Neuromeningeal tuberculosis in HIV-negative patients: a retrospective study in Rabat, Morocco.

Neuro-Meningeal Tuberculosis (NMT) is a severe infection of the central nervous system which causes a public health problem in Morocco and in several countries in the world. In order to describe the epidemiological, clinical, paraclinical and outcome among NMT patients without HIV, we carried out a retrospective study at the neurology department of the Military Hospital of Rabat in Morocco, over a period of 17 years (2000-2017). Forty patients were included with a mean age of 44 years (± 18) and a sex ratio of 1.66. A history evoking the possibility of tuberculous origin was found in 8 patients (20%). Febrile confusion was the most common clinical manifestation and was observed in 22 patients (55%) followed by febrile meningeal syndrome in 12 patients (30%). The main abnormalities noted in brain magnetic resonance imaging (MRI) were: hydrocephalus in 13 cases (32.5%), intra-cranial tuberculomas in 10 patients (25%) and leptomeningitis in 9 cases (22.5%). Cerebrospinal fluid study found clear aspect in 29 patients (75%), direct acid fast bacilli smear examination was positive in 4 patients (10%) and positive culture in 4 patients (10%). The Polymerase chain reaction (PCR) study returned positive in 6 patients (35%) of the 17 patients tested. The outcome was good in 18 patients (45%) while 19 patients suffered from neurological sequelae (47.5%) and 3 cases of death recorded (7.5%). Febrile confusion was the most reported manifestation in our patients. Subacute onset of symptoms was the most predominant feature in our patients as reported in the literature. Our results are consistent with the literature and confirm the severity of this infectious disease, even in HIV-negative patients.

Spectrum of central nervous system tuberculosis: An experience from a large tertiary care institution of India.

OBJECTIVES: Central nervous system (CNS) is an important site for extrapulmonary tuberculosis. The present study evaluated the spectrum of CNS tuberculosis in a high tuberculosis endemic region. METHODS: The study included 306 cases of CNS tuberculosis. All cases were assessed for clinical evaluation and neuroimaging. All cases were followed up for 3 months. Modified Barthel index was used to assess the outcome. RESULTS: Out of 306 cases of CNS tuberculosis, 174 (56.86%) had intracranial tuberculosis, 55 (17.97%) had spinal tuberculosis, 15 (4.91%) had both intracranial and spinal pathology. Sixty-two (20.26%) patients had disseminated tuberculosis. Two-hundred and fourteen (69.9%) cases had tuberculous meningitis. Disseminated tuberculosis patients had significantly poor modified Barthel index and 3-month outcome. Culture positivity was significantly higher in the disseminated group. Ten (27.02%) out of 37 culture positive tuberculous meningitis cases had multi-drug-resistant tuberculosis. On multivariate analysis disseminated tuberculosis, baseline modified Barthel index ≤12, and stage 3 predicted poor outcome. Fifty-five patients had spinal tuberculosis. Thirty-four (75.56%) patients with Pott's spine improved with antituberculosis treatment and only 11 (24.44%) patients had modified Barthel index ≤12, after 3 months. CONCLUSIONS: In tuberculosis-endemic areas a varied form of CNS tuberculosis is frequent. CNS tuberculosis is often part of disseminated tuberculosis.

Características diagnósticas de tuberculosis intracraneal en hospitalizados del Servicio de Neurología del Hospital Nacional Guillermo Almenara Irigoyen 2008 - 2012 / Diagnostic features of the intracranial tuberculosis in hospitalized in the Neurology Service at the National Hospital Guillermo Almenara Irigoyen 2008 - 2012

