RESUMO
OBJECTIVES: We aimed to characterize the clinical and radiological features, and outcomes, of a large cohort of hypertrophic pachymeningitis (HP) patients from a single center. METHODS: We conducted a retrospective study at a tertiary referral center, encompassing patients diagnosed with HP between 2003 and 2022. The diagnosis of HP relied on the identification of thickening of the dura mater via magnetic resonance imaging (MRI) of the brain or spine. RESULTS: We included 74 patients with a mean age of 43.6 ± 14.2 years, of whom 37 (50%) were male. Among them, 32 (43.2%) had an immune-mediated origin, including 21 with granulomatosis with polyangiitis (GPA) (predominantly PR3-ANCA positive), four with systemic lupus erythematosus, three with IgG4-related disease, three with idiopathic HP, and one with rheumatoid arthritis. Non-immune-mediated HP accounted for 45 cases (56.8%). Within this category, 21 (28.4%) were infectious cases, with 14 being Mycobacterium tuberculosis infection (TB-HP), and 21 (28.4%) were malignancy-associated HP. Clinical and MRI characteristics exhibited variations among the four etiological groups. Hypoglycorrhachia was primarily observed in infectious and malignancy-associated HP. Immune-mediated HP was associated with a peripheral pattern of contrast enhancement and the Eiffel-by-night sign. MRI features strongly indicative of TB-HP included leptomeningeal involvement, brain parenchymal lesions, and arterial stroke. MPO-ANCA GPA was associated with a higher prevalence of spinal HP. CONCLUSIONS: Within our cohort, GPA and Mycobacterium tuberculosis emerged as the predominant causes of HP. We identified significant disparities in clinical and radiological features among different etiologies, which could have implications for diagnosis.
RESUMO
BACKGROUND: Ventriculoperitoneal shunt (VPS) represents one of the most classic and widely used treatments for hydrocephalus in pediatric patients. Migration and externalization of the distal end of the catheter through the rectum are extremely rare complications of intestinal perforation with devastating consequences such as meningitis or peritonitis due to enteric bacteria that are significantly life-threatening. Besides, one of the biggest topics with that is that it can happen without producing symptoms, like the patient we present in this case report, which further masks the condition and puts the patient's life more at risk. CASE PRESENTATION: We present a case of a 9-month-old infant patient, with a history of prematurity, tuberculous meningitis (TBM), and hydrocephalus, who came to ED with a functional VPS and the distal end of the catheter protruding outside the rectum for 7 days, without presenting neurological or intestinal symptoms accompanying. One of the parameters that guided the diagnosis and made us suspicious of asymptomatic intestinal perforation (IP) was the background of TMB. The patient was immediately transferred to the OR where both ends of the shunt were removed: in the first instance, the shunt tube was disconnected through the abdomen, thus withdrawing through the anus, and subsequently, the proximal end of the catheter was exteriorized. In turn, the intestinal fistula was successfully repaired laparoscopically, and prophylactic antibiotic treatment was early administered. On the 6th postop day, a shunt was internalized, and a child was discharged on postop day 15 without complications with alarm guidelines. CONCLUSIONS: The authors of this article strongly suggest that (1) anal extrusion of catheters is an uncommon complication but real: for this reason, its development should be considered in all patients with VPS, especially in infants. (2) The patients are often asymptomatic since false tracts can form around the catheter protecting it from spillage, and thus can be removed without complications. (3) Special care should be taken in patients with conditions that increase the risk of developing IP, such as TMB.
Assuntos
Hidrocefalia , Tuberculose Meníngea , Derivação Ventriculoperitoneal , Humanos , Derivação Ventriculoperitoneal/efeitos adversos , Tuberculose Meníngea/complicações , Tuberculose Meníngea/cirurgia , Lactente , Hidrocefalia/cirurgia , Hidrocefalia/etiologia , Migração de Corpo Estranho/cirurgia , Migração de Corpo Estranho/complicações , Migração de Corpo Estranho/diagnóstico por imagem , Masculino , Canal Anal/cirurgiaRESUMO
Se presenta el caso de un paciente varón de 55 años que ingresó por alteración del estado de conciencia por una hiponatremia severa secundaria a una meningitis tuberculosa. No hubo mejoría de la hiponatremia al tratamiento con solución salina hipertónica, por lo cual se planteó el diagnóstico de síndrome de secreción inapropiada de hormona antidiurética (SIADH) y se evidenció mejoría con la restricción hídrica. El interés del presente caso es reportar una complicación frecuente pero olvidada de la meningitis tuberculosa.
We present the case of a 55-year-old male patient who was admitted due to an altered state of consciousness due to severe hyponatremia secondary to tuberculous meningitis. There was no improvement in hyponatremia after treatment with hypertonic saline solution, therefore the diagnosis of syndrome of inappropriate secretion of antidiuretic hormone (SIADH) was proposed, and improvement was evidenced with fluid restriction. The interest of this case is to report a common but forgotten complication of tuberculous meningitis.
