento de Patologia Clínica Veterinária, Faculdade de Veterinária, Universidade Federal do Rio Grande do Sul (UFRGS), Av. Bento Gonçalves 9090, Porto Alegre, RS, 91540-000, Brazil
| | - Daniele Mariath Bassuino
- Setor de Patologia Veterinária, Departamento de Patologia Clínica Veterinária, Faculdade de Veterinária, Universidade Federal do Rio Grande do Sul (UFRGS), Av. Bento Gonçalves 9090, Porto Alegre, RS, 91540-000, Brazil
| | - Matheus Viezzer Bianchi
- Setor de Patologia Veterinária, Departamento de Patologia Clínica Veterinária, Faculdade de Veterinária, Universidade Federal do Rio Grande do Sul (UFRGS), Av. Bento Gonçalves 9090, Porto Alegre, RS, 91540-000, Brazil
| | - Marcele Bettim Bandinelli
- Setor de Patologia Veterinária, Departamento de Patologia Clínica Veterinária, Faculdade de Veterinária, Universidade Federal do Rio Grande do Sul (UFRGS), Av. Bento Gonçalves 9090, Porto Alegre, RS, 91540-000, Brazil
| | - David Driemeier
- Setor de Patologia Veterinária, Departamento de Patologia Clínica Veterinária, Faculdade de Veterinária, Universidade Federal do Rio Grande do Sul (UFRGS), Av. Bento Gonçalves 9090, Porto Alegre, RS, 91540-000, Brazil
| | - Saulo Petinatti Pavarini
- Setor de Patologia Veterinária, Departamento de Patologia Clínica Veterinária, Faculdade de Veterinária, Universidade Federal do Rio Grande do Sul (UFRGS), Av. Bento Gonçalves 9090, Porto Alegre, RS, 91540-000, Brazil.
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Miftode EG, Dorneanu OS, Leca DA, Juganariu G, Teodor A, Hurmuzache M, Nastase EV, Anton-Paduraru DT. Tuberculous Meningitis in Children and Adults: A 10-Year Retrospective Comparative Analysis. PLoS One 2015; 10:e0133477. [PMID: 26186004 PMCID: PMC4506084 DOI: 10.1371/journal.pone.0133477] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 06/29/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Tuberculous meningitis (TBM) is the most lethal form of Mycobacterium tuberculosis infection, which has a high rate of neurological complications and sequelae. OBJECTIVES Our study offers a real-world infectious disease clinic perspective, being thus representative for the clinical environment of developing countries. METHODS We performed a retrospective analysis of the 127 adult and 77 pediatric cases diagnosed with TBM in the Infectious Disease Hospital of the School of Medicine of Iasi, Romania between 2004-2013. RESULTS Definite diagnosis of TBM was established in 31% of children but in only 20% of adults (p = 0.043). A contact with an individual with pulmonary tuberculosis was documented in 30% of children vs. 13% of adults (p = 0.0007). Coma occurred in 19% of patients (similar in children and adults); other consciousness abnormalities were seen in 27% of children and in 72% of adults (p = 0.000001). Cranial nerve palsies occurred prior to therapy in 9% of cases (12% vs 7% of children and adults, respectively, p>0.05), and developed 2-7 days after treatment initiation in 10% (12 vs 9%). CSF cultures were positive for M. tuberculosis in 24% of patients (31% vs. 20%, p>0.05). Overall mortality was 7.35%, similar for children and adults. Yet, permanent neurological sequelae, which were seen in 23% of patients occurred significantly more frequent in children vs. adults (36% vs. 14%, respectively, p = 0.0121). In conclusion, our retrospective analysis on a significant number of cases of TBM identified striking differences between children and adults: while children were in an earlier stage at the admission, they associated a higher frequency of neurological sequelae and miliary pattern, and they were more likely to have normal CSF protein levels and positive cultures of CSF.
