Relationship between nutritional factors and clinical outcome in children with tuberculous meningitis / 中华儿科杂志

Objective: To investigate the relationship between nutritional risk status and clinical outcome in children with tuberculous meningitis (TBM). Methods: The clinical data (basic information, clinical symptoms and laboratory test results) of 112 patients with TBM, who were admitted to Department of Pediatric Infectious Diseases of West China Second Hospital of Sichuan University,from January 2013 to December 2020 were retrospectively analyzed. The patients were divided into the nutritional risk group and the non-nutritional risk group according to the assessment of the nutritional risk by the STRONGkids Scale. The variables of basic information, clinical symptoms and laboratory test measurements etc. were compared between the two groups by using Student t test, Rank sum test or Chi-square test. Multivariate Logistic regression analysis were used to analyze nutritional risk factors. Results: Among 112 patient with TBM, 55 were males and 57 females. There were 62 cases in the nutritional risk group and 50 cases in the non-nutritional risk group. The proportion of cases with nutritional risk was 55.4% (62/112). Patients in the nutritional risk who lived in rural areas, had symptoms of brain nerve damage, convulsions, emaciation and anorexia, with a diagnosis time of ≥21 days, and the level of cerebrospinal fluid (CSF) protein were all higher than those in the non-nutritional risk group ((50 cases (80.6%) vs. 32 cases (64.0%), 20 cases (32.3%) vs.8 cases (16.0%), 33 cases (53.2%) vs. 15 cases (30.0%), 30 cases (48.4%) vs. 2 cases (4.0%), 59 cases (95.2%) vs. 1 case (2.0%),41 cases (66.1%) vs.18 cases (36.0%), 1 406 (1 079, 2 068) vs. 929 (683, 1 208) mg/L, χ2=3.91, 3.90, 6.10, 26.72, 98.58, 10.08, Z=4.35, all P<0.05). The levels of serum albumin,hemoglobin,lymphocyte count, white blood cell count, and CSF glucose were significantly lower in patients with nutritional risk ((36±5) vs. (41±4) g/L, (110±17) vs. (122±14) g/L, 1.4 (1.0, 2.0)vs. 2.3 (1.6, 3.8)×109/L, 7.8 (6.3, 10.0)×109 vs. 10.0 (8.3, 12.8)×109/L, 1.0 (0.8, 1.6) vs. 2.1 (1.3, 2.5) mmol/L, t=-6.15, -4.22, Z=-4.86, -3.92, -4.16, all P<0.05).Increased levels of serum albumin (OR=0.812, 95%CI:0.705-0.935, P=0.004) and lymphocyte count (OR=0.609, 95%CI:0.383-0.970, P=0.037) may reduce the nutritional risk of children with TBM; while convulsions (OR=3.853, 95%CI:1.116-13.308, P=0.033) and increased level of CSF protein (OR=1.001,95%CI:1.000-1.002, P=0.015) may increase the nutritional risk of children with TBM. Similarly, the rate of complications and drug-induced liver injury was higher in the nutritional risk group (47 cases (75.8%) vs. 15 cases(30.0%), 31 cases (50.0%) vs.8 cases (16.0%), χ2=23.50, 14.10, all P<0.05). Moreover, the length of hospital stay was also longer in the nutritional risk group ((27±13) vs. (18±7) d, t=4.38, P<0.05). Conclusions: Children with TBM have a high incidence of nutritional risk. Convulsive, the level of serum albumin, the level of lymphocyte count and CSF protein may affect the nutritional risk of children with TBM. The nutritional risk group has a high incidence of complications and heavy economic burden.It is necessary to carry out nutritional screening and nutritional support for children with TBM as early as possible.

Tuberculosis meníngea: reporte de casos años 2005-2017 / Meningeal tuberculosis: cases report years 2005-2017

