ABSTRACT
Immune modulating therapy, such as tumour necrosis factor (TNF)-alpha inhibitors, is becoming increasingly more widespread in the treatment of many autoimmune diseases. One of the well-documented side effects of TNF-alpha inhibitors is an increased risk of reactivating latent tuberculosis infection (LTBI). Diagnostic tools available for diagnosing LTBI lack sensitivity and specificity. We report the case of a rheumatoid arthritis (RA) patient at high-risk of reactivation of LTBI, who should have been offered prophylactic anti-tuberculous treatment on two separate occasions: firstly, before initiating anti-TNF-α treatment and secondly, as part of routine tuberculosis contact tracing. He subsequently developed severe pulmonary tuberculosis and was hospitalised for 6 weeks.
ABSTRACT
BACKGROUND: Tuberculous meningitis is the most severe manifestation of extrapulmonary tuberculosis with a high mortality rate and a high rate of sequelae among survivors. The aim of this study is to assess the current epidemiology, clinical features, diagnostic procedures, treatment and outcome in patients with tuberculous meningitis in Denmark, a country with a low tuberculosis incidence. METHODS: A nationwide retrospective study was conducted, comprising all patients notified with tuberculous meningitis (TBM) in Denmark from 2000-2008. Medical records were reviewed using a standardised protocol. RESULTS: Fifty patients, including 12 paediatric patients, were identified. 78% of the patients were immigrants from countries of high tuberculosis endemicity. 64% of all patients had a pre-existing immunosuppressive condition; 10% were HIV positive, 48% were HIV seronegative and 42% had an unknown HIV status. Median symptom duration before admission was 14 days in the Danish patient population and 20 days in the immigrant group. Biochemical analysis of cerebrospinal fluid (CSF) samples revealed pleocytosis in 90% with lymphocyte predominance in 66%. Protein levels were elevated in 86%. The most common findings on neuro-radiological imaging were basal meningeal enhancement, tuberculomas and hydrocephalus. Lumbar puncture was performed on 42 patients; 31 of these specimens (74%) had a positive CSF culture for mycobacteria and 9.5% were smear positive for acid-fast bacilli. The overall mortality rate was 19% and 48% of the remaining patients had neurological sequelae of varying degree. CONCLUSION: TBM is a rare but severe manifestation of extrapulmonary TB in Denmark. The clinician must be prepared to treat empirically if the suspicion of TBM has arisen to improve treatment outcome.