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Affiliation(s)
- Egidia G. Miftode
- Department of Infectious Diseases, University of Medicine and Pharmacy “Grigore T. Popa”, Iasi, Romania
- * E-mail:
| | - Olivia S. Dorneanu
- Department of Microbiology, University of Medicine and Pharmacy “Grigore T. Popa”, Iasi, Romania
| | - Daniela A. Leca
- Department of Infectious Diseases, University of Medicine and Pharmacy “Grigore T. Popa”, Iasi, Romania
| | - Gabriela Juganariu
- Department of Infectious Diseases, University of Medicine and Pharmacy “Grigore T. Popa”, Iasi, Romania
| | - Andra Teodor
- Department of Infectious Diseases, University of Medicine and Pharmacy “Grigore T. Popa”, Iasi, Romania
| | - Mihnea Hurmuzache
- Department of Infectious Diseases, University of Medicine and Pharmacy “Grigore T. Popa”, Iasi, Romania
| | - Eduard V. Nastase
- Department of Infectious Diseases, University of Medicine and Pharmacy “Grigore T. Popa”, Iasi, Romania
| | - Dana T. Anton-Paduraru
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”, Iasi, Romania
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Viswanathan S, Muthu V, Iqbal N, Remalayam B, George T. Scrub typhus meningitis in South India--a retrospective study. PLoS One 2013; 8:e66595. [PMID: 23799119 PMCID: PMC3682970 DOI: 10.1371/journal.pone.0066595] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 05/08/2013] [Indexed: 12/13/2022] Open
Abstract
Background Scrub typhus is prevalent in India although definite statistics are not available. There has been only one study on scrub typhus meningitis 20 years ago. Most reports of meningitis/meningoencephalitis in scrub typhus are case reports Methods A retrospective study done in Pondicherry to extract cases of scrub typhus admitted to hospital between February 2011 and January 2012. Diagnosis was by a combination of any one of the following in a patient with an acute febrile illness- a positive scrub IgM ELISA, Weil-Felix test, and an eschar. Lumbar puncture was performed in patients with headache, nuchal rigidity, altered sensorium or cranial nerve deficits. Results Sixty five cases of scrub typhus were found, and 17 (17/65) had meningitis. There were 33 males and 32 females. Thirteen had an eschar. Median cerebrospinal fluid (CSF) cell count, lymphocyte percentage, CSF protein, CSF glucose/blood glucose, CSF ADA were 54 cells/µL, 98%, 88 mg/dL, 0.622 and 3.5 U/mL respectively. Computed tomography was normal in patients with altered sensorium and cranial nerve deficits. Patients with meningitis had lesser respiratory symptoms and signs and higher urea levels. All patients had received doxycycline except one who additionally received chloramphenicol. Conclusion Meningitis in scrub typhus is mild with quick and complete recovery. Clinical features and CSF findings can mimic tuberculous meningitis, except for ADA levels. In the Indian context where both scrub typhus and tuberculosis are endemic, ADA and scrub IgM may be helpful in identifying patients with scrub meningitis and in avoiding prolonged empirical antituberculous therapy in cases of lymphocytic meningitis.
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Affiliation(s)
- Stalin Viswanathan
- Department of General Medicine, Indira Gandhi Medical College, Kathirkamam, Pondicherry, India.
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17
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Garg RK, Singh SK, Malhotra HS, Singh MK. Abnormal head movement in a patient with tuberculous meningitis. BMJ Case Rep 2012; 2012:bcr-2012-006663. [PMID: 23035162 DOI: 10.1136/bcr-2012-006663] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The bobble-head doll syndrome is characterised by abnormal head movements. These head movements are usually 'yes-yes' (up and down) type; rarely, head movements are 'no-no' (side-to-side) type. Commonly described causes of the bobble-head doll syndrome include third ventricular tumours, suprasellar arachnoid cysts, aqueductal stenosis and other lesions in the region of the third ventricle of the brain. We report a case of tuberculous meningitis with hydrocephalus; in this patient bobble-head doll syndrome developed following external ventricular drainage. In our patient, placement of intraventricular drain led to massive dilatation of the frontal horn of the left lateral ventricle because of blocked foramina of Monro on the left side. The bobble-head doll syndrome, presumably, developed because of the pressure effect of the dilated third ventricle on the dorsomedial nucleus of the thalamus, red nucleus and dentatorubrothalamic pathways. We think that distortion of the third ventricle was responsible for the impairment of the functions of all these structures.
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Affiliation(s)
- Ravindra Kumar Garg
- Department of Neurology, Chhatrapati Shahuji Maharaj Medical University, Lucknow, Uttar Pradesh, India.