Objetivos: Describir las características diagnosticas epidemiológicas, clínicas, de LCR, imagenológicas de tuberculosis intracraneal (TBC Meníngea, Tuberculoma) en hospitalizados del Servicio de Neurología del Hospital Nacional Guillermo Almenara Irigoyen 2008-2012. Materiales y Métodos: Se seleccionó la historia de todos los pacientes hospitalizados en el Servicio de Neurología del Hospital Nacional Guillermo Almenara Irigoyen entre los años 2008 y 2012 con diagnóstico de tuberculosis intracraneal confirmada o sospechosa con un número total de 26 casos. Se obtuvo datos de filiación, antecedentes epidemiológicos, historia de enfermedad, examen neurológico de los 26 pacientes; estudios en LCR: bioquímicos y citoquímicos en 25 pacientes, bk en 20 pacientes, ADA en 20 pacientes, PCR en 8 pacientes y cultivo en 7 pacientes; a los 26 casos se realizó TAC de encéfalo, y a 17 RMN de encéfalo. Resultados: En el Servicio de Neurología del Hospital Nacional Guillermo Almenara referente de la red Almenara se hospitalizaron 26 casos de Tuberculosis Intracraneal (1.47 por ciento de hospitalizados en el Servicio de Neurología) del año 2008 al 2012, de los cuales 19 casos (73.07 por ciento) fueron Tuberculoma cerebral y 07 casos (26.93 por ciento) Meningoencefalitis Tuberculosa (MEC TBC); 17 casos (65.381 por ciento) fueron de sexo masculino y 9 (35.62 por ciento) de sexo femenino, la mayoría estuvieron comprendidos entre el segmento 26 a 40 años con 14 (54.85 por ciento) casos siendo predominante tanto para tuberculoma cerebral 11 (57.89 por ciento), como para MEC TBC 03 (42.86 por ciento); la mayoría provinieron de la Red Almenara 20 (76.91 por ciento) a diferencia de otros 6 casos (23.08 por ciento) que provinieron de otras redes; el tipo de seguro en su mayoría fue obligatorio (principal aportante activo del seguro social) con 15 (57.68 por ciento) pacientes. De los antecedentes epidemiológicos 08 pacientes (30.77 por ciento) tuvieron contacto familiar de tuberculosis...

Objectives: Describe diagnostic epidemiological, clinical, CSF, imaging of intracranial tuberculosis (TBC Meningeal, Tuberculoma) in hospitalized Neurology Service of the National Hospital Guillermo Almenara Irigoyen 2008-2012. Materials and methods: The history of all patients hospitalized in the Neurology Service of Guillermo Almenara Irigoyen National Hospital between 2008 and 2012 confirmed or suspected diagnosis of a total number of 26 cases intracranial tuberculosis was selected. Personal data, epidemiological history, history of disease, neurological examination of 26 patients was obtained; CSF studies: Biochemical and cytochemical in 25 patients, 20 patients bk, ADA in 20 patients, 8 patients PCR and culture in 7 patients; the 26 cases of brain CT scan was performed, and 17 NMR brain. Results: In the Neurology Service of the Guillermo Almenara National Hospital, Almenara benchmark of 26 cases of Tuberculosis Intracranial (1.47 per cent of hospitalized in the Neurology Service) they were hospitalized 2008 to 2012, of which 19 cases (73.07 per cent) were Tuberculoma cerebral and 07 cases (26.93 per cent) meningoencephalitis Tuberculous (TBC MEC); 17 cases (65.381 per cent) were males and 9 (35.62 per cent) were female, most were between the segment 26 to 40 years with 14 (54.85 per cent) cases being predominant both cerebral tuberculoma 11 (57.89 per cent) and for MEC TBC 03 (42.86 per cent); most carne from Beacon Red 20 (76.91 per cent) unlike another 6 cases (23.08 per cent) that carne from other networks; the type of insurance was mostly compulsory (primary active contributor of social insurance) 15 (57.68 per cent) patients. The epidemiological history of 08 patients (30.77 per cent) had household contact with tuberculosis; 03 (11.54 per cent) patients had associated immune suppression, with only 3 cases of TBC MEC (MEC 42.86 per cent). The most common general symptoms were headache in 20 cases (76.92 per cent), followed by nausea and vomiting in...

Solitary tuberculous brain lesions: 24 new cases and a review of the literature.