RESUMO
BACKGROUND: Tuberculous meningitis (TBM) is the most frequent, severe, and disabling form of central nervous system (CNS) tuberculosis (TB). TBM paradoxical manifestations are characterized by clinical or paraclinical worsening after 1 month of effective anti-TB treatment in patients who initially responded to treatment despite the use of adjunctive corticosteroids. METHODS: Retrospective descriptive study of consecutive HIV-negative adult patients (≥ 18 years) with definitive TBM who developed a paradoxical manifestation following anti-TB in a tertiary-care hospital in Mexico from 2009 to 2019; we also conducted a literature review of published cases/series of paradoxical manifestations in HIV-negative patients from 1980 to 2020. RESULTS: We detected 84 cases of definitive TBM; 55 (68.7%) HIV-negative patients and 29 (36.3%) HIV-infected patients. Among HIV-negative patients, four (7.3%), three female and one male (19-49 years old), developed a paradoxical manifestation within 4-14 weeks following treatment initiation despite receiving adequate corticosteroid doses; Mycobacterium bovis was isolated from the cerebrospinal fluid of three cases and Mycobacterium tuberculosis in one more. Two patients developed vasculopathy-related cerebral infarctions, one severe basilar meningitis, and hydrocephalus, one more a tuberculoma. Two were treated with intravenous cyclophosphamide, and two with steroids. One of the patients treated with steroids died; patients who received cyclophosphamide had a good clinical response. CONCLUSIONS: This case series illustrates the diverse clinical/radiologic paradoxical manifestations of TBM in HIV-negative patients. Cyclophosphamide may be safe and effective in treating TBM-associated paradoxical manifestations. Specific diagnostic and care protocols for these patients are needed.
Assuntos
Infecções por HIV , Mycobacterium tuberculosis , Tuberculose Meníngea , Adulto , Antituberculosos/uso terapêutico , Feminino , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tuberculose Meníngea/líquido cefalorraquidiano , Tuberculose Meníngea/complicações , Tuberculose Meníngea/tratamento farmacológico , Adulto JovemRESUMO
Resumen La meningitis por Mycobacterium tuberculosis es infrecuente en pediatría y su diagnóstico definitivo representa un desafío clínico. Presentamos el caso de un lactante de dos años, que presentó un cuadro de meningitis crónica. Se logró el diagnóstico tras la sospecha imagenológica y la confirmación tras la búsqueda seriada del complejo M. tuberculosis por RPC en LCR y en biopsia de tejido cerebral. A pesar de sus complicaciones, el paciente respondió favorablemente al tratamiento antituberculoso. En Chile, la tuberculosis es infrecuente en niños y los síntomas son generalmente inespecíficos. Los hallazgos en RM cerebral asociados a alteraciones del LCR permiten sospechar el compromiso meníngeo precozmente. Se recomienda iniciar el tratamiento antituberculoso empírico ante la sospecha, ya que mejora el pronóstico. A pesar de los avances diagnósticos y terapéuticos, la meningitis tuberculosa sigue teniendo una alta tasa de complicaciones y un pronóstico ominoso.
Abstract Mycobacterium tuberculosis meningitis is rare in the pediatric population and its definitive diagnosis represents a clinical challenge. We present the case of a 2-year-old infant with chronic meningitis. Diagnosis was accomplished by suggestive radiological findings and serial search for M. tuberculosis complex by real-time polymerase chain reaction (qPCR) in cerebrospinal fluid (CSF) and in brain tissue. Despite the complications, the patient evolved favorably with the tuberculosis treatment. In Chile, tuberculosis is a rare disease in children and symptoms are generally nonspecific. Brain MRI findings associated with CSF alterations allow early suspicion of MTBC. Start of empirical antituberculosis treatment upon suspicion is recommended given it is associated with better prognosis. Despite diagnostic and therapeutic advances, MTBC continues to have a high complication rate and an ominous prognosis.
Assuntos
Humanos , Masculino , Lactente , Tuberculose Meníngea/diagnóstico , Tuberculose Meníngea/microbiologia , Tuberculose Meníngea/tratamento farmacológico , Tuberculose Meníngea/diagnóstico por imagem , Imageamento por Ressonância Magnética , Tomografia Computadorizada por Raios X , Líquido Cefalorraquidiano/microbiologia , Reação em Cadeia da Polimerase em Tempo Real , Mycobacterium tuberculosis/isolamento & purificação , Antituberculosos/uso terapêuticoRESUMO
INTRODUCTION: Tuberculosis (TB) in Mexico remains an important cause of morbidity and mortality; in the past 4 years, 110,681 cases of pulmonary tuberculosis and 1571 cases of tuberculous meningitis were reported. OBJECTIVE: To determine the neurocognitive sequelae, clinical presentation and neuroimaging alterations in patients with central nervous system tuberculosis. METHODS: A retrospective, analytical, and cross-sectional study was carried out from 2010 to 2019. Patients with central nervous system tuberculosis, with and without HIV/AIDS coinfection, were included. RESULTS: During the study period, 104 cases with a definitive or probable central nervous system tuberculosis diagnosis were included; 38% had HIV/AIDS coinfection, and 55%, various comorbidities (p = 0.0001); 49% had cognitive alterations, and 14% died. CONCLUSIONS: Although HIV/AIDS infection can contribute to cognitive decline in patients with tuberculous meningitis, no differences were observed between patients with and without HIV/AIDS. Cognitive sequelae showed improvement during follow-up with adequate management and therapeutic control of the patients.
