Presentation and outcome of tuberculous meningitis in adults in the - PDF document

Epidemiol. Infect. (2008), 136 , 1455–1462. f 2008 Cambridge University Press doi:10.1017/S0950268807000258 Printed in the United Kingdom Presentation and outcome of tuberculous meningitis in adults in the province of Castellon, Spain: a retrospective study B. ROCA*, N. TORNADOR AND E. TORNADOR Infectious Diseases Division, Hospital General of Castellon, University of Valencia, Spain ( Accepted 6 December 2007; first published online 21 January 2008 ) SUMMARY The aim of this study was to describe the epidemiological and clinical features of tuberculous meningitis in the province of Castellon, Spain. Retrospective analysis was done of all cases attended during the last 15 years. The following groups of variables were assessed: sociodemographic data, medical antecedents, clinical presentation, imaging study results, analyses, cerebrospinal fluid microbiology, treatment, and outcome. Twenty-nine cases were included. Median of age of patients was 34 years, and 17 (59%) were males. HIV infection was present in 15 cases (52%), fever, the most common symptom, occurred in 27 (93%), nuchal rigidity was noted in only 16 (55%), and syndrome of inappropriate ADH secretion (SIADH) occurred in 13 cases (45%). Chest radiograph was abnormal in 15 cases (52%). Anaemia was found in 22 subjects (76%), hypoalbuminaemia in 18 (62%) and hyponatraemia in 15 (52%). Macroscopic aspect of cerebrospinal fluid was normal in 17 cases (65%). Acid-fast stain was positive in only one case (4%). Two patients presented resistance to anti-tuberculous medications. Twelve patients (41%) died and eight (28%) presented sequelae. An association was found between death as outcome and presence of SIADH and lower level of serum cholesterol. Tuberculous meningitis is a rare and frequently difficult to recognize disease, which results in significant morbidity and mortality. We found an association of mortality with SIADH and lower level of serum cholesterol. subarachnoid space. The disease may present acutely INTRODUCTION with altered sensorium and neck rigidity, or much Tuberculosis (TB) has re-emerged in the last two more subtly with malaise, headache and minimal decades in developed countries, mainly due to the mental change. For that reason, in many patients, the HIV epidemic and immigration [1, 2]. Central nervous disease is difficult to recognize, and a high index of system involvement by the disease is estimated to oc- suspicion is necessary to establish the diagnosis. Un- cur in 5–10% of patients, with tuberculous meningitis fortunately, when TM goes unrecognized and without (TM) as the most common manifestation [3–5]. early treatment, mortality and permanent disability TM usually results from the haematogenous spread rates are high [5, 6]. of primary or post-primary pulmonary infection, or Descriptive studies of TM are useful for under- from the rupture of a subependymal tubercle into the standing the impact of the disease and to determine possible changes in its presentation over time, which may be useful for optimization of medical care for * Author for correspondence: Dr B. Roca, Catalunya, 33-A, the condition. In recent years, a few reports of TM in 4. 12004 Castellon, Spain. the adult population have been reported worldwide. (Email: brocav@meditex.es) Downloaded from https://www.cambridge.org/core. IP address: 192.151.151.66, on 18 Aug 2020 at 00:52:32, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0950268807000258

1456 B. Roca, N. Tornador and E. Tornador In general the condition remains a serious compli- probable if: ( a ) the clinical picture was suggestive of cation of TB, although prognosis is nowadays better TM, ( b ) CSF laboratory results or meningeal biopsy than it was in earlier reports, probably due to im- were compatible with TM, ( c ) diagnostic tests ex- proved medical care [7, 8]. cluded other aetiologies, and ( d ) a clinical response to Research in this field in Spain is scant. In a review anti-tuberculous treatment was observed. of the literature of the last 10 years, we found only In compliance with Spanish regulations regarding two reports of TM cases, both of which concerned confidentiality, no personal data that could allow children [9, 10]. Therefore, we undertook this study identification of patients was used throughout the to describe the epidemiological and clinical features study. of TM in adults, and to assess the changing pattern of the disease over time in our institution. We also Study variables attempted to determine factors associated with TM- From each case of TM the following variables were related mortality. recovered and assessed: ( a ) sociodemographic data: year of occurrence, hospital attended, and patient’s METHOD age, gender and nationality; ( b ) patient’s medical antecedents: previous episodes of TB, human im- Study design munodeficiency virus (HIV) infection, intravenous This study consisted of a retrospective analysis of drug use (IVDU), alcohol abuse, diabetes mellitus, all cases of TM diagnosed from 1 January 1991 to 31 use of immunosuppressant medications, and presence December 2005 in the five hospitals of Castellon, a of other immunodeficiencies; ( c ) clinical presentation province of 500 000 inhabitants, situated in the North of TM: main symptom, duration of symptoms of the Comunidad Valenciana, Spain. The ethnic before diagnosis, duration of hospitalizations before background of almost all the population of Castellon diagnosis, presence/absence of nuchal rigidity, level is Caucasian. of consciousness (alert, lethargic or comatose), high- est axilar temperature, early complications of TM [seizures, syndrome of inappropriate ADH secretion Recovery of cases (SIADH), cranial nerve palsy or other], presence/ab- Cases of TM were recovered with the help of the sence of active TB in other locations, presence/absence electronic databases of the Medical Records Depart- of other infections and duration of hospitalization; ment (MRD) of each of the five institutions. The ( d ) imaging studies: computed tomography (CT) scan databases include all admissions, classified in accord- findings, magnetic resonance imaging (MRI) findings, ance with the Spanish version of The International and chest radiograph results; ( e ) analyses results: Classification of Diseases, 9th Revision, Clinical blood biochemistry, blood cell counts and coagulation Modification (ICD-9-CM) [11]. All cases with ICD- tests, as well as CD4 cell count and HIV RNA in HIV- 9-CM code 013 which relates to patients aged > 14 infected patients, urine analyses results, CSF macro- years were initially searched, and those corresponding scopic aspect, CSF analyses results (glucose, protein, to TM were selected. The cerebrospinal fluid (CSF) white blood cell count and differential); ( f ) CSF results database of the Department of Microbiology, microbiology results: acid-fast stain, culture and/or Hospital General of Castellon, where all micro- nucleic acid test; ( g ) treatment: anti-tuberculous biology specimens are processed in the province of medications, other medications, other treatments, Castellon, and the admissions databases of the duration of anti-tuberculous treatment, and resistance departments of Medicine, Neurology, Neurosurgery, to anti-tuberculous medications; and ( h ) outcome and Infectious Disease of all five hospitals were also (complete recovery, sequelae or death). For the searched, and cases of TM were also selected, if they purpose of this study, the diagnosis of SIADH was had not been found in the MRD database. The established when hyponatraemia was present and the medical records of all selected cases were reviewed, disorder was not explained by any other cause. and all confirmed or probable cases of TM in adults were included in the study. A case was considered Statistical analyses confirmed if Mycobacterium tuberculosis was isolated A Little’s missing completely at random (MCAR) test in the CSF or if nucleic acid of M. tuberculosis was was used to assess deviation from randomness in detected in the CSF. A case was considered as Downloaded from https://www.cambridge.org/core. IP address: 192.151.151.66, on 18 Aug 2020 at 00:52:32, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0950268807000258