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18
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Lattke M, Magnutzki A, Walther P, Wirth T, Baumann B. Nuclear factor κB activation impairs ependymal ciliogenesis and links neuroinflammation to hydrocephalus formation. J Neurosci 2012; 32:11511-23. [PMID: 22915098 PMCID: PMC6703776 DOI: 10.1523/jneurosci.0182-12.2012] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 05/25/2012] [Indexed: 11/21/2022] Open
Abstract
Hydrocephalus formation is a frequent complication of neuropathological insults associated with neuroinflammation. However, the mechanistic role of neuroinflammation in hydrocephalus development is unclear. We have investigated the function of the proinflammatory acting inhibitor of κB kinase (IKK)/nuclear factor κB (NF-κB) signaling system in neuroinflammatory processes and generated a novel mouse model that allows conditional activation of the IKK/NF-κB system in astrocytes. Remarkably, NF-κB activation in astrocytes during early postnatal life results in hydrocephalus formation and additional defects in brain development. NF-κB activation causes global neuroinflammation characterized by a strong, astrocyte-specific expression of proinflammatory NF-κB target genes as well as a massive infiltration and activation of macrophages. In this animal model, hydrocephalus formation is specifically induced during a critical time period of early postnatal development, in which IKK/NF-κB-induced neuroinflammation interferes with ependymal ciliogenesis. Our findings demonstrate for the first time that IKK/NF-κB activation is sufficient to induce hydrocephalus formation and provides a potential mechanistic explanation for the frequent association of neuroinflammation and hydrocephalus formation during brain development, namely impairment of ependymal cilia formation. Therefore, our study might open up new perspectives for the treatment of certain types of neonatal and childhood hydrocephalus associated with hemorrhages and infections.
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MESH Headings
- Age Factors
- Animals
- Animals, Newborn
- Astrocytes/drug effects
- Astrocytes/enzymology
- Brain/enzymology
- Brain/growth & development
- Brain/pathology
- Cell Adhesion Molecules/genetics
- Cell Adhesion Molecules/metabolism
- Cells, Cultured
- Cerebral Cortex/cytology
- Chemokines/genetics
- Chemokines/metabolism
- Complement System Proteins/genetics
- Complement System Proteins/metabolism
- Disease Models, Animal
- Doxycycline/administration & dosage
- Encephalitis/etiology
- Enzyme Activation/drug effects
- Enzyme Activation/genetics
- Gene Expression Regulation, Developmental/drug effects
- Gene Expression Regulation, Developmental/physiology
- Glial Fibrillary Acidic Protein/genetics
- Glioma, Subependymal/etiology
- Glioma, Subependymal/pathology
- Humans
- Hydrocephalus/complications
- Hydrocephalus/enzymology
- Hydrocephalus/pathology
- I-kappa B Kinase/genetics
- I-kappa B Kinase/metabolism
- I-kappa B Proteins/metabolism
- Lateral Ventricles/growth & development
- Lateral Ventricles/pathology
- Lateral Ventricles/ultrastructure
- Mice
- Mice, Inbred C57BL
- Mice, Transgenic
- Microarray Analysis
- Microscopy, Electron, Scanning
- NF-KappaB Inhibitor alpha
- Protein Serine-Threonine Kinases/genetics
- Protein Serine-Threonine Kinases/metabolism
- Signal Transduction/drug effects
- Signal Transduction/genetics
- Statistics, Nonparametric
- Transcription Factor RelA/metabolism
- NF-kappaB-Inducing Kinase
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Affiliation(s)
| | | | - Paul Walther
- Central Facility for Electron Microscopy, Ulm University, 89081 Ulm, Germany
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Nath A, Berger JR. Complications of immunosuppressive/immunomodulatory therapy in neurological diseases. Curr Treat Options Neurol 2012; 14:241-55. [PMID: 22528294 PMCID: PMC4910875 DOI: 10.1007/s11940-012-0172-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OPINION STATEMENT The first critical step in the appropriate treatment of neurological infectious disease accompanying immunosuppressive states or immunomodulatory medication is to properly identify the offending organism. Broadly immunosuppressive conditions will predispose to both common and uncommon infectious diseases. There are substantial differences between neurological infectious disorders complicating disturbances of the innate immunity (neutrophils, monocytes and macrophages) and those due to abnormal adaptive immunity (humoral and cellular immunity). Similarly, there are differences in the types of infections with impaired humoral immunity compared to disturbed cellular immunity and between T- and B-cell disorders. HIV/AIDS has been a model of acquired immunosuppression and the nature of opportunistic infections with which it has been associated has been well characterized and generally correlates well with the degree of CD4 lymphopenia. Increasingly, immunotherapies target specific components of the immune system, such as an adhesion molecule or its ligand or surface receptors on a special class of cells. These targeted perturbations of the immune system increase the risk of particular infectious diseases. For instance, natalizumab, an α4β1 integrin inhibitor that is highly effective in multiple sclerosis, increases the risk of progressive multifocal leukoencephalopathy for reasons that still remain unclear. It is likely that other therapies that result in a disruption of a specific component of the immune system will be associated with other unique opportunistic infections. The risk of multiple simultaneous neurological infections in the immunosuppressed host must always be considered, particularly with a failure to respond to a therapeutic regimen. With respect to appropriate and effective therapy, diagnostic accuracy assumes primacy, but occasionally broad spectrum therapy is necessitated. For a number of opportunistic infectious disorders, particularly some viral and fungal diseases, antimicrobial therapy remains inadequate.