INTRODUCCIÓN: La tuberculosis (TBC) continúa siendo un problema de salud pública mundial; su forma meníngea conlleva mayor letalidad y secuelas, en particular si se asocia a la infección por VIH/SIDA. OBJETIVO: Describir las características demográficas, presentación clínica, laboratorio y de las imágenes de los pacientes con TBC meníngea (aislamiento de Mycobacterium tuberculosis en LCR), analizando diferencias entre pacientes con y sin infección por VIH/SIDA. PACIENTES Y MÉTODOS: Estudio observacional y descriptivo, retrospectivo, de una serie de casos atendidos en el Hospital Dr. Alejandro Posadas de Buenos Aires, Argentina, desde enero de 2005 hasta diciembre de 2017. RESULTADOS: Se analizaron 36 pacientes, 22 de ellos mujeres, con una mediana de edad de 36,5 años. Veintidós pacientes presentaron co-infección por VIH, todos en estadio SIDA. El tiempo de inicio de síntomas tuvo una mediana 11 días. predominando fiebre, estado de conciencia alterado y cefalea. En el LCR se hallaron linfocitosis, hipoglucorraquia, hiperproteinorraquia y ácido láctico elevado. Se realizó tomografía computada de encéfalo a 34 pacientes, 16 sin alteraciones. En otros 16 se realizó resonancia magnética (RM) cerebral, 9 presentaban trastornos vasculares. La RM fue más sensible para identificar refuerzo meníngeo, trastornos de tipo vasculares, y lesiones de tipo granulomatosas. La mediana de inicio de tratamiento fue de 1 día, con 72,2% recibiendo co-adyuvancia con corticosteroides. La mortalidad observada fue de 27,7% y secuelas hubo en 36,1%. Sólo 5 pacientes requirieron intervención neuro-quirúrgica. CONCLUSIÓN: Siendo la TBC meníngea una afección de alta morbimortalidad, es imperioso asegurar un diagnóstico temprano en su evolución mediante la incorporación de la biología molecular e imagenología (RM) al amplio uso clínico.

BACKGROUND. Tuberculosis (TB) continues to be a global public health problem; its meningeal form leads to greater lethality and sequelae, particularly if it is associated with HIV / AIDS infection. AIM: To describe the demographic characteristics, clinical presentation, laboratory and images of patients with meningeal TB (isolation of Mycobacterium tuberculosis in CSF), analyzing differences between HIV and non-HIV patients. METHODS: We performed an observational and descriptive study, with retrospective analysis of patients attending at the Dr. Alejandro Posadas Hospital, Buenos Aires, since January 2005 to December 2017. RESULTS: Thirty-six patients were analyzed, with 22 women with a median age of 36.5 years. Twenty two patients had HIV coinfection, all in the AIDS stage. The symptom onset time was median 11 days. The predominant ones were fever, altered consciousness and headache. In the cerebrospinal fluid were lymphocitosis, hypoglycorrhachia, hyperproteinorrhachia and high lactic acid, according to previously described findings. Of 34 patients who underwent brain scan, 16 patients had no significant pathological findings. MRI was performed in 16 patients, 9 had vascular disorders. Brain MRI was more sensitive to identify meningeal reinforcement than computerized tomography, vascular disorders, and granulomatous lesions. The median onset of treatment was 1 day, with 72.2% of the total receiving coadjuvants with corticosteroids. Mortality of 27.7% and sequelae in 36.1% were observed. Only 5 patients required neurosurgical intervention. CONCLUSION: Since meningeal TB is a disease with high morbidity and mortality, it is imperative to ensure an early diagnosis in its evolution by incorporating molecular biology and imaging (MRI) into broad clinical use.

Diagnostic characteristics of Xpert MTB/RIF assay for the diagnosis of tuberculous meningitis and rifampicin resistance in Southern Brazil / Características diagnósticas do Xpert MTB/RIF para o diagnóstico de meningite tuberculosa e resistência à rifampicina no Sul do Brasil

ABSTRACT Background: The timely diagnosis of tuberculous meningitis (TBM) is challenging. Molecular diagnostic tools are necessary for TBM, particularly in low- and middle-income countries. Objectives: We aimed to calculate the diagnostics characteristics of Xpert MTB/RIF for the detection of Mycobacterium tuberculosis in the cerebrospinal fluid (CSF) and the frequency of rifampicin (RIF)-resistance in the CSF samples. Methods: A total of 313 consecutive CSF samples were studied and categorized into TBM definite, probable, possible, or not TBM cases based on the clinical, laboratory, and imaging data. Results: For the definite TBM cases (n=7), the sensitivity, specificity, efficiency, and positive likelihood ratio were 100, 97, 97, and 38%, respectively. However, for the TBM definite associated with the probable cases (n=24), the sensitivity decreased to 46%. All CSF samples that were Xpert MTB/RIF-positive were RIF susceptible. Conclusion: Xpert MTB/RIF showed high discriminating value among the microbiology-proven TBM cases, although the values for the probable and possible TBM cases were reduced. Xpert MTB/RIF contributes significantly to the diagnosis of TBM, mainly when coupled with the conventional microbiological tests and clinical algorithms.