A solitary tuberculous brain lesion (STBL) can be difficult to distinguish from a glioma, metastasis or other infectious disease, especially from a pyogenic brain abscess. We analyzed the clinical characteristics, diagnostic procedures and outcomes of 24 patients with STBL diagnosed in three centers from France, India and Mexico. We also reviewed 92 STBL cases previously reported in the literature. General symptoms were found in 54% of our patients, including enlarged lymph nodes in 20%. Cerebrospinal fluid was typically abnormal, with lymphocytic pleocytosis and a high protein level. The lung CT scan was abnormal in 56% of patients, showing lymphadenopathy or pachipleuritis. Brain MRI or CT was always abnormal, showing contrast-enhanced lesions. Typically, MRI abnormalities were hypointense on T1-weighted sequences, while T2-weighted sequences showed both a peripheral hypersignal and a central hyposignal. The diagnosis was documented microbiologically or supported histologically in 71% of cases. Clinical outcome was good in 83% of cases.

Predictors of paradoxical tuberculoma in tuberculous meningitis.

SETTING: A tertiary care teaching hospital in Lucknow, India. OBJECTIVE: To evaluate the frequency and predictors of paradoxical tuberculoma in definite tuberculous meningitis (TBM) and its influence on TBM outcome. DESIGN: Demographic, clinical, biochemical, cerebrospinal fluid (CSF) findings, CD4 counts and magnetic resonance imaging (MRI) findings of 34 patients with definite TBM included were noted. The patients received four-drug anti-tuberculosis treatment and prednisolone. They were followed up clinically and radiologically at 3 and 6 months; serum chemistry, CD4 counts and CSF were tested at 3 months. Functional outcome was defined on the basis of the Barthel index score. Predictors of paradoxical response were evaluated using univariate and multivariate analysis. RESULTS: The median age of the patients was 33.5 years; 13 were females. Of the 34 study participants, 22 patients developed paradoxical tuberculoma, mostly within 3 months of initiating anti-tuberculosis treatment. Paradoxical tuberculoma was associated with clinical deterioration in 12 patients. Bacille Calmette-Guérin vaccination, higher CSF glucose and abnormal baseline MRI were associated with paradoxical tuberculoma in univariate analysis. After adjustment of covariates, only female sex was independently associated with paradoxical tuberculoma (OR 0.06, 95%CI 0.004-0.79, P= 0.03). Paradoxical response, however, did not influence 6-month outcome. CONCLUSION: Paradoxical tuberculoma occurs in two thirds of patients with definite TBM, and in 50% it is asymptomatic. Females are more susceptible to paradoxical tuberculoma; however, 6-month outcome is not influenced by paradoxical tuberculoma.

Decrease in the incidence of culture-positive meningitis and cerebral tuberculomas in France from 1990 to 2007.

We evaluated the incidence rate of culture-positive central nervous system tuberculosis (CNS TB) in France in 2007 and its time trend between 1990 and 2007. We used a capture-recapture analysis by using data recorded in 2007 by the mandatory notification system and the national network of the National Reference Centre (NRC). The 2007 sensitivity of the NRC was 79·4%. The previous sensitivity for 2000 (75·6%) and that for 2007 yielded a pooled estimate of 77·4% (95% confidence interval 64·8-88·0), which was used to extrapolate the number of culture-positive CNS TB cases from those reported in four surveys (1990, 1995, 2000, 2007). The extrapolated number of culture-positive CNS TB cases fell from 90 to 35 between 1990 and 2007, and the extrapolated incidence rates fell from 1·6 to 0·55 cases/million (P < 0·001). This favourable trend should be closely monitored following the change of the BCG vaccination policy in 2007.

Natural course of epilepsy concomitant with CNS tuberculomas.