INTRODUCCIÓN: La tuberculosis en México sigue siendo causa importante de morbimortalidad; en los últimos cuatro años, se reportaron 110 681 casos de tuberculosis pulmonar y 1571 casos de tuberculosis meníngea. OBJETIVO: Determinar las secuelas neurocognoscitivas, presentación clínica y alteraciones en los estudios de neuroimagen en pacientes con tuberculosis del sistema nervioso central. MÉTODOS: Se realizó un estudio retrospectivo, analítico y transversal de 2010 a 2019. Se incluyeron pacientes con tuberculosis del sistema nervioso central, con y sin coinfección por VIH/sida. RESULTADOS: Durante el periodo de estudio se incluyeron 104 casos con diagnóstico definitivo y probable de tuberculosis del sistema nervioso central; de acuerdo con los criterios de Marais, 38 % presentó coinfección por VIH/sida y 55 %, diversas comorbilidades (p = 0.0001); 49 % presentó alteraciones cognoscitivas y 14 % falleció. CONCLUSIONES: Aunque la infección por VIH/sida puede contribuir al deterioro cognitivo del paciente con tuberculosis meníngea, no se observaron diferencias entre pacientes con y sin VIH/sida. Las secuelas cognoscitivas mostraron mejoría en el seguimiento con el adecuado manejo y control terapéutico de los pacientes.
Assuntos
Disfunção Cognitiva , Tuberculose do Sistema Nervoso Central , Tuberculose Meníngea , Disfunção Cognitiva/epidemiologia , Disfunção Cognitiva/etiologia , Estudos Transversais , Humanos , Estudos Retrospectivos , Tuberculose do Sistema Nervoso Central/complicações , Tuberculose do Sistema Nervoso Central/diagnóstico , Tuberculose do Sistema Nervoso Central/epidemiologia , Tuberculose Meníngea/complicações , Tuberculose Meníngea/diagnóstico , Tuberculose Meníngea/epidemiologiaRESUMO
BACKGROUND: Tuberculous meningitis (TbM) is the most severe complication of extra pulmonary tuberculosis (Tb). There is a higher frequency of positive cerebrospinal fluid (CSF) cultures for Mycobacterium tuberculosis (MTb) in samples from human immunodeficiency virus (HIV) co-infected patients than in those from HIV-negative patients. We hypothesized that real time PCR assays for MTb (MTb qPCR) using CSF would be more sensitive in HIV co-infected patients owing to a greater MTb burden. The present study aimed to verify the diagnostic performance of MTb qPCR in CSF of TbM patients who either were co-infected with HIV or were HIVnegative. METHODS: A total of 334 consecutive participants with suspected TbM were divided into two groups: HIV co-infected and HIV-negative; each group was categorized into definite TbM, probable TbM, possible TbM, and TbM-negative subgroups based on clinical, laboratory and imaging data. We evaluated the diagnostic characteristics of MTb qPCR analysis to detect TbM in CSF by comparing the results to those obtained for definite TbM (i.e., positive MTb culture) and/or probable TbM in CSF, as gold standard. RESULTS: The sensitivity of MTb qPCR in the definite and probable subgroups of the HIV coinfected participants (n = 14) was 35.7%, with a specificity of 93.8%, negative predictive value (NPV) of 94.4%, and negative clinical utility index (CUI-) of 0.89. Results of the HIV-negative group (n = 7) showed lower sensitivity (14.3%) and similar specificity, NPV, and CUI-. CONCLUSION: The findings confirmed our hypothesis, despite the low sensitivity. MTb qPCR may significantly contribute to diagnosis when associated with clinical criteria and complementary examinations.