RESUMO Introdução: O diagnóstico da meningite tuberculosa (TBM) é desafiador. Ferramentas de diagnóstico molecular são necessárias para esse diagnóstico, particularmente em países de baixa e média renda. Objetivos: Calcular as características diagnósticas do Xpert MTB/RIF para a detecção de Mycobacterium tuberculosis no líquido cefalorraquidiano (LCR) e a frequência de resistência à rifampicina (RIF) nas amostras do LCR. Métodos: Um total de 313 amostras consecutivas de LCR foram estudadas e categorizadas em casos de TBM definida, provável, possível ou não TBM, com base nos dados clínicos, laboratoriais e de imagem. Resultados: Para os casos definidos de TBM (n=7), sensibilidade, especificidade, eficiência e razão de verossimilhança positiva foram de 100, 97, 97 e 38%, respectivamente. No entanto, para os casos de TBM definidos associados aos prováveis (n=24), a sensibilidade diminuiu para 46%. Todas as amostras de LCR que foram positivas para Xpert MTB/RIF foram suscetíveis a RIF. Conclusão: O Xpert MTB/RIF mostrou alto valor discriminante entre os casos TBM comprovados por microbiologia, porém o valor nos casos prováveis e possíveis de TBM foram reduzidos. O Xpert MTB/RIF contribui significativamente para o diagnóstico de TBM, principalmente quando associado aos testes microbiológicos convencionais e algoritmos clínicos.

Tuberculoid Granuloma in the Brainstem: Case Report

Meningitis or meningoencephalitis are the most common presentations of Koch bacilli infection on the central nervous system (CNS), especially in immunosuppressed patients, in whom the bacilli normally reaches the meninges and the cerebral parenchyma.. A least common pathological presentation is the tumoral growth pattern disease known as tuberculoma. This pathological entity is more common in the cerebral hemispheres and is rarely located in the brainstem. The present case report describes a case of a 55-year-old patient under regular antiretroviral therapy who was hospitalized with signs of brainstem and cerebellar disturbances. Computed tomography (CT) and magnetic resonance imaging (MRI) of the brain showed an exophytic lesion in the dorsal region of the pons. The patient underwent total resection of the lesion and the histopathologic analysis was consistent with a tuberculoma.

Diabetes insipidus secondary to tuberculous meningoencephalitis with hypothalamic involvement extending to the hypophysis: a case report

Abstract The involvement of Mycobacterium tuberculosis in the central nervous system (CNS) is an uncommon and devastating manifestation of tuberculosis. We report a case of disseminated tuberculosis presenting as meningoencephalitis, hypothalamic involvement with extension to the hypophysis, and secondary insipidus diabetes diagnosed at autopsy.

Utilidad de la cuantificación de carga viral de VIH en líquido cefalorraquídeo, a propósito de un caso / Clinical utility of HIV viral load assessment in cerebral spinal fluid, a case report

Resumen La detección de virus en el líquido cefalorraquídeo (LCR) en pacientes infectados por VIH con carga viral (CV) indetectable en el plasma se ha denominado escape viral. Estas fugas pueden ser asintomáticas o asociadas con enfermedad neurológica. La discordancia de la carga viral de VIH entre plasma y LCR evidenciaría la presencia de distintos compartimentos del virus, con la posibilidad de identificar quasiespecies con mutaciones específicas que confieran resistencia a la TARV. Presentamos el caso clínico de un paciente con infección por VIH en etapa SIDA y una tuberculosis diseminada que presentó un cuadro neurológico manifestado por cefalea y un síndrome convulsivo, en que se encontró una discordancia entre la CV para VIH en plasma y LCR. El estudio genotípico del virus obtenido del LCR identificó nuevas mutaciones que determinaron un cambio de la TARV, con evolución posterior satisfactoria.

Detection of virus in cerebrospinal fluid (CSF) in HIV-infected patients with HIV viral load (VL) undetectable in plasma has been termed viral escape. These leaks may be asymptomatic from a neurological point of view, similar to plasma blips, or associated with neurological disease, with discordant VL between plasma and CSF, and may be evidence of a compartmentalization of the virus and the possibility of identifying quasispecies with mutations that confer resistance to ART. We present the case of a man with AIDS and disseminated tuberculosis who presented neurological symptomatology evidenced by headache and convulsive syndrome, who presented a discordance between plasma and CSF HIV VL; the genotypic test of the virus, obtained by lumbar puncture, identified new mutations that determined a change in ART with subsequent satisfactory evolution.