BACKGROUND: Epilepsy is relatively common in CNS tuberculomas, but its natural course is unclear. AIM: To determine the prevalence and prognosis of epilepsy in patients with seizures related to CNS tuberculomas. METHODS: We retrospectively reviewed the charts of patients with CNS tuberculomas who presented at our institution between 1983 and 2001. RESULTS: Seizures occurred in 22 of 93 (23.6%) of the patients with CNS tuberculomas. These patients were treated with standard antituberculous therapy for a period varying between 6 and 20 months. Sixty-three out of 93 patients were cured of tuberculosis, and 21 of the 63 (33%) who had concomitant epilepsy became seizure-free. TB recurred in 3 patients, and 1 out of 22 who had concomitant epilepsy continued to have seizures; 3 died and 24 were lost to follow-up. Anti-epileptic medications were discontinued after completion of the anti-TB course. CONCLUSION: Seizures are commonly associated with CNS tuberculomas and most often resolve after successful treatment of the underlying CNS tuberculosis.

Manifestations of cerebral tuberculosis.

Intracranial tuberculosis continues to be a serious problem in both the developing and developed world, with significant morbidity and mortality. It has protean manifestations and at times, poses significant diagnostic challenges to both the radiologist and the treating physician. This pictorial essay aims to acquaint the radiologist with the varied imaging spectrum of intracranial tuberculosis, both the common and uncommon appearances.

Intracranial tuberculomas in patients with tuberculous meningitis: predictors and prognostic significance.

SETTING: Intracranial tuberculomas are commonly observed neuroimaging abnormalities in tuberculous meningitis (TBM). OBJECTIVE: to evaluate the predictors and prognostic significance of tuberculomas in patients with TBM. DESIGN: In a retrospective follow-up study, contrast-enhanced magnetic resonance imaging was performed at study inclusion and after 9 months of follow-up. Univariate analysis and multivariate analysis were used to identify predictive factors for tuberculoma. Prognosis (death and severe disability) was assessed using the modified Rankin scale. RESULTS: At inclusion, 43 of 110 patients had cerebral tuberculomas. Seven patients developed paradoxical tuberculomas. Predictors of tuberculomas were raised cerebrospinal fluid (CSF) protein (>3 g/l) and meningeal enhancement. Multivariate analysis did not show any significant predictors. During follow-up, the only significant predictor of paradoxical development of tuberculomas was raised CSF protein (>3 g/l). After 9 months of follow-up, 32 patients had died or had severe disability. Survival analysis revealed that patients with tuberculomas and those without tuberculomas had a similar prognosis. CONCLUSION: Tuberculomas occurred in approximately 39% of the patients with TBM. Significant predictors were meningeal enhancement and raised CSF protein. TBM patients with or without tuberculomas had a similar prognosis.

Retrospective study of 23 pathologically proven cases of central nervous system tuberculomas.

INTRODUCTION: Extrapulmonary manifestations of tuberculosis involving the central nervous system (CNS) due to haematogenous spread are not a rare entity. It presents as meningitis or tuberculoma. Tuberculoma is a granulomatous inflammatory process mimicking a neoplasm radiologically, so usually a biopsy is performed. MATERIAL AND RESULTS: Our study consisted of 23 pathologically proven cases of tuberculomas between 1988 and 2003. Patients were discussed clinically, radiologically and histologically. Headache, fever, weight loss and weakness are the most common clinical manifestations. Our patient's ages vary from 3 to 67 years with a mean of 31.8 years. Ninety-five percent of patients had bad social, economic and nutritional conditions. None of them were infected by human immunodeficiency virus (HIV). All patients had similar contrast-enhancing lesions radiologically. The majority of tuberculomas were located supratentorially. Only one patient presented two foci of (cerebral and cerebellar) tuberculomas. Nineteen tuberculomas were intracerebral; two were located in the cerebellum and one was intramedullary. Among those lesions, one cavernous sinus tuberculoma and one sellar tuberculoma were identified. Only two patients underwent stereotactic biopsy and 21 patients underwent surgical excision. Histopathologic examination revealed granulomatous inflammation with central caseous necrosis in all patients. DISCUSSION: Diagnosis of tuberculoma can be difficult, and in most of our cases, the clinical diagnosis was 'neoplasm'. For this reason, clinicians must always be aware of it and consider it in the differential diagnosis of central nervous system mass lesions.

Intracranial tuberculomas and caries spine: an experience from Children's Hospital Islamabad.

