Year: 2012
Type: dissertation
Study design: Observational Study
Abstract: Tuberculous meningitis (TBM) is the most severe extrapulmonary complication of tuberculosis, with high morbidity and mortality rates. The objective of this study was to assess the relationship between presenting clinical characteristics and outcome of pediatric TBM. We present a retrospective cohort study of all of the children diagnosed with TBM in a large university hospital in South Africa between January 1985 and April 2005. We compared demographic, clinical, and diagnostic characteristics with clinical outcome after 6 months of treatment. We included 554 patients. Common characteristics on admission were young age (82%; 1 week (58%), poor weight gain or weight loss (91%), loss of consciousness (96%), motor deficit (63%), meningeal irritation (98%), raised intracranial pressure (23%), brainstem dysfunction (39%), and cranial nerve palsies (27%). Common features of TBM on computed tomography scan of the brain were hydrocephalus (82%), periventricular lucency (57%), infarctions (32%), and basal meningeal enhancement (75%). Clinical outcome after 6 months was as follows: normal (16%), mild sequelae (52%), severe sequelae (19%), and death (13%). All of the patients diagnosed with stage I TBM had normal outcome. factors associated with poor outcome in univariate analyses were as follows: African ethnicity, young age, HIV co-infection, stage III TBM, absence of headache and vomiting, convulsions, decreased level of consciousness, motor deficits, cranial nerve palsies, raised intracranial pressure, brainstem dysfunction and radiographic evidence of hydrocephalus, periventricular lucency, and infarction. Ethnicity, stage of disease, headache, convulsions, motor function, brainstem dysfunction, and cerebral infarctions were independently associated with poor outcome in multivariate logistic regression analysis. TBM starts with non-specific symptoms and is often only diagnosed when brain damage has already occurred. Earlier diagnosis will improve outcome significantly. We were able to identify presenting variables independently associated with poor clinical outcome. epidemiology of TBM in South Africa 25 C H A PT ER 2 BackGRound Two billion people are infected with Mycobacterium tuberculosis (M. tub), and each year 9 million people develop tuberculosis (TB) [1]. Although the incidence of TB is increasing, prevalence and mortality rates are declining. Annually, ∼2 million people die as a result of this disease [2]. Tuberculous meningitis (TBM) is the most severe complication of TB and frequently occurs in childhood. Lymphohematogenous spread from a primary pulmonary focus leads to the development of a Rich focus in the brain. Rupturing of this caseous granuloma into the subarachnoid space causes 3 features responsible for the clinical manifestations of TBM: development of further tuberculomas; basal inflammatory exudates that cause cranial nerve palsies and obstruct CSf pathways, resulting in hydrocephalus; and obliterative vasculitis, which leads to infarctions [3]. Once the Rich focus has ruptured, a prodromal period of nonspecific symptoms, such as fever, vomiting, and behavioral changes, develops. As the disease progresses, neck stiffness, loss of consciousness, motor deficits, and convulsions will follow. The diagnosis is often only considered once irreversible neurologic damage has already occurred [4]. The Western Cape Province has the highest incidence of TB in South Africa (998 per 100 000) and a 1.9% prevalence of HIV. HIV coinfection increases the risk of developing TBM and leads to more complications and a higher case fatality rate [5,6]. Incidence rates of TBM are age specific and range from 31.5 per 100 000 (< 1 year) to 0.7 per 100 000 (10–14 years) in the Western Cape Province [7]. paTIenTs and MeThods
Author: Gijs T. van Well
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W2147053511