Childhood tuberculous meningitis: a thirty year review of clinical and cerebrospinal fluid factors associated with bacteriological confirmation

Roos, Michelle (2017-12)

Thesis (MMed)--Stellenbosch University, 2017.

Thesis

ENGLISH ABSTRACT: Background: Tuberculous meningitis (TBM) is one of the most devastating complications of tuberculosis (TB)3 and contributes significantly to the morbidity and mortality of children in high burden TB countries.2 Early diagnosis of TBM is notoriously difficult due to its inconsistent clinical presentation and lack of a rapid, sensitive and specific diagnostic test. Decision-making in resource-constrained countries is most often guided by use of simple cerebrospinal fluid (CSF) analysis. However, the classical CSF findings of lymphocyte predominance, low glucose and high protein,5,7,16-20 are only simultaneously present in one third of cases5, whilst bacteriological confirmation only occurs in 15-40% of cases.17,18,21,23 Neutrophil predominance,22,24,26 high protein concentrations and Human Immunodeficiency virus (HIV) infection24 is thought to increase likelihood of microbiological culture. Defining the CSF parameters that are associated with confirmation of Mycobacterium Tuberculosis will allow for an increased suspicion, and hopefully earlier diagnosis and treatment; especially if those parameters identified are associated with a traditionally atypical TBM CSF picture, higher bacillary load and is influenced by HIV status. Aim: To describe the CSF parameters that affect the sensitivity of bacteriological confirmation of TBM in 491 CSF samples of children diagnosed with the disease in the past 30 years, at Tygerberg Children’s Hospital (TCH) in the Western Cape Province of South Africa. Methods: Retrospective analysis of 491 cases, meeting the diagnostic criteria of definite and probable TBM. Conclusion: 46% of TBM cases do not display the characteristic CSF profile traditionally associated with TBM. Clinico-diagnostic features including neutrophil predominance is not predictive of bacteriological confirmation. However neutrophil predominance was associated with earlier disease manifestations.

AFRIKAANSE OPSOMMING: Agtergrond: Tuberkuleuse breinvliesontsteking is een van die mees verwoestende komplikasies van tuberkulose, en dra betekenisvol tot die morbiditeit en mortaliteit van kinders in hoë TB-belaste nasies by.2 Die vroeë diagnose van tuberkuleuse breinvliesontsteking is berug daarvoor om moeilik te wees, dit is grootendeels as gevolg van die onkonsekwente manier waarop dit klinies voordoen, asook die gebrek aan ‘n spoedige, sensitiewe en spesifieke diagnostiese toets. Besluitneming in lande met beperkte hulpbronne word meestal gelei deur die gebruik van eenvoudige serebrospinale vog (SSV) ontleding. Die klassieke SSV bevindinge van oorheersende limfosiete, lae glukose en ‘n hoë proteïen5,7,16-20is egter net gelyktydig teenwoordig in ‘n derde van gevalle,5 en tuberkuleuse breinvliesontsteking word bakterieël bevesting in slegs sowat 15-40% van gevalle.17,18,21,23Oorheersende neutrofiele,22,24,26 hoë proteïen konsentrasies en HIV positiwiteit24 is geidentifiseer as faktore wat die waarskynlikheid van mikrobiologiese kweking kan verhoog. Deur die SSV parameters te identifiseer wat geassosieer word met bevestigte Mycobacterium Tuberculosis infeksie, sal dit toelaat vir verhoogde suspisie, en hopelik vroeër diagnose an behandeling; veral as daardie geidentifiseerde parameters geassosieer word met ‘n tradisioneel atipiese tuberkuleuse breinvliesontsteking SSV beeld, hoër basillêre lading en deur HIV beïnvloed word. Doelstelling: Om die SSV parameters te beskryf wat die sensitiwiteit van bakteriologiese bevestiging van tuberkuleuse breinvliesontsteking affekteer, in 491 SSV monsters van kinders wat met diè siekte gediagnoseer is in die afgelope 30 jaar, by die Tygerbergse Kinder Hospitaal in die Wes-Kaap Provinsie van Suid Afrika. Metodes: Retrospektiewe ontleding van 491 gevalle wat aan die diagnostiese kriteria voldoen vir definitiewe en waarskynlike tuberkuleuse breinvliesontsteking. Resultate: 46% van die tuberkuluese breinvliesontsteking gevalle vertoon nie die klassieke SSV bevindinge wat tradisioneel daarmee geassosieer word nie. Kliniese en diagnostiese voordoening, insluitend ‘n beeld van oorheersende neutrofiele op SSV is nie aanduidend van ‘n verhoogde kans op mikrobiologiese bevestiging nie. Oorheersende neutrofiele is egter gessosieer met vroeë siekte.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/102609
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