A fatal case of tuberculous meningitis in a child with juvenile idiopathic arthritis: a diagnostic challenge

Abstract The prognosis of tuberculous meningitis, a rare form of extrapulmonary tuberculosis, depends on the stage of treatment initiation. We report a fatal case of tuberculous meningitis. The patient had received successive tumor necrosis factor (TNF) antagonists and abatacept to treat juvenile idiopathic arthritis, with negative results for polymerase chain reaction and acid-fast bacilli on smear, had normal cerebrospinal fluid (CSF) adenosine deaminase and glucose levels. Six weeks post-admission, the CSF culture demonstrated Mycobacterium tuberculosis. The altered immunological responses caused by anti-TNF treatment made the diagnosis challenging. Clinicians should bear this in mind and, if suspected, treatment should be initiated immediately.

Tratamiento de meningitis tuberculosa en paciente HIV negativo, posible reacción paradojal / Possible paradoxical reaction to treatment of tubercular meningitis in an HIV negative patient

La respuesta paradojal al tratamiento tuberculoso es la aparición de manifestaciones clínico-radiológicas nuevas, o el empeoramiento de las previas, luego de una mejoría inicial con el tratamiento específico. Se puede observar en 6-30% de los casos de tuberculosis meníngea. Es una reacción inmunológica exagerada y debe tenerse presente ya que su tratamiento se basa en el uso de inmunomoduladores y no en el cambio de las drogas antituberculosas. Presentamos el caso de una paciente adulta HIV negativa con meningitis tuberculosa que, luego de una adecuada respuesta inicial al tratamiento, intercurre a las 10 semanas con una reacción paradojal tratada satisfactoriamente con corticoides.

The paradoxical response to tuberculosis treatment consists in the appearance of new clinical or radiologic manifestations or worsening of previous injuries after an initial improvement with anti-tuberculosis therapy. It can be observed in 6 to 30 percent of the cases of tubercular meningitis. It is the consequence of an exaggerated immune reaction that should be considered since the treatment is based on the use of immunomodulators and not in the change of anti-tuberculous drugs. We present the case of an HIV negative adult with tuberculous meningitis with a good initial response to specific therapy who showed, 10 weeks later, a paradoxical reaction to treatment that responded successfully to corticosteroids.

Tuberculous meningitis in childhood: new aspects of neurologic complications / Meningite tuberculosa na infância: novos aspectos das complicações neurológicas

Tuberculous Meningitis (TBM) is a severe manifestation of tuberculosis that represents 1% of the cases of infection by Mycobacterium tuberculosis. Children are among the other age groups the most affected and when present, HIV-1 is responsible for poorer prognosis. It was carried out a search on the databases of Pubmed, Lilacs and Scielo, looking for articles that approach the principals news aspects of neurologic complications caused by TBM. The literature cite as major neurologic findings the hydrocephalus in approximately 80% patients, meningeal irritation, coma, seizures, intracranial pressure signs, cranial nerve palsy, hemiparesis and disorders in the movement. Neurologic sequelae occur in up to 50% of survivors and early diagnosis is crucial to reduce the occurrence of major functional losses. In this way, discussions presenting more specific methods for TBM as well as better assessment of the signs and symptoms of the disease is necessary for a better prognosis and lower mortality rate of these patients.

A meningite tuberculosa (MTB) é uma manifestação grave da tuberculose que representa 1% dos casos de infecção por Mycobacterium tuberculosis. As crianças estão as faixas etárias mais afetadas e quando presente, o HIV-1 é responsável pelo pior prognóstico. Foi realizada uma revisão de bancos de dados Pubmed, Lilacs e Scielo, à procura de artigos que abordem os principais aspectos das complicações neurológicas causadas pela MTB. Os principais achados neurológicos compreendem a hidrocefalia em aproximadamente 80% dos pacientes, irritação meníngea, coma, convulsões, sinais de pressão intracraniana, paralisia de nervo craniano, hemiparesia e distúrbios movimento. Sequelas neurológicas ocorrem em até 50% dos sobreviventes e o diagnóstico precoce é crucial para reduzir a ocorrência de perdas. Desta forma, as discussões apresentando métodos mais TBM, bem como uma melhor avaliação dos sinais e sintomas da doença é necessária para um melhor prognóstico e menor taxa de mortalidade desses pacientes.

