Prospective Analysis of 55 Cases of Tuberculosis Meningitis (TBM) in North India

The role of isoniazid dosage and NAT2 gene polymorphism in the treatment of tuberculous meningitis

Background

Tuberculous meningitis (TBM) is a non-purulent inflammatory condition affecting the meninges and spinal membranes, caused by Mycobacterium tuberculosis (MTB) infection. This study seeks to explore the impact of varying INH dosages and NAT2 gene polymorphisms on TBM treatment, contributing new insights to improve clinical management and patient prognosis.

Methods

Patients with TBM hospitalized between July 2020 and December 2022 were categorized into two groups based on INH dosage: the standard-dose group (300 mg/day) and the high-dose group (600 mg/day). General and baseline data were collected, and NAT2 genotypes were identified using real-time fluorescent PCR with melting curve analysis. The clinical characteristics and outcomes of patients with TBM under varying INH dosages were analyzed.

Results

This study enrolled 119 patients with TBM, including 32 (26.9%) in the standard-dose group and 87 (73.1%) in the high-dose group. The NAT2 genotypes were distributed as follows: 34 (28.6%) fast acetylators (FA), 73 (61.3%) intermediate acetylators (IA), and 12 (10.1%) slow acetylators (SA). By month 12, 25 patients (21.0%) experienced disability or death, with 22 cases (18.5%) occurring by the end of the 3rd month. Disability and mortality rates differed significantly between the standard-dose and high-dose groups for IA-type TBM patients (P = 0.014). Univariate analysis showed significant differences between groups in baseline focal neurological impairment and disability or mortality by the 3rd and 12th months. Multivariate logistic regression identified INH dosage, cranial nerve palsy, age, and headache as key prognostic factors for TBM.

Conclusion

High-dose INH treatment was associated with a reduced incidence of disability or death compared to the standard-dose regimen, indicating better efficacy and prognosis. In patients with IA-type TBM, the high-dose group showed a significantly lower rate of disability or mortality, suggesting that higher INH dosages may reduce the risk of adverse outcomes.

Inside the Brain: Cerebrospinal Fluid Insights in Meningitis

Background Our study focused on meningitis, an infection that can spread through the bloodstream as a primary or secondary infection from other body parts, such as sinuses, ears, and lungs. It can affect patients who have experienced trauma or surgery, as well as those with congenital defects like spina bifida. Specifically, we examined bacterial, viral, and tuberculous meningitis (TBM) cases. The primary method for confirming the diagnosis of these types of meningitis is to analyze the cerebrospinal fluid (CSF). Early diagnosis can utilize cytological and biochemical parameters. Our objective is to determine CSF's cytological and biochemical profile in patients with these specific types of meningitis. Methods A study was carried out at the central pathology lab from October 24, 2017, to April 24, 2018. CSF samples from suspected meningitis patients were examined for various parameters, including hematological, biochemical, microbiological, and cytomorphological aspects and specific tests for bacterial, fungal, and TBM. The study focused on patients aged 16 and above, excluding those under 16, non-compliant patients, and individuals with specific health conditions. Data were analyzed using IBM SPSS Statistics for Windows, Version 20 (Released 2011; IBM Corp., Armonk, New York, United States), and the results were presented through the use of mean, standard deviation, and percentages. Statistical tests were utilized to compare categorical variables and mean, with a significance level of p<0.05. Results We included a total of 156 cases, with the mean age of presentation being 56.628 years. The male-to-female ratio was 1.0526:1. Of the patients, 81 (52.1%) had been diagnosed with TBM, had elevated adenosine deaminase (ADA) levels of 48.8733±37.43740 IU/L, and CSF lymphocytosis (99%). Additionally, cases of bacterial meningitis showed markedly raised mean total leukocyte count (TLC) of 2085.50±445.47727 cells/mm3 and mean CSF protein levels of 349.45±113.73105 mg/dL. The study found a significant increase in protein levels and a decrease in glucose levels in the CSF of TBM and bacterial meningitis patients compared to those with other causes of meningitis (p<0.001). Guillain-Barre syndrome (GBS) and multiple sclerosis (MS) patients had TLC and ADA within normal limits. CSF ADA level greater than 6 IU/L showed a sensitivity of 97.53% and a specificity of 96.0%, making it the most specific test. A protein level in the CSF greater than 45 mg/dL demonstrated a sensitivity of 98.78% and a specificity of 24.32%, indicating it is sensitive but less specific in diagnosing TBM. Lymphocytic predominance, defined as TLC of more than 5 cells/mm3 with at least 50% of the cells being lymphocytes in the CSF of TBM patients, showed a sensitivity of 97.53% and a specificity of 6.67%. CSF glucose had a sensitivity of 38.27%, making it the least reliable indicator for diagnosing meningitis. Conclusion The CSF analysis is the primary diagnostic method for detecting meningitis. Its cost-effectiveness is a key factor, especially for patients from lower socioeconomic backgrounds in government medical colleges in India, where access to expensive diagnostic tests is limited. The efficiency of CSF analysis for early diagnosing different types of meningitis aids in management, helping to prevent complications and fatal outcomes.