BACKGROUND: Pulmonary tuberculosis in infants and children in Pakistan is quite common. However, there is limited data about uncommon forms of tuberculous infection of central nervous system. Tuberculosis of nervous system is a serious disease and if not treated adequately, carries high morbidity and mortality. This study was undertaken to highlight the occurrence of relatively uncommon forms of tuberculosis in children. METHODS: This was a retrospective review of the case records of the patients who were admitted in Children's Hospital, Islamabad with the diagnosis of cerebral tubercloma or tuberculosis of spine between January, 1994 and August, 2002. Diagnosis was based on clinical features, history of contact with tuberculous patient, abnormalities on chest X-rays and neuroimaging studies of brain and spine. RESULTS: Nine children had cerebral tuberculomas, six more than one and in five were bilateral. Eight had caries spine, 2 cervical, 4 thoracic and 2 lumbar regions. Three had been vaccinated with Bacillus-Calemette-Guerin and family history of tuberculosis was positive in 7 (41%) children. Nine (53 %) patients had evidence of pulmonary tuberculosis on chest x-ray. Ten computed scan brain, four magnetic resonance imaging, two spinal scan and two myelographic studies were performed. Three patients with tuberculomas and five with caries recovered and 8 were left with neurological deficit. One child with cerebral tuberculomas died. CONCLUSION: Intracranial tuberculomas and spinal tuberculosis are not rare problems in children. Early diagnosis and prompt antituberculous therapy are the most important factors for the favourable outcome.

Brain tuberculoma in Hong Kong.

We report two cases of brain tuberculoma occurring in patients residing in Hong Kong. Both patients presented with headache and had space-occupying lesions evident on computed tomography scans of the brain. The patients had no history of tuberculosis and no symptoms of concurrent extracranial tuberculosis were evident. The diagnosis of tuberculoma was made at the time of surgical excision. Delayed diagnosis of brain tuberculoma is likely to occur in industrialised countries where tuberculosis is rare. In Hong Kong, however, with a constant influx of foreign domestic workers from endemic regions, a high index of suspicion should be maintained. Imaging studies support, but do not confirm, the diagnosis of brain tuberculoma. We recommend obtaining a definitive histological diagnosis, with computed tomography-guided stereotactic biopsy, before starting antituberculous therapy. Surgical excision is necessary in patients with raised intracranial pressure secondary to the lesion, who are not responding to medical therapy.

Tuberculosis of the central nervous system in children: a 20-year survey.

OBJECTIVE: To review our experience of central nervous system (CNS) tuberculosis at a major British paediatric tertiary referral centre, following the introduction of CT Scan facilities. METHODS: This was a retrospective case survey (prospective in nine patients) of patients admitted to Great Ormond Street over a 20-year period (1977-1997), who fulfilled criteria for a diagnosis of CNS tuberculosis. Data were collected with regard to the clinical, laboratory and demographic characteristics of patients, as well as results of radiological investigations and data on clinical outcome. RESULTS: We identified 38 children with CNS tuberculosis: 23 with tuberculous meningitis (TBM), 10 with tuberculous meningitis and associated tuberculomas and five with tuberculomas alone. The mean age of this group was 3.7 years, ranging from 8 months to 16 years. Only 14 (37%) were of Caucasian origin. A contact source was identified in 18 patients (47%). Previous BCG had only been given to six (16%). The main clinical symptoms and signs present on admission were alteration in consciousness in 30 patients (79%), focal neurological signs in 25 (66%) and fever in 25 (66%). Seizures were observed in 20 patients (53%) and meningism in 18 (47%). Mycobacterium tuberculosis was either cultured or identified by acid-fast stain from CSF or brain tissue from 24 patients (63%). The Mantoux reaction was positive in 17/33 (51%); abnormalities of the chest X-ray were found in 15 (40%). Cranial CT scans of the patients presenting with TBM showed hydrocephalus in 31 patients (94%), and basilar enhancement in 27 (93%) out of the 29 patients who received intravenous contrast. Anti-tuberculous therapy administered varied according to current recommendations of the period; concurrent steroids were given to 31 patients (82%). Neurosurgical procedures were required in the majority of patients with TBM, 25 (76%). In five patients with TBM, new tuberculoma developed during treatment. The overall mortality for our group of patients was 13%, whilst permanent neurological sequelae were seen in 47% of the patients. None of the patients who received BCG either died or had severe sequelae. Mortality and morbidity rates were higher in the first 10 years of the study and amongst those patients admitted in Stage III disease. CONCLUSIONS: CNS tuberculosis continues to be a condition which carries significant morbidity and mortality. Early diagnosis and prompt initiation of treatment are essential to improve the poor outcome.