Assuntos
Infecções por HIV/diagnóstico , HIV/genética , Mycobacterium tuberculosis/genética , Reação em Cadeia da Polimerase em Tempo Real/estatística & dados numéricos , Tuberculose Meníngea/diagnóstico , Adulto , Coinfecção , Testes Diagnósticos de Rotina , Feminino , HIV/patogenicidade , Infecções por HIV/líquido cefalorraquidiano , Infecções por HIV/patologia , Infecções por HIV/virologia , Humanos , Masculino , Pessoa de Meia-Idade , Mycobacterium tuberculosis/patogenicidade , Sensibilidade e Especificidade , Tuberculose Meníngea/líquido cefalorraquidiano , Tuberculose Meníngea/patologia , Tuberculose Meníngea/virologiaRESUMO
Tuberculous Meningitis (TBM) is the most common form of central nervous system Tuberculosis (TB), accounting for 5-6% of extrapulmonary TB cases. Nowadays, TBM continues to be a major topic in public health because of its high prevalence worldwide. This retrospective study aimed to describe the clinical, laboratory, and imaging characteristics at admission; and in-hospital outcome of adult Mexican patients with TBM. We collected data from medical records of patients aged ≥18 years diagnosed with TBM according to the uniform case definition for clinical research who were treated at Tijuana General Hospital between January 2015 and March 2018 and compared them according to the subtype of diagnosis. We included 41 cases (26 males, median age 28 years, range 18-57 years), 13 (31.7%) patients were HIV positive, and 21 (51.2%) were illicit drug users. At admission, 7 (17.1%) patients were in stage I, 22 (53.6%) in stage II, and 12 (29.3%) in stage III. A definitive diagnosis was established in 23 (56.1%) patients, probable in 14 (34.1%), and possible in four (9.8%). Molecular testing was positive in 83% of the cases, yielding significantly higher positive results than other microbiological studies. There were eight (19.5%) deaths, without statistical difference between mortality and not having a definitive diagnosis (p = 0.109). We found that the baseline characteristics of our population were similar to those described by other authors worldwide. In this series, molecular testing showed to be very useful when used in the early stages, particularly in subjects with subacute onset of headache, fever, weight loss, and altered mental status.
Assuntos
Tuberculose Meníngea/diagnóstico , Tuberculose Meníngea/tratamento farmacológico , Tuberculose Meníngea/epidemiologia , Tuberculose Meníngea/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Masculino , México/epidemiologia , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Adulto JovemRESUMO
La tuberculosis es una enfermedad muy frecuente en nuestro medio. A pesar de que la detección precoz y el tratamiento adecuado logran la curación en la mayoría de los pacientes, la dificultad en el diagnóstico, el abandono del tratamiento y la aparición de resistencia a los fármacos tradicionales generan que, en la actualidad, continúe siendo un importante problema de salud pública. En la Argentina, la tasa de morbilidad es de 25/100 000 habitantes, con un leve aumento en la mortalidad.Se presenta el caso de una paciente pediátrica con tuberculosis, que tuvo múltiples complicaciones asociadas a la enfermedad y a su tratamiento, entre las cuales se incluye el síndrome in-flamatorio de reconstitución inmunológica, también conocido como reacción paradojal al tratamiento antituberculoso. Este representa una consecuencia clínica adversa al restablecimien-to de la inmunidad en el paciente que padece una infección sistémica grave, como la tuberculosis miliar.
Tuberculosis is a very frequent disease in our environment. Although early detection and adequate treatment achieve cure in most patients, the difficulty in diagnosis, the abandonment of treatment and the appearance of resistance to traditional drugs generate that at present it continues to represent an im-portant public health problem. In Argentina, the morbidity rate is 25/100,000 inhabitants, with a slight increase in mortality.We present the case of a pediatric patient with tuberculosis and multiple complications associated with the disease and its treatment. One of these complications was the immune re-constitution inflammatory syndrome or paradoxical reaction to antituberculosis treatment. It represents an adverse clinical con-sequence of the restoration of immunity in the patient suffering from a serious systemic infection such as miliary tuberculosis.
Assuntos
Humanos , Feminino , Criança , Tuberculose/complicações , Tuberculose Miliar/diagnóstico , Síndrome Inflamatória da Reconstituição Imune , Tuberculose Meníngea , Tuberculose Miliar/tratamento farmacológicoRESUMO
Tuberculosis is a very frequent disease in our environment. Although early detection and adequate treatment achieve cure in most patients, the difficulty in diagnosis, the abandonment of treatment and the appearance of resistance to traditional drugs generate that at present it continues to represent an important public health problem. In Argentina, the morbidity rate is 25/100,000 inhabitants, with a slight increase in mortality. We present the case of a pediatric patient with tuberculosis and multiple complications associated with the disease and its treatment. One of these complications was the immune reconstitution inflammatory syndrome or paradoxical reaction to antituberculosis treatment. It represents an adverse clinical consequence of the restoration of immunity in the patient suffering from a serious systemic infection such as miliary tuberculosis.