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Affiliation(s)
- Avindra Nath
- Department of Neurology, University of Kentucky College of Medicine, Kentucky Clinic L-445, 740 S. Limestone Street, Lexington, KY 40536-0284, USA
| | - Joseph R. Berger
- Department of Neurology, University of Kentucky College of Medicine, Kentucky Clinic L-445, 740 S. Limestone Street, Lexington, KY 40536-0284, USA
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Trendelenburg G, Jussen D, Grimmer S, Jakob W, Hiemann NE, Horn P. Invasive pressure monitoring saves from tuberculous meningitis with fulminant generalized brain edema. Front Neurol 2011; 2:69. [PMID: 22110466 PMCID: PMC3216125 DOI: 10.3389/fneur.2011.00069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 10/21/2011] [Indexed: 11/18/2022] Open
Abstract
We report a 57-year old female patient with a rapid and dramatic dynamic of whole brain edema caused by tuberculous meningitis. After initiation of tuberculostatic medication, general condition of the patient worsened and finally she was intubated due to a progredient loss of consciousness and respiratory insufficiency. Repeated cerebral computer tomography (CCT) revealed a global brain edema with slit ventricles and a dramatic progress of generalized brain swelling. Highly interesting, a rapid expanded regime of brain pressure monitoring and treatment according to a neurosurgical intensive standard ICP/CPP management protocol, which was complemented by the tuberculostatic therapy and high dose steroid application, dramatically improved the general conditions, so that the patient is now in a general condition which corresponds that before the occurrence of tuberculous meningitis. Thus, it is mandatory in situations with a rapid progressive brain swelling caused by bacterial meningitis to consider an intensified cerebral monitoring and stratified treatment protocol in order to avoid the devasting effects of a long lasting increase in intracranical pressure.
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21
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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.
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Affiliation(s)
- Christina A Nelson
- Department of Neurology, Global Health, Medicine, and Epidemiology, University of Washington School of Medicine, Seattle, Washington, USA
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Garg RK, Sinha MK. Tuberculous meningitis in patients infected with human immunodeficiency virus. J Neurol 2010; 258:3-13. [PMID: 20848123 DOI: 10.1007/s00415-010-5744-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Accepted: 09/01/2010] [Indexed: 12/11/2022]
Abstract
Tuberculosis is the most common opportunistic infection in human immunodeficiency virus (HIV) infected persons. HIV-infected patients have a high incidence of tuberculous meningitis as well. The exact incidence and prevalence of tuberculous meningitis in HIV-infected patients are not known. HIV infection does not significantly alter the clinical manifestations, laboratory, radiographic findings, or the response to therapy. Still, some differences have been noted. For example, the histopathological examination of exudates in HIV-infected patients shows fewer lymphocytes, epithelioid cells, and Langhan's type of giant cells. Larger numbers of acid-fast bacilli may be seen in the cerebral parenchyma and meninges. The chest radiograph is abnormal in up to 46% of patients with tuberculous meningitis. Tuberculous meningitis is likely to present with cerebral infarcts and mass lesions. Cryptococcal meningitis is important in differential diagnosis. The recommended duration of treatment in HIV-infected patients is 9-12 months. The benefit of adjunctive corticosteroids is uncertain. Antiretroviral therapy and antituberculosis treatment should be initiated at the same time, regardless of CD4 cell counts. Tuberculous meningitis may be a manifestation of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome. Some studies have demonstrated a significant impact of HIV co-infection on mortality from tuberculous meningitis. HIV-infected patients with multidrug-resistant tuberculous meningitis have significantly higher mortality. The best way to prevent HIV-associated tuberculous meningitis is to diagnose and isolate infectious cases of tuberculosis promptly and administer appropriate treatment.
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Affiliation(s)
- Ravindra Kumar Garg
- Department of Neurology, Chhatrapati Shahuji Maharaj Medical University, Lucknow, 226003, Uttar Pradesh, India.
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