Intramedullary Tuberculoma after Tuberculous Meningitis ­A Rare Case with an Uncommon Radiological Presentation / Tuberculoma intramedular secundário à meningite tuberculosa­um caso raro com apresentação radiológica incomum

Tuberculosis is a chronic bacterial infection caused by Mycobacterium tuberculosis. Despite advances in treatment, resistant strains and unusual sites of involvement have been diagnosed. We present a case of a 13-year-old patient in treatment for tuberculous meningitis who presented with progressive paraparesis. The MRI showed two intramedullary nodular lesions at T4­T6 levels, isointense with annular hyperintensity on T1W, hypointense on T2W, becoming hypointense with ring enhancement after contrast. These characteristics differ from those usually described for intramedullary tuberculomas. Surgical excision was performed, confirming the diagnosis of intramedullary tuberculoma. The formation of intramedullary tuberculomas is rare, with a ratio of two cases per thousand diagnosed with CNS tuberculosis, and the thoracic spine is most frequently affected. The clinical picture is of progressive subacute spinal cord compression, and it may lead to paraplegia. At MRI, the lesion in early stage appears as hypointense rings on T1W and hyperintense on T2W, with homogeneous enhancement after contrast. After the formation of the solid caseous granuloma, it becomes isointense on T1W and hypointense on T2W with homogeneous enhancement after contrast. When the center of the granuloma becomes liquefied, it shows hypointense sign on T1W and hyperintense with peripheral enhancement on T2W. The treatment of choice is medical, with the current protocol including rifampin, isoniazid, pyrazinamide, and ethambutol. Surgery is reserved for cases of progressive neurologic deficits or for diagnostic confirmation. Although benign and potentially curable, intramedullary tuberculoma should be promptly diagnosed and treated to prevent irreversible damage.

A tuberculose é uma infecção bacteriana crônica causada pelo Mycobacterium tuberculosis. Apesar dos avanços no tratamento, cepas resistentes e locais incomuns de envolvimento vêm sendo diagnosticados. Apresentamos o caso de um paciente de 13 anos de idade, em tratamento para meningite tuberculosa que se apresentou com paraparesia progressiva. A ressonância magnética mostrou duas lesões nodulares intramedulares no nível de T4­T6, isointensas com bordos hiperintensos em T1, hipointensos em T2, tornando-se hipointensos com realce anelar após contraste. Essas características diferem daquelas usualmente descritas para tuberculomas intramedulares. Foi realizada a excisão cirúrgica, confirmando o diagnóstico de tuberculoma intramedular. A formação de tuberculomas intramedulares é rara, com uma proporção de dois casos por mil diagnosticados com tuberculose do sistema nervoso central (SNC), e a coluna torácica é a mais frequentemente acometida. O quadro clínico é de compressão da medula espinal progressiva subaguda, podendo levar à paraplegia. Na ressonância magnética, a lesão em fase inicial aparece como anéis hipointensos em T1 e hiperintensos em T2, com realce homogêneo após contraste. Após a formação do granuloma caseoso sólido, torna-se isointensa em T1 e hipointensa em T2, com realce homogêneo após contraste. Quando o centro do granuloma torna-se liquefeito, mostra sinal hipointenso em T1 e hiperintenso com realce periférico em T2. O tratamento de escolha é medicamentoso, com o protocolo corrente de rifampicina, isoniazida, pirazinamida e etambutol. A cirurgia é reservada para os casos de déficit neurológico progressivo ou para confirmação diagnóstica. Embora benigna e potencialmente curável, deve ser diagnosticada e tratada para evitar danos irreversíveis.

Valor diagnóstico da nested PCR em tempo real em pacientes com meningite tuberculosa / Diagnostic value of the nested real time PCR patients with tuberculous meningitis