La tuberculosis es una enfermedad muy frecuente en nuestro medio. A pesar de que la detección precoz y el tratamiento adecuado logran la curación en la mayoría de los pacientes, la dificultad en el diagnóstico, el abandono del tratamiento y la aparición de resistencia a los fármacos tradicionales generan que, en la actualidad, continúe siendo un importante problema de salud pública. En la Argentina, la tasa de morbilidad es de 25/100 000 habitantes, con un leve aumento en la mortalidad. Se presenta el caso de una paciente pediátrica con tuberculosis, que tuvo múltiples complicaciones asociadas a la enfermedad y a su tratamiento, entre las cuales se incluye el síndrome inflamatorio de reconstitución inmunológica, también conocido como reacción paradojal al tratamiento antituberculoso. Este representa una consecuencia clínica adversa al restablecimiento de la inmunidad en el paciente que padece una infección sistémica grave, como la tuberculosis miliar.
Assuntos
Antituberculosos/efeitos adversos , Síndrome Inflamatória da Reconstituição Imune/induzido quimicamente , Tuberculose Miliar/tratamento farmacológico , Antituberculosos/uso terapêutico , Criança , Feminino , HumanosRESUMO
Background Timely diagnosis of tuberculous meningitis (TBM) remains challenging. Molecular diagnostic tools are necessary, particularly in low- and middle-income countries. There is no approved commercial polymerase chain reaction (PCR) assay that can be used to detect Mycobacterium tuberculosis in non-respiratory samples, such as the cerebrospinal fluid (CSF). We aimed to validate the threshold cycle (Ct) cut-off points; calculate the operational characteristics of real-time PCR for detection of M. tuberculosis (MTb qPCR) in the CSF; and the inhibitory affect of CSF red blood cells (RBC) and total proteins on MTb qPCR. Methods A total of 334 consecutive participants were enrolled. Based on clinical, laboratory and imaging data, cases of suspected TBM were categorized as definite, probable, possible or not TBM cases. Receiver operating characteristic curve analysis was used to select the best discriminating Ct value. Results For TBM cases categorized as definite or probable (n=21), the Ct validated for CSF (≤39.5) improved the diagnostic performance of MTb qPCR on CSF samples. The sensitivity was 29%, specificity was 95%, positive predictive value was 26%, negative predictive value was 95%, efficiency was 90% and positive likelihood was 5.3. The CSF RBC and total protein did not affect the positivity of the MTb qPCR. Conclusions These data support the validation of a highly specific but low sensitive MTb qPCR assay for the TBM diagnosis using CSF samples. MTb qPCR contributes significantly to the diagnosis, mainly when associated with conventional microbiology tests and clinical algorithms.
Assuntos
Líquido Cefalorraquidiano/microbiologia , Mycobacterium tuberculosis/genética , Reação em Cadeia da Polimerase em Tempo Real , Tuberculose Meníngea/diagnóstico , Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Tuberculose Meníngea/microbiologia , Adulto JovemRESUMO
Resumen La tuberculosis (TBC) cerebral o tuberculoma(s) sin meningitis es una enfermedad poco frecuente y de alta morbimortalidad. Presentamos el caso clínico de un lactante de 11 meses, previamente sano, que consultó por fiebre prolongada y síntomas neurológicos. La RM de encéfalo mostró múltiples imágenes micronodulares e hidrocefalia. El estudio de LCR para bacterias, hongos y micobacterias fue negativo. Se prescribió terapia empírica como una meningoencefalitis subaguda y tratamiento antituberculoso tetraconjugado y corticoesteroides. La confirmación del diagnóstico de TBC cerebral se realizó por biopsia de la lesión, con presencia de inflamación granulomatosa crónica necrosante y bacilos ácido-alcohol resistentes. Se enfatiza la importancia de considerar esta presentación de TBC en niños, y la necesidad de la búsqueda exhaustiva del agente etiológico en diferentes líquidos y tejidos, aun por métodos invasores.
Cerebral tuberculosis TB (tuberculomas) without meningitis is an uncommon disease with a high morbidity and mortality. We report on a case that illustrates the complexity of this clinical presentation. An 11 month old, previously healthy male infant was brought to the clinic due to fever present during the last 1.5 months, associated with loss of neurodevelopmental goals and signs of endocranial hypertension. CT scan of the skull revealed dilatation of the ventricular system with transependimary edema; MRI showed multiple intra- and extra-axial micronodular images and hydrocephalus. Studies of CSF (cyto-chemical analysis, staining, culture for aerobes, fungi, mycobacteria, and molecular tests for TB were negative). Empirical management for subacute meningoencephalitis was prescribed complemented with tetraconjugated treatment for TB and steroids. As there was no microbiological isolation, biopsy of a cerebellar lesion was performed, which revealed chronic necrotizing granulomatous inflammation and acid-alcohol resistant bacilli. The diagnosis of cerebral TB without meningeal involvement was confirmed. The objective of the present report is to emphasize the importance of considering this presentation of TB in children, to remark the need of exhaustive search for the etiologic agent by obtaining samples of the different fluids and tissues even if it implies recurring to invasive methods.
