Post-TB health and wellbeing

TB affects around 10.6 million people each year and there are now around 155 million TB survivors. TB and its treatments can lead to permanently impaired health and wellbeing. In 2019, representatives of TB affected communities attending the '1st International Post-Tuberculosis Symposium´ called for the development of clinical guidance on these issues. This clinical statement on post-TB health and wellbeing responds to this call and builds on the work of the symposium, which brought together TB survivors, healthcare professionals and researchers. Our document offers expert opinion and, where possible, evidence-based guidance to aid clinicians in the diagnosis and management of post-TB conditions and research in this field. It covers all aspects of post-TB, including economic, social and psychological wellbeing, post TB lung disease (PTLD), cardiovascular and pericardial disease, neurological disability, effects in adolescents and children, and future research needs.

CSF protein concentration associated with ventriculoperitoneal shunt obstruction in tuberculous meningitis

INTRODUCTION

Hydrocephalus occurs in 85% of patients with tuberculous meningitis (TBM). Ventriculoperitoneal shunt (VPS) insertion is first-line treatment for relieving increased intercranial pressure. VPS obstruction secondary to increased protein levels in cerebrospinal fluid (CSF) is a known complication.

OBJECTIVE

To ascertain if there is a difference in protein levels 1) between cranial and lumbar CSF, and to quantify levels associated with VPS obstruction, and 2) obtained from lumbar puncture vs. ventricular CSF.

METHOD

A 30-year retrospective analysis was undertaken. CSF protein levels were statistically analysed to determine correlation between these levels and VPS obstruction.

RESULTS

Of 214 children and 376 adults who underwent VPS insertion for TBM, respectively 27.5% and 25.5% sustained blocked VPS. The mean protein level in CSF collected from the non-obstructed group was 1.76 g/l, compared to 2.94 g/l in the obstructed group. The mean CSF protein level from intraoperative ventricular vs. lumbar puncture samples in the VPS obstruction group was respectively 2.471 g/l and 2.474 g/l.

CONCLUSION

Patients with increased protein levels in CSF are at a high risk of VPS blockage. In these patients, temporary measures should be employed until CSF protein levels decrease.

IMCI indicators of childhood TBM at primary health care level in the Western Cape Province of South Africa

BACKGROUND

The diagnosis of tuberculous meningitis (TBM) in children is often delayed, with disastrous consequences. The Integrated Management of Childhood Illness (IMCI) strategy aims to ensure the accurate assessment of ill children using simple yet reliable clinical signs.

METHODS

We conducted a retrospective observational study of 30 consecutive children aged 3 months to 5 years diagnosed with TBM at Tygerberg Hospital, Cape Town, South Africa. Clinical records were reviewed to assess diagnostic delay and identify IMCI indicators that were present at the time of initial presentation.

RESULTS

Six patients (20%) presented with stage I, 6 (20%) with stage II and 18 (60%) with stage III TBM. Recent contact with an adult TB source case was recorded in 21 (70%) cases. The median number of health care visits before hospital admission was 4.0 (range 1-6). At the first health care visit, 21 (70%) had potential TB features and recent contact with an adult household TB source case.

CONCLUSION

Adequate implementation of IMCI clinical indicators is essential to ensure earlier diagnosis and prompt treatment initiation in children with TBM, as the majority of cases present with advanced disease. Recent contact with an adult TB source case is an important consideration.

Lipoarabinomannan enzyme-linked immunosorbent assay for early diagnosis of childhood tuberculous meningitis

SETTING

Tuberculous meningitis (TBM) is a severe complication of tuberculosis (TB) predominantly affecting young children. Early initiation of treatment is important to prevent morbidity and mortality associated with TBM, emphasising the importance of early diagnosis. Among the most promising new methods for diagnosing TB are antigen-detection assays based on the detection of lipoarabinomannan (LAM).

OBJECTIVE

To evaluate the diagnostic value of a commercial, antigen-capture enzyme-linked immunosorbent assay (ELISA) test based on the detection of LAM in urine for the early diagnosis of TBM in children.

METHOD

A cross-sectional study in which urine samples from paediatric patients with suspected TBM attending the Tygerberg Children's Hospital, Cape Town, South Africa, were tested for LAM.

RESULTS

Complete data were available for 50 of 56 patients with suspected TBM. TBM was diagnosed in 21 (42%) patients and excluded in 29 (58%). The LAM ELISA had a sensitivity of 4.8% and a specificity of 93.1%. Serial measurements in the first 2 weeks after treatment initiation did not improve test performance.

CONCLUSION

We have shown that urinary LAM detection was of little value for the diagnosis of TBM in a cohort of paediatric patients with suspected TBM.

Feigned bereavement: twelve cases

Twelve patients who feigned bereavement are described. Most appeared depressed on admission, and in over half bereavement was erroneously believed by staff to be an important cause of their depression. This type of behaviour, leading to admission to hospital, may be regarded as abnormal illness behaviour, and reasons are given for considering most of the cases as variants of the Münchausen syndrome. Motivation for these deceptions is discussed, and reference is made to features which might arouse suspicion that bereavement is feigned.