Introdução: A meningite tuberculosa (MTB) é a forma mais grave e fatal de tuberculose. O diagnóstico oportuno e o tratamento adequado e precoce são os principais fatores associados com o bom prognóstico. Os métodos utilizados na prática médica diária - achados clínicos, exames de imagem e análise de líquido cefalorraquidiano (LCR) - têm baixa acurácia. A pesquisa do DNA do Mycobacterium tuberculosis no LCR através da reação em cadeia da polimerase (PCR, do inglês polimerase chain reaction) com a metodologia nested é promissora, especialmente quando associada à praticidade da amplificação do DNA em tempo real. Objetivo: Avaliar o valor diagnóstico da nested PCR em tempo real (nRT-PCR, do inglês nested real-time PCR) na investigação de pacientes com MTB. Métodos: Estudo observacional realizado em duas fases: uma prospectiva e outra retrospectiva. Na fase prospectiva, foram incluídos pacientes com suspeita de MTB internados no Instituto de Infectologia Emílio Ribas (IIER). Informações clínicas, laboratoriais e radiológicas foram coletadas, assim como amostra de LCR de todos os pacientes. A partir de critérios internacionais padronizados, os pacientes foram categorizados como "MTB Definitiva", "MTB Provável", "MTB Possível" e "Não MTB". A nRT-PCR, utilizando o gene alvo mpt64, foi realizada em todas as amostras de LCR no Laboratório de Meningites Bacterianas do Instituto Adolfo Lutz. Sensibilidade, especificidade e intervalos de confiança (IC 95%) da nRT-PCR foram calculados com base no padrão-ouro (cultura positiva para M. tuberculosis ou isolamento de BAAR no sistema nervoso central) e nos pacientes com outros diagnósticos estabelecidos (Não MTB). Também foi calculada a proporção de pacientes com a nRT-PCR positiva em cada categoria clínica. Na fase retrospectiva, foi realizada uma revisão de prontuários de pacientes que tiveram a nRT-PCR solicitada no IIER e no Centro de Referência e Treinamento em DST/AIDS. Os mesmos procedimentos...

Background: Tuberculous meningitis (TBM) is the most serious and lethal presentation of tuberculosis. Timely diagnosis and appropriated treatment are the main factors associated with good outcome. Methods used in the daily medical practice - clinical, radiological and cerebrospinal fluid (CSF) findings - have low accuracy. Search for Mycobacterium tuberculosis DNA in the CSF by polymerase chain reaction (PCR) using the nested methodology is promising, especially when combined with the practical approach of the real time DNA amplification. Objective: To evaluate the diagnostic value of a nested real-time PCR (nRT-PCR) in the investigation of patients with TBM. Methods: A two-phase observational study was carried out: prospective and retrospective. In the prospective phase, patients with suspected TBM hospitalized at "Instituto de Infectologia Emílio Ribas" (IIER) were included. Clinical, laboratory and radiological data were collected, as well as CSF samples of all patients. According to international standard criteria, patients were categorized as "TBM Definite", "TBM Probable", "TBM Possible" and "Not TBM". The nRT-PCR, using the mpt64 gene, was performed on all CSF sample in the Laboratory of Bacterial Meningitis, Adolfo Lutz Institute. Sensitivity, specificity and confidence intervals (95% CI) of the nRT-PCR were calculated based on the gold standard (culture positive for M. tuberculosis or AFB isolation on the central nervous system) and on patients with other established diagnoses ("Not TBM"). The proportion of patients with a positive nRT-PCR in each clinical category was also calculated. In the retrospective phase, medical chart review was performed in those patients who had the nRT-PCR requested in IIER and in the "Centro de Referência e Treinamento em DST/AIDS". The same diagnostic categorization and calculations of sensitivity and specificity were adopted. Results: 102 patients were included in the prospective phase, 92 of them...

Reacción paradojal al tratamiento antituberculoso en un paciente inmunocompetente: a propósito de un caso / Paradoxical reaction during tuberculosis treatment in immunocompetent children: case report

Tuberculosis is an important public health problem. It is estimated that around 5-10% of patients with tuberculosis present with central nervous system involvement; meningitis and tuberculoma being two of the most frequent manifestations. The paradoxical reaction in patients undergoing antituberculosis treatment is infrequent, nevertheless it is an important consideration in patients, who after an appropriate initial response to specific treatment, present with worsening clinical and radiological signs or the appearance of new lesions.

La tuberculosis (TBC) es un problema de importancia en salud pública. Se estima que alrededor de 5 a 10% de los pacientes con TBC presentan compromiso de sistema nervioso central, siendo la meningitis y el tuberculoma las manifestaciones más frecuentes. La reacción paradojal en pacientes con tratamiento antituberculoso es infrecuente, sin embargo, es importante considerarla en pacientes que durante la terapia, luego de una respuesta inicial apropiada, presentan un empeoramiento clínico y/o radiológico o aparición de nuevas lesiones.

Neurotuberculosis mimicking brain tumour; A case report.