Assuntos
Humanos , Masculino , Lactente , Tuberculose Meníngea/patologia , Tuberculoma Intracraniano/patologia , Tuberculose Meníngea/tratamento farmacológico , Biópsia , Imageamento por Ressonância Magnética , Radiografia Torácica , Tomografia Computadorizada por Raios X , Tuberculoma Intracraniano/tratamento farmacológico , Combinação Amoxicilina e Clavulanato de Potássio/uso terapêutico , Diagnóstico Diferencial , Imunocompetência , Meningoencefalite/diagnóstico , Antituberculosos/uso terapêuticoRESUMO
Se presenta un caso de paciente masculino de 54 años de edad, sin inmunosupresión ni evidencia de la misma durante su hospitalización, que consulta por cefalea y signos meníngeos. Se realiza Punción Lumbar (PL) compatible con meningitis bacteriana por lo que se indica tratamiento empírico con mejoría franca de la sintomatología con excepción de la esorientación. Una vez en mejores condiciones se reciben los valores de la ADA los cuales están elevados compatibles con Tuberculosis Meníngea (TBM). Se realiza nueva PL para confirmar dicho valor, lo que se logra y además se demuestra un aumento leve. A los 20 días de la hospitalización, y luego de la mejoría franca, el paciente presenta nuevamente cefalea, fiebre y bradilalia por lo que se inicia tratamiento anti TB con mejoría progresiva de los síntomas. Se presenta el caso y se revisa la literatura(AU)
We present a 54-year-old male patient, with no immunosuppression who consulted for headache and meningeal signs. Lumbar tap (LT) was compatible with bacterial meningitis and empirical treatment was startes with a clear improvement in symptomatology, except for disorientation. Then ADA values were received and its values were francly compatible with Meningeal Tuberculosis (TBM). A new LT was performed to confirm this value, also showeds a slight increase. Twenty days after the hospitalization, and after the frank improvement, the patient again presented again with headache, fever and bradylalia, thus initiating anti-TB treatment with progressive improvement of symptoms. The case is presented and the literature is reviewed(AU)
Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Tuberculose Meníngea/fisiopatologia , Meningites Bacterianas/fisiopatologia , Doenças do Sistema Nervoso , Diagnóstico Clínico , Medicina InternaRESUMO
Tuberculosis is a chronic bacterial infection caused by Mycobacterium tuberculosis. Despite advances in treatment, resistant strains and unusual sites of involvement have been diagnosed. We present a case of a 13-year-old patient in treatment for tuberculous meningitis who presented with progressive paraparesis. The MRI showed two intramedullary nodular lesions at T4T6 levels, isointense with annular hyperintensity on T1W, hypointense on T2W, becoming hypointense with ring enhancement after contrast. These characteristics differ from those usually described for intramedullary tuberculomas. Surgical excision was performed, confirming the diagnosis of intramedullary tuberculoma. The formation of intramedullary tuberculomas is rare, with a ratio of two cases per thousand diagnosed with CNS tuberculosis, and the thoracic spine is most frequently affected. The clinical picture is of progressive subacute spinal cord compression, and it may lead to paraplegia. At MRI, the lesion in early stage appears as hypointense rings on T1W and hyperintense on T2W, with homogeneous enhancement after contrast. After the formation of the solid caseous granuloma, it becomes isointense on T1W and hypointense on T2W with homogeneous enhancement after contrast. When the center of the granuloma becomes liquefied, it shows hypointense sign on T1W and hyperintense with peripheral enhancement on T2W. The treatment of choice is medical, with the current protocol including rifampin, isoniazid, pyrazinamide, and ethambutol. Surgery is reserved for cases of progressive neurologic deficits or for diagnostic confirmation. Although benign and potentially curable, intramedullary tuberculoma should be promptly diagnosed and treated to prevent irreversible damage.
A tuberculose é uma infecção bacteriana crônica causada pelo Mycobacterium tuberculosis. Apesar dos avanços no tratamento, cepas resistentes e locais incomuns de envolvimento vêm sendo diagnosticados. Apresentamos o caso de um paciente de 13 anos de idade, em tratamento para meningite tuberculosa que se apresentou com paraparesia progressiva. A ressonância magnética mostrou duas lesões nodulares intramedulares no nível de T4T6, isointensas com bordos hiperintensos em T1, hipointensos em T2, tornando-se hipointensos com realce anelar após contraste. Essas características diferem daquelas usualmente descritas para tuberculomas intramedulares. Foi realizada a excisão cirúrgica, confirmando o diagnóstico de tuberculoma intramedular. A formação de tuberculomas intramedulares é rara, com uma proporção de dois casos por mil diagnosticados com tuberculose do sistema nervoso central (SNC), e a coluna torácica é a mais frequentemente acometida. O quadro clínico é de compressão da medula espinal progressiva subaguda, podendo levar à paraplegia. Na ressonância magnética, a lesão em fase inicial aparece como anéis hipointensos em T1 e hiperintensos em T2, com realce homogêneo após contraste. Após a formação do granuloma caseoso sólido, torna-se isointensa em T1 e hipointensa em T2, com realce homogêneo após contraste. Quando o centro do granuloma torna-se liquefeito, mostra sinal hipointenso em T1 e hiperintenso com realce periférico em T2. O tratamento de escolha é medicamentoso, com o protocolo corrente de rifampicina, isoniazida, pirazinamida e etambutol. A cirurgia é reservada para os casos de déficit neurológico progressivo ou para confirmação diagnóstica. Embora benigna e potencialmente curável, deve ser diagnosticada e tratada para evitar danos irreversíveis.