Diagnostic Challenges and Prospects Associated With Zoonotic Tuberculosis of Central Nervous System

Introduction:

The diagnosis of Tuberculous Meningitis (TBM) has remained a challenge due to its insidious onset and the failure of conventional diagnostic tests. The present study aimed to identify the mycobacterial pathogen in the CSF of patients with TBM and a poor prognosis.

Methods:

We retrospectively recruited 224 TBM and 34 non-TBM patients admitted to the Central India Institute of Medical Sciences, Nagpur, India, in 2014. The CSF samples of these patients were subjected to a duplex PCR assay for the species-specific identification of the causative pathogen.

Results:

M. bovis and infection with M.tuberculosis were detected in 7% (18) and 32.9% (85) of the patients, respectively. Moreover, 14% (36) of the study samples were culture positive; however, the mycobacterial pathogens could not be differentiated to the species level.

Conclusion:

The present study findings emphasized the potentially vital importance of M. bovis identification for appropriate patient management. The obtained data also demonstrated the persistent significance of M. bovis, as a zoonotic pathogen.

Methods for rapid diagnosis of meningitis etiology in adults

Infectious meningitis can be caused by viral, bacterial or fungal pathogens. Despite widely available treatments, many types of infectious meningitis are still associated with significant morbidity and mortality. Delay in diagnosis contributes to poor outcomes. Cerebrospinal fluid cultures have been used traditionally but are time intensive and sensitivity is decreased by empiric treatment prior to culture. More rapid techniques such as the cryptococcal lateral flow assay (IMMY), GeneXpert MTB/Rif Ultra (Cepheid) and FilmArray multiplex-PCR (Biofire) are three examples that have drastically changed meningitis diagnostics. This review will discuss a holistic approach to diagnosing bacterial, mycobacterial, viral and fungal meningitis.

Tuberculosis deaths are predictable and preventable: Comprehensive assessment and clinical care is the key

The goal of reducing tuberculosis (TB) mortality in the END TB Strategy can be achieved if TB deaths are considered predictable and preventable. This will require programs to examine and address some key gaps in the understanding of the distribution and determinants of TB mortality and the current model of assessment and care in high burden countries.

Most deaths in high-burden countries occur in the first eight weeks of treatment and in those belonging to the age group of 15–49 years, living in poverty, with HIV infection and/or low body mass index (BMI). Deaths result from extensive disease, comorbidities like advanced HIV disease complicated with other infections (bacterial, fungal, bloodstream), and moderate-severe undernutrition. Most early deaths in patients with TB, even with TB-HIV co-infection, are due to TB itself.

Comprehensive assessment and clinical care are a prerequisite of patient-centered care. Simple independent predictors of death like unstable vital signs, BMI, mid-upper arm circumference, or inability to stand or walk unaided can be used by programs for risk assessment. Programs need to define criteria for referral for inpatient care, address the paucity of hospital beds and develop and implement guidelines for the clinical management of seriously ill patients with TB, advanced HIV disease and severe undernutrition as co-morbidities. Programs should also consider notification and audit of all TB deaths, similar to audit of maternal deaths, and address the issues in delays in diagnosis, treatment, and quality of care.

Comparison of Standard and Intensified Regimens for HIV-Negative Adults With Tuberculous Meningitis in West China: A Retrospective Observational Study

Background: Tuberculous meningitis (TBM) is an extremely devastating inflammation of the central nervous system; however, no available optimum treatment can effectively control the disease so far. Method: The medical records of TBM patients from May 2011 to August 2016 in West China hospital were retrospectively analyzed. Patients were divided into three groups based on their treatment regimens {Group1: 4 standard therapy; Group2: 3 standard drugs + Levofloxacin; Group3: 4 standard therapy + Levofloxacin (G3a)/ Moxifloxacin (G3b)}. Using the intention-to-treat analysis, eventually, the treatments' efficacy and safety were compared among all groups. Results: Two hundred two patients with TBM were enrolled and followed up for at least 2 years. Among them, 99 patients were in G1; 18 in G2; and 85 in G3 (Moxifloxacin=39/ Levofloxacin=49). One hundred fifteen (56.9%) patients were males, and the median age was 42 years. At admission, 74 patients (36.6%) were in stage I, 102 (50.5%) in stage II and 26 (12.9%) in stage III. The most common symptoms were headache in 194 (96.0%) patients, fever in 162 (80.2%), vomiting in 120 (59.7%), neck stiffness in 104 (51.5%), and malaise in 96 (47.5%). The overall outcome at 1 year showed that 47 patients (47.5%) in G1, 10 patients (55.6%) in G2 and 48 patients (56.5%) in G3 had good outcome; however, there was no significant difference among all groups (P = 0.397); at 2 years there was also no difference among treatment groups (P = 0.295). However, in Group3b 22 patients (56.4%) at 1-year and 26 (66.7%) at 2-year follow up had a full recovery, which is significantly superior to other treatment groups, the P value at 1 and 2 years was 0.002 and 0.027, respectively. Conclusion: The overall outcome in patients with TBM at 1 and 2 years follow up did not show any statistically significant difference between the standard chemotherapy and other intensified regimens. Furthermore, Hydrocephalus (OR = 3.461, 95% CI: 1.349-8.882, P = 0.010) was the only independent risk factor for a poor outcome.