Single-enhancing CT lesions in Indian patients with seizures: a review.

Single enhancing CT lesions are the commonest radiological abnormality in Indian patients with new-onset partial seizures. In few patients the lesions may be 'tuberculoma' (especially in presence of evidence of tuberculosis elsewhere). However, histopathological studies have proved that neurocysticercosis is the most frequent cause for these lesions. Acute inflammation in and around the cerebral lesions of cysticercosis manifests as acute seizure disorder. These cysticercal granulomas represent 'colloidal' and 'nodular-granular' stages of Escobar's pathological classification of natural evolution of a parenchymal cysticercus cyst. In 8-12 weeks time majority of these lesions spontaneously disappear, few may calcify. As albendazole therapy is of controversial value, these patients, possibly, need to be treated only with antiepileptic drugs. Associated seizure disorder is also benign in nature and remit in majority within 6-8 months, recurrences are usually infrequent. Antiepileptic drug may be withdrawn once follow-up CT scan shows resolution of the lesion. If seizures recur after resolution of the lesion, CT lesion persists or CT lesion calcified, a long-term (2-3 years) antiepileptic therapy may be required. The single enhancing CT lesions which persist despite anticysticercal or antituberculous therapy may need histopathological evaluation to establish the correct diagnosis.

Intracranial tuberculoma.

Six patients with cerebral tuberculoma seen over a 2 year period are reported. Their clinical presentations, the result of investigations including radiological findings and their response to medical treatment are discussed and correlated with other reports in the literature. Eighty five percent of the patients were above the age of 30 years. All patients had negative past history of tuberculosis and both chest x-ray and erythrocyte sedimentation rate were within normal limits. Five patients presented with symptoms and signs of space occupying lesions but none had papilloedema. Two patients showed paradoxical enlargement or development of new tuberculous lesions during antituberculous therapy. The diagnosis was established by brain magnetic resonance imaging in 3 patients, and was further confirmed by brain biopsy in the other 3. All patients received antituberculous treatment for 12 months, except one who continued medication for 2 years. Four patients normalized with medical treatment. Intracranial tuberculoma must be included in the differential diagnosis of a space occupying lesion. Magnetic resonance imaging is a sensitive, non-invasive method to diagnose cerebral tuberculoma. Paradoxical enlargement or development of new tuberculomas during antituberculous therapy is a documented phenomenon which can be overcome by continuation of antituberculous treatment. Twelve months of antituberculous treatment is considered to be adequate to resolve intracranial tuberculoma.

Neurologic manifestations of AIDS: a comparative study of two populations from Mexico and the United States.

Neurologic complications associated with human immunodeficiency virus type 1 (HIV-1) infection vary geographically. To understand the pattern of HIV-associated neurologic complications in Mexico, 120 AIDS patients from Mexico City, Mexico, and 500 AIDS patients from Houston, Texas, were studied cross-sectionally and retrospectively. Neurologic, laboratory, imaging, and pathologic examinations identified 40 Mexican patients and 130 U.S. patients with neurologic complications. Whereas AIDS dementia complex was the most common neurologic manifestation in both groups, intracranial tuberculoma was present only in the Mexican population (10%). Primary brain lymphoma was more prevalent in the U.S. population (8.4%). The different findings in the Mexican population likely reflect afflictions common to developing countries--a high prevalence of tuberculosis and a high mortality rate. These conditions preclude complications such as lymphoma, which develop later in the natural course of HIV infection.