Assuntos
Humanos , Masculino , Adolescente , Tuberculose Meníngea/diagnóstico , Tuberculose Meníngea/terapia , Tuberculoma Intracraniano/diagnósticoRESUMO
La afectación del sistema nervioso central es una de las localizaciones extrapulmonares de la tuberculosis con peor pronóstico. El retraso en el diagnóstico y tratamiento es uno de los factores relacionados con mayor tasa de mortalidad y secuelas. Se describe la "reacción paradojal" como un deterioro sintomático de grado variable, durante el tratamiento efectivo de la tuberculosis. El aumento de la resistencia del Mycobacterium tuberculosis a fármacos observado en los últimos años genera mayor preocupación ante la aparición de una reacción paradojal durante el tratamiento. Se presenta el caso de un niño con meningitis tuberculosa que, luego de un mes de tratamiento, presentó empeoramiento clínico y nuevas lesiones en la tomografía y resonancia magnética nuclear de cerebro. Se excluyeron patologías asociadas, se verificó que la toma de medicamentos haya sido supervisada, y la sensibilidad del bacilo a fármacos antituberculosos de primera línea fue confirmada. El paciente no requirió cambios en el esquema de tratamiento antituberculoso y se administraron esteroides para el alivio sintomático. La reacción paradojal durante el tratamiento antituberculoso es infrecuente y debida a una reacción de hipersensibilidad entre el huésped y el bacilo tuberculoso. Cuando aparece, se debe asegurar la efectividad y el cumplimiento del tratamiento administrado.
The central nervous system is one of the locations of extrapulmonary tuberculosis with worse prognosis. The delay in diagnosis and treatment is one of the factors associated with higher mortality and sequelae. The "paradoxical reaction" is described as a variable degree of symptomatic deterioration during the effective treatment of tuberculosis. The increased resistance of Mycobacterium tuberculosis to drugs observed in recent years generates greater concern about the emergence of a paradoxical reaction during treatment. The case of a child with tuberculous meningitis that after one month of treatment presented clinical worsening and new lesions in CT and MRI images of the brain is presented. Comorbidities were excluded, it was verified that taking drugs has been monitored, and the sensitivity of the bacillus to first-line antituberculosis drugs was confirmed. The patient required no change in the pattern of tuberculosis treatment and steroids were administered for symptomatic relief. The paradoxical reaction during antituberculosis treatment is rare and due to a hypersensitivity reaction between the host and the tuberculous bacillus. When it appears you must ensure the effectiveness and compliance of the treatment.
Assuntos
Humanos , Criança , Tuberculose Meníngea , Criança , Tuberculose do Sistema Nervoso CentralRESUMO
La afectación del sistema nervioso central es una de las localizaciones extrapulmonares de la tuberculosis con peor pronóstico. El retraso en el diagnóstico y tratamiento es uno de los factores relacionados con mayor tasa de mortalidad y secuelas. Se describe la "reacción paradojal" como un deterioro sintomático de grado variable, durante el tratamiento efectivo de la tuberculosis. El aumento de la resistencia del Mycobacterium tuberculosis a fármacos observado en los últimos años genera mayor preocupación ante la aparición de una reacción paradojal durante el tratamiento. Se presenta el caso de un niño con meningitis tuberculosa que, luego de un mes de tratamiento, presentó empeoramiento clínico y nuevas lesiones en la tomografía y resonancia magnética nuclear de cerebro. Se excluyeron patologías asociadas, se verificó que la toma de medicamentos haya sido supervisada, y la sensibilidad del bacilo a fármacos antituberculosos de primera línea fue confirmada. El paciente no requirió cambios en el esquema de tratamiento antituberculoso y se administraron esteroides para el alivio sintomático. La reacción paradojal durante el tratamiento antituberculoso es infrecuente y debida a una reacción de hipersensibilidad entre el huésped y el bacilo tuberculoso. Cuando aparece, se debe asegurar la efectividad y el cumplimiento del tratamiento administrado.(AU)
