Meningitis tuberculosa: un desafío diagnóstico en pediatría

Resumen La meningitis por Mycobacterium tuberculosis es infrecuente en pediatría y su diagnóstico definitivo representa un desafío clínico. Presentamos el caso de un lactante de dos años, que presentó un cuadro de meningitis crónica. Se logró el diagnóstico tras la sospecha imagenológica y la confirmación tras la búsqueda seriada del complejo M. tuberculosis por RPC en LCR y en biopsia de tejido cerebral. A pesar de sus complicaciones, el paciente respondió favorablemente al tratamiento antituberculoso. En Chile, la tuberculosis es infrecuente en niños y los síntomas son generalmente inespecíficos. Los hallazgos en RM cerebral asociados a alteraciones del LCR permiten sospechar el compromiso meníngeo precozmente. Se recomienda iniciar el tratamiento antituberculoso empírico ante la sospecha, ya que mejora el pronóstico. A pesar de los avances diagnósticos y terapéuticos, la meningitis tuberculosa sigue teniendo una alta tasa de complicaciones y un pronóstico ominoso.

Abstract Mycobacterium tuberculosis meningitis is rare in the pediatric population and its definitive diagnosis represents a clinical challenge. We present the case of a 2-year-old infant with chronic meningitis. Diagnosis was accomplished by suggestive radiological findings and serial search for M. tuberculosis complex by real-time polymerase chain reaction (qPCR) in cerebrospinal fluid (CSF) and in brain tissue. Despite the complications, the patient evolved favorably with the tuberculosis treatment. In Chile, tuberculosis is a rare disease in children and symptoms are generally nonspecific. Brain MRI findings associated with CSF alterations allow early suspicion of MTBC. Start of empirical antituberculosis treatment upon suspicion is recommended given it is associated with better prognosis. Despite diagnostic and therapeutic advances, MTBC continues to have a high complication rate and an ominous prognosis.

Absceso hipofisiario como causa de meningitis crónica / Pituitary abscess as cause of chronicle meningitis

Se presenta el caso clínico de una paciente con un cuadro de Meningitis crónica recurrente en que el diagnóstico de absceso selar sólo se logró al operarla con el diagnóstico de Adenoma Hipofisiario. Siendo el absceso hipofisiario una patología de muy baja frecuencia, la presencia de una Meningitis crónica recurrente como forma de presentación es aún más infrecuente. La literatura en general presenta muy pocas series de abscesos hipofisiarios, siendo la mayoría sólo comunicaciones de casos clínicos.

We present the case of a patient with a history of Recurrent Chronic Meningitis, in which the diagnosis of Pituitary abscess was only made after surgery under the diagnosis of Pituitary Adenoma. Given the low frequency of the Pituitary Abscess, the presence of a Recurrent Chronic Meningitis as its presentation is even more infrequent. The common literature presents only a few series of pituitary abscess, which, in most cases, are only case reports.

Histoplasmosis in immunocompetent individuals living in an endemic area in the Brazilian Southeast

Introduction The distribution of infection by Histoplasma capsulatum in Brazil is heterogeneous, and the number of cases affecting immunocompetent individuals is relatively small. This study reports the epidemiological and clinical data regarding histoplasmosis in non-immunosuppressed individuals. Methods The study included only the immunocompetent patients with histoplasmosis who were diagnosed between 1970 and 2012 at a university hospital located in Ribeirão Preto, State of São Paulo, Brazil. Clinical and epidemiological data were collected retrospectively from the patient records. Results Of the 123 patients analyzed, 95 had an active disease that manifested in the different clinical forms of histoplasmosis. Men were the predominant gender, and most patients resided in the Northeast of the State of São Paulo and in the nearby municipalities of the State of Minas Gerais. The risk factors for acquiring histoplasmosis and prolonged contact in a rural environment were recorded in 43.9% and 82.9% of cases, respectively. Smoking, alcoholism, and comorbidity rates were high among the patients with the chronic pulmonary and subacute/chronic disseminated forms of histoplasmosis. Many patients achieved clinical cure spontaneously, but 58.9% required antifungals; the disease lethality rate was 5.3%. Conclusions Immunocompetent individuals manifested the diverse clinical forms of histoplasmosis over a period of 4 decades, revealing an additional endemic area of this fungal disease in the Brazilian Southeast. .

In-hospital mortality of intermittent vs daily antitubercular regimen in patients with meningeal tuberculosis-a retrospective study.

Introduction: The Revised National Tuberculosis Control Programme (RNTCP), the State-run Tuberculosis Control Initiative of the Government of India, recommends intermittent thrice a week Directly Observed Treatment Short course (DOTS) both during intensive phase and continuation phase for a total of nine months for tubercular meningitis. However, most recent guidelines recommend daily regimen. Objective: Assessment of the in-hospital mortality in patients with meningeal tuberculosis. Material and Methods: We retrospectively analyzed the data of patients (n-98) admitted with a diagnosis of meningeal tuberculosis from January Ist 2006 to December 3lst 2009 in a tertiary care centre in South India. Thwaites index score of four or less was used for diagnosis of meningeal tuberculosis which is a weighted diagnostic index score for dichotomised clinical variables including age, blood white cell count, duration of illness, CSF total white cell count, and CSF neutrophil percentage. We compared in-hospital treatment outcome of patients on thrice weekly intermittent DOTS regimen with daily regimen patients. Results: The inhospital mortality was same (27%) in the two treatment regimens (p 0.944). However, there was less incidence of hepatic dysfunction in the intermittent DOTS regimen, even though it was not statistically significant (p 0.148). Conclusions: In the short term, both regimens have similar mortality outcomes and no statistically significant difference in hepatic dysfunction during the hospital stay.