Summary: Neurotuberculosis is one of the grave complications of primary tuberculous infection. Extensive BCG vaccination of children and inadequate antituberculous drug therapy have led to the emergence of newer complex clinical pictures and diagnostic dilemma. Here we report a case of right-sided hemiparesis with features of raised intracranial tension in a sixyear- old boy. Neuroimaging revealed presence of a high grade astrocytoma. On clinical examination, right-sided cervical lymphadenopathy with discharging sinus and tenderness over right hip joint were present. On further investigation, these were proved to be of tubercular origin. All preliminary findings were in favour of disseminated tuberculosis, but the nature of CNS lesion was creating diagnostic dilemma. Etiological diagnosis of the CNS lesion was necessary, as, if it was not of tubercular origin, the management protocol would be different and with any delay we could have lost the patient. Though on routine CSF study, no AFB were present, but we confirmed the presence of mycobacterial DNA by polymerase chain reaction. Patient showed considerable improvement after being put on Anti-tubercular Treatment (ATT) and steroids. Tuberculous brain abscess is rare. Very few cases have been reported even in adults. Most reported cases are in immunocompromised patients. This case highlights the fact that tuberculous brain abscess can have atypical presentation even in immunocompetent children mimicking CNS malignancy. Careful examination and thorough investigation are required to establish the diagnosis. Timely initiation of appropriate therapy can reduce mortality and neurological sequelae.

Tuberculous meningitis: do modern diagnostic tools offer better prognosis prediction.

Background: The British Medical Research Council (BMRC) staging has been extensively used to evaluate the disease severity and establish the approximate prognosis of tuberculous meningitis. Aims: This study aimed at analyzing the predictive accuracy for mortality and neurological sequelae of a set of clinical features, laboratory tests and imaging. Methods: We compared the British Medical Research Council (BMRC) staging with a new scoring proposal to predict the prognosis of patients with Central Nervous System Tuberculosis. Data from Ecuador was collected. A score was built using a Spiegelhalter and Knill-Jones method and compared with BMRC staging with a ROC curve. Results: A total of 213/310 patients (68.7%) were in BMRC stage II or III. Fifty-seven patients died (18.3%) and 101 (32.5%) survived with sequelae. The associated predictors were consciousness impairment (p= 0.010), motor deficit (p = 0.003), cisternal effacement (p=0.006) and infarcts (p=0.015). The new score based on these predictors yielded a larger area under the curve of 0.76 (95% CI: 0.70-0.82), but not significantly different from the BMRC (0.72: 95% CI: 0.65-0.77). Conclusions: This modern score is easy to apply and could be a sound predictor of poor prognosis. However, the availability of modern tests did not improve the ability to predict a bad outcome.

Tuberculous meningitis: do modern diagnostic tools offer better prognosis prediction.

Background: The British Medical Research Council (BMRC) staging has been extensively used to evaluate the disease severity and establish the approximate prognosis of tuberculous meningitis. Aims: This study aimed at analyzing the predictive accuracy for mortality and neurological sequelae of a set of clinical features, laboratory tests and imaging. Methods: We compared the British Medical Research Council (BMRC) staging with a new scoring proposal to predict the prognosis of patients with Central Nervous System Tuberculosis. Data from Ecuador was collected. A score was built using a Spiegelhalter and Knill-Jones method and compared with BMRC staging with a ROC curve. Results: A total of 213/310 patients (68.7%) were in BMRC stage II or III. Fifty-seven patients died (18.3%) and 101 (32.5%) survived with sequelae. The associated predictors were consciousness impairment (p= 0.010), motor deficit (p = 0.003), cisternal effacement (p=0.006) and infarcts (p=0.015). The new score based on these predictors yielded a larger area under the curve of 0.76 (95% CI: 0.70-0.82), but not significantly different from the BMRC (0.72: 95% CI: 0.65-0.77). Conclusions: This modern score is easy to apply and could be a sound predictor of poor prognosis. However, the availability of modern tests did not improve the ability to predict a bad outcome.

Comparación de adenosina deaminasa y detección de anticuerpos anti-antígeno A60 para el diagnóstico de meningitis tuberculosa / A comparative study for adenosine deaminase and anti-antigen A-60 antibodies detection for the diagnosis of tuberculous meningitis