HIV-associated opportunistic CNS infections: pathophysiology, diagnosis and treatment

Nearly 30 years after the advent of antiretroviral therapy (ART), CNS opportunistic infections remain a major cause of morbidity and mortality in HIV-positive individuals. Unknown HIV-positive disease status, antiretroviral drug resistance, poor drug compliance, and recreational drug abuse are factors that continue to influence the morbidity and mortality of infections. The clinical and radiographic pattern of CNS opportunistic infections is unique in the setting of HIV infection: opportunistic infections in HIV-positive patients often have characteristic clinical and radiological presentations that can differ from the presentation of opportunistic infections in immunocompetent patients and are often sufficient to establish the diagnosis. ART in the setting of these opportunistic infections can lead to a paradoxical worsening caused by an immune reconstitution inflammatory syndrome (IRIS). In this Review, we discuss several of the most common CNS opportunistic infections: cerebral toxoplasmosis, progressive multifocal leukoencephalopathy (PML), tuberculous meningitis, cryptococcal meningitis and cytomegalovirus infection, with an emphasis on clinical pearls, pathological findings, MRI findings and treatment. Moreover, we discuss the risk factors, pathophysiology and management of IRIS. We also summarize the challenges that remain in management of CNS opportunistic infections, which includes the lack of phase II and III clinical trials, absence of antimicrobials for infections such as PML, and controversy regarding the use of corticosteroids for treatment of IRIS.

Old age and hydrocephalus are associated with poor prognosis in patients with tuberculous meningitis: A retrospective study in a Chinese adult population

Tuberculous meningitis (TBM) is the most common form of central nervous system tuberculosis with a very poor prognosis. We aimed at assessing risk factors related to the prognosis of patients with TBM.Forty-five inpatients with TBM in our institution from January 2013 to December 2015 were enrolled retrospectively. The good or poor prognosis in the patients was defined, based on Glasgow Outcome Scale System at discharge. Patients with a GOS score less than 5 were defined as "poor prognosis." Univariate and multivariate logistic regression analyses were performed to assess the predictors for TBM outcome.Among 45 TBM patients, 35 (77.8%) and 10 (22.2%) were in good, poor prognoses, respectively. Old age, disturbance of consciousness, moderate to severe electroencephalogram abnormality, hydrocephalus, remarkable increase of protein (≥ 236 mg/dL) and white blood cell counts (≥ 243 /μL) in cerebral spinal fluid were associated with poor prognosis. Multivariate analysis indicated that old age (odds ratio (OR) = 18.395, P = .036) and hydrocephalus (OR = 32.995, P = .049) were independent factors for a poor outcome of TBM.In conclusion, old age and hydrocephalus are the predictors for poor prognosis of TBM. Patients with these risk factors should be treated promptly with a special care paid to improve their outcomes.

High rate of drug resistance among tuberculous meningitis cases in Shaanxi province, China

The clinical and mycobacterial features of tuberculous meningitis (TBM) cases in China are not well described; especially in western provinces with poor tuberculosis control. We prospectively enrolled patients in whom TBM was considered in Shaanxi Province, northwestern China, over a 2-year period (September 2010 to December 2012). Cerebrospinal fluid specimens were cultured for Mycobacterium tuberculosis; with phenotypic and genotypic drug susceptibility testing (DST), as well as genotyping of all positive cultures. Among 350 patients included in the study, 27 (7.7%) had culture-confirmed TBM; 84 (24.0%) had probable and 239 (68.3%) had possible TBM. DST was performed on 25/27 (92.3%) culture positive specimens; 12/25 (48.0%) had "any resistance" detected and 3 (12.0%) were multi-drug resistant (MDR). Demographic and clinical features of drug resistant and drug susceptible TBM cases were similar. Beijing was the most common genotype (20/25; 80.0%) with 9/20 (45%) of the Beijing strains exhibiting drug resistance; including all 3 MDR strains. All (4/4) isoniazid resistant strains had mutations in the katG gene; 75% (3/4) of strains with phenotypic rifampicin resistance had mutations in the rpoB gene detected by Xpert MTB/RIF®. High rates of drug resistance were found among culture-confirmed TBM cases; most were Beijing strains.