Chronic meningitis by histoplasmosis: report of a child with acute myeloid leukemia

Meningitis is a common evolution in progressive disseminated histoplasmosis in children, and is asymptomatic in many cases. In leukemia, the impaired of the T cells function can predispose to the disseminated form. The attributed mortality rate in this case is 20 percent-40 percent and the relapse rate is as high as 50 percent; therefore, prolonged treatment may be emphasized. We have described a child with acute myeloid leukemia (AML), that developed skin lesions and asymptomatic chronic meningitis, with a good evolution after prolonged treatment with amphotericin B deoxycholate followed by fluconazole.

Detection of Cysticercus antigens and antibodies in cerbrospinal fluid of patients with chronic meningitis

Chronic meningitism is a less frequent manifestation of neurocysticercosis caused by Taenia solium cysticerci. In the present study we used Co-agglutination (Co-A), a simple and rapid slide agglutination test to detect specific Cysticercus antigen in the 67 cerebrospinal fluid (CSF) samples from patients with chronic meningitis of unknown etiology. The results were compared with that of ELISA for detection of antibodies. Among these samples four (5.97 percent) were positive for Cysticercus antigen by Co-A test and six (8.95 percent) were positive for antibodies by ELISA. Two samples were positive by both Co-A and ELISA, two were positive only by Co-A and four were positive only by ELISA. In the present study, although Cysticercus antigen and antibodies were present in CSF samples from eight (11.94 percent) patients, we cannot affirm that all the cases of chronic meningitis are due to cysticercosis, but for any case of chronic meningitis of unknown origin, it would be useful to consider the possibility of cysticercal meningitis.

Meningite crônica é manifestação pouco freqüente de neurocisticercose causada por cisticerco de Taenia solium. No presente estudo utilizamos co-aglutinação (Co-A) um teste simples e rápido de aglutinação para detectar antígeno específico de Cysticercus nas 67 amostras de fluido cerebrospinal (CSF) de pacientes com meningite crônica de etiologia desconhecida. Os resultados foram comparados com os de ELISA para detecção de anticorpos. Dentre estas amostras quatro (5,97 por cento) foram positivas para antígenos de Cysticercus pelo teste Co-A e seis (8,95 por cento) foram positivas para anticorpos por ELISA. Duas amostras foram positivas por ambos Co-A e ELISA, duas foram positivas somente por Co-A e quatro foram positivas somente por ELISA. No presente estudo embora antígenos e anticorpos de Cysticercus estivessem presentes nas amostras de CSF de oito pacientes (11,94 por cento), não podemos afirmar que todos os casos de meningite crônica sejam devidos à cisticercose, mas para qualquer caso de meningite crônica de origem desconhecida seria útil considerar a possibilidade de meningite por cisticerco.

Meningitis mortality in Neurology Ward of Dr. Cipto Mangunkusumo hospital Jakarta.

Mortality rate of meningitis is not decreased even though there is decreasing meningitis rate and advanced development of antibiotics. The purpose of this study is to find out meningitis mortality pattern and to evaluate factors related to meningitis mortality in hospitalized patients. Study was done using retrospective data from medical records of the patients administered in the Neurology ward of Cipto Mangunkusumo hospital from January 1997 – December 2005. Data were reported descriptively in texts and tables, and analyzed with Chi-square for categorical data and Student’s “t” test for numerical data, then for final model using multinomial logistic regression analysis. Two hundred and seventy three patients were included in this study, consisted of 81 female patients and 192 male patients age between 12 to 78 years old. A hundred and fourteen patients died during and 159 patients lived. Decreased level of consciousness, especially stupor (OR 10.44, p 0.000) and coma (OR 53.333, p 0.000), and presence of motor weakness (OR 2.068, p 0.009) had relationship with outcome. Mortality rate of meningitis is still high (41.8%) because there are some factors that affect its prognosis. From this study, onset, level of consciousness, and motor weakness are predictors for meningitis death.

Primary Diffuse Leptomeningeal Gliomatosis: Report of a Case Presenting with Chronic Meningitis

Neoplastic meningitis occurs in approximately 5% of patients with cancer. Primary diffuse leptomeningeal gliomatosis is a rare condition whereby a glioma arises from heterotopic cell nests in the leptomeninges. We report here a case presenting with clinical features similar to those of chronic infectious meningitis without positive cerebrospinal fluid cytology. Neurological signs in our patient deteriorated progressively without responding to antitubercular, antiviral, or antibiotic therapy. Leptomeningeal biopsy sampling revealed the condition to be primary diffuse leptomeningeal gliomatosis.