Background: Diagnosis of tuberculous meningitis (TBM) is hampered by the lack of rapid and accurate diagnostic tools. We evaluated the immunological response to Mycobacterium tuberculosis anti-A60 antibodies in cerebrospinal fluid (CSF) in comparison to adenosine deaminase (ADA) determination, for the diagnosis of TBM. Methods: A total of 63 CSF samples were analyzed by indirect ELISA for the detection of anti- A60 IgG, IgM and IgA. These include samples from 17 patients with confirmed TBM and 46 control patients with other infections. Results: The mean individual anti-A60 IgM, IgG and IgA CSF antibody titers were significantly higher in TBM in comparison with control groups (p < 0.01). The best discriminatory CSF antibody for confirming TBM diagnosis was IgM, with an area under the receiver operating characteristic curve of 0.928 (95%CI 0.834-0.978), compared to 0.863 (95% CI: 0.752-0.936) for ADA testing (p = NS). The sensitivity of anti- A60 IgM CSF antibody titers (cutoff > 0.06 U/ml) was 94.1% compared to 88.2% for ADA (cutoff > 6.2 U/ml), p = NS. Both anti A60 IgM and ADA showed the same moderate specificity (80.4%). Two cases of TBM were correctly identified by anti-A60 IgM but missed by ADA. Conclusion: The ELISA test for anti-antigen A60 antibodies (IgM) is a rapid and sensitive tool for the rapid diagnosis of TBM that can be a complement to ALDA determination. The specificity of both tests is still a limitation in TBM diagnosis.

Antecedentes: El diagnóstico de meningitis tuberculosa (MTBC) se ve limitado por la ausencia de técnicas diagnósticas rápidas y precisas en líquido cefalorraquídeo (LCR). En este estudio evaluamos la respuesta inmunoló-gica de anticuerpos anti-antígeno A60 de Mycobacterium tuberculosis en LCR en comparación a la determinación de adenosina deaminasa (ADA). Métodos: Un total de 63 muestras de LCR fueron estudiadas mediante ELISA indirecto para detección de IgG, IgM e IgA anti-A60. Estas muestras incluyeron 17 casos de MTBC confirmada y 46 controles con otras infecciones. Resultados: Los títulos de IgG, IgM e IgA anti A-60 resultaron significativamente superiores en casos de MTBC versus controles (p > 0,01). El anticuerpo con mej or poder discriminatorio resultó IgM, con un área bajo la curva ROC de 0,928 (95%IC 0,8340,978), comparado a 0,863 (95% IC: 0,752-0,936) para ADA (p = NS). La sensibilidad de IgM anti-A60 (nivel de corte > 0,06 U/ml) fue de 94,1% versus 88,2% para ADA (nivel de corte > 6,2 U/ml), p = NS. Ambos IgM anti-A60 y ADA presentaron la misma especificidad baja-moderada (80,4%). Dos casos de MMTBC fueron correctamente identificados por IgM anti-A60 pero no por ALDA. Conclusión: La detección de anticuerpos anti-A60 (IgM) puede ser de ayuda en el diagnostico de MTBC en forma complementaria a la determinación de ALDA. La baja especificidad de ambos tests constituye su principal limitante.

Neurotuberculosis. Hallazgos intracraneanos en RM / Neurotuberculosis. Intracranial MRI findings

Objetivos. Mostrar nuestra casuística de pacientes con diagnóstico de tuberculosis intracraneana y describir los diferentes tipos de lesiones documentadas en Resonancia Magnética (RM) que caracterizan a esta entidad. Materiales y Métodos. Para el presente trabajo fueron seleccionados, de forma retrospectiva, 20 pacientes con hallazgos positivos de tuberculosis intracraneana. Doce eran de sexo masculino y 8 de sexo femenino, conun rango etario de 8 meses a 49 años de edad (edad media: 21 años). El diagnóstico clínico fue realizado con punción lumbar y cultivo de LCR. Once pacientes presentaron serología positiva para VIH. Las RM fueron realizadas en resonadores de 0.5T y 1.5T, complementadas en dos casos con Tomografía Computada (TC) de cerebro. A dos pacientes se les realizó difusión (DWI) y a un paciente espectroscopía. Resultados. Del total de pacientes (n=20), 14 presentaron compromiso subaracnoideo en la convexidad y 13 compromiso subaracnoideo cisternal basal (afectación leptomeníngea). En 13 se observaron tuberculomas y 11 presentaron angeítis de grandes vasos; mientras que 7 tuvieron angeítis de pequeños vasos, 7 hidrocefalia, 6 infartos parenquimatosos y 1 afectación paquimeníngea. Quince pacientes tenían lesiones combinadas.Conclusión. La localización más frecuente de neurotuberculosis en esta serie fue meníngea con compromiso leptomeníngeo (14 pacientes con afectación subaracnoidea, seguido de afectación cisternal en 13 pacientes) y sólo en un caso fue paquimeníngea. La manifestación parenquimatosa más frecuente fue el tuberculoma (granulomas tuberculosos) con 13 casos. De estos, 5 presentaron un patrón miliar y sólo uno comportamiento pseudotumoral...