The central nervous system is one of the locations of extrapulmonary tuberculosis with worse prognosis. The delay in diagnosis and treatment is one of the factors associated with higher mortality and sequelae. The "paradoxical reaction" is described as a variable degree of symptomatic deterioration during the effective treatment of tuberculosis. The increased resistance of Mycobacterium tuberculosis to drugs observed in recent years generates greater concern about the emergence of a paradoxical reaction during treatment. The case of a child with tuberculous meningitis that after one month of treatment presented clinical worsening and new lesions in CT and MRI images of the brain is presented. Comorbidities were excluded, it was verified that taking drugs has been monitored, and the sensitivity of the bacillus to first-line antituberculosis drugs was confirmed. The patient required no change in the pattern of tuberculosis treatment and steroids were administered for symptomatic relief. The paradoxical reaction during antituberculosis treatment is rare and due to a hypersensitivity reaction between the host and the tuberculous bacillus. When it appears you must ensure the effectiveness and compliance of the treatment.(AU)
RESUMO
CASE REPORT: The case is presented of a 29-year-old woman who complained of headache over a period of several days, with loss of visual acuity and pain in her left eye. She had a 3-year history of type 1 diabetes mellitus, and was an immigrant from Ecuador. The funduscopic examination revealed a papilledema. The polymerase chain reaction (PCR) study of the cerebrospinal fluid was positive for Mycobacterium tuberculosis (MTB). She showed a marked improvement after treatment with anti-TB drugs. DISCUSSION: About a third of the world's population has a latent infection of MTB, comorbidity between diabetes mellitus and tuberculosis has been reported, particularly in undeveloped countries.
Assuntos
Diabetes Mellitus Tipo 1/complicações , Papiledema/etiologia , Tuberculose Meníngea/diagnóstico , Adulto , Antituberculosos/uso terapêutico , Atrofia , Líquido Cefalorraquidiano/microbiologia , Países em Desenvolvimento , Quimioterapia Combinada , Equador/etnologia , Reações Falso-Negativas , Feminino , Humanos , Hospedeiro Imunocomprometido , Isoniazida/uso terapêutico , Tuberculose Latente/epidemiologia , Mycobacterium tuberculosis/isolamento & purificação , Oftalmoscopia , Nervo Óptico/patologia , Rifampina/uso terapêutico , Punção Espinal , Teste Tuberculínico , Tuberculose Meníngea/líquido cefalorraquidiano , Tuberculose Meníngea/complicaçõesRESUMO
OBJECTIVES: To assess the diagnostic validity of laboratory cerebrospinal fluid (CSF) parameters for discriminating between tuberculous meningitis (TBM) and other causes of meningeal syndrome in high tuberculosis incidence settings. METHODS: From November 2009 to November 2011, we included patients with a clinical suspicion of meningitis attending two hospitals in Lima, Peru. Using a composite reference standard, we classified them as definite TBM, probable TBM, and non-TBM cases. We assessed the validity of four CSF parameters, in isolation and in different combinations, for diagnosing TBM: adenosine deaminase activity (ADA), protein level, glucose level, and lymphocytic pleocytosis. RESULTS: One hundred and fifty-seven patients were included; 59 had a final diagnosis of TBM (18 confirmed and 41 probable). ADA was the best performing parameter. It attained a specificity of 95%, a positive likelihood ratio of 10.7, and an area under the receiver operating characteristics curve of 82.1%, but had a low sensitivity (55%). None of the combinations of CSF parameters achieved a fair performance for 'ruling out' TBM. CONCLUSIONS: Finding CSF ADA greater than 6 U/l in patients with a meningeal syndrome strongly supports a diagnosis of TBM and permits the commencement of anti-tuberculous treatment.
Assuntos
Tuberculose Meníngea/líquido cefalorraquidiano , Tuberculose Meníngea/diagnóstico , Adenosina Desaminase/líquido cefalorraquidiano , Adulto , Área Sob a Curva , Feminino , Glucose/líquido cefalorraquidiano , Humanos , Masculino , Pessoa de Meia-Idade , Peru , Curva ROC , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
En el contexto de una severa inmunodepresión existe una marcada dificultad para hacer diagnóstico definitivo de las infecciones oportunistas que son causa principal de morbilidad y mortalidad. La presencia de infecciones del SNC durante la evolución del paciente con VIH, es frecuente, siendo menos habitual la presencia múltiple y concurrente de éstas, pues tal situación somete a los pacientes a peor pronóstico. Por este motivo se muestra el estudio de un paciente que presentó múltiples infecciones oportunistas en el SNC, quien tras iniciar y continuar el TARGA mostró buena evolución. Caso clínico: varón de 51 años con antecedentes de alcoholismo que acude al hospital con s¡ndrome de hipertensión endocraneana. Es diagnosticado de meningitis criptocócica e infección por VIH estadio C sin TARGA. Durante el tratamiento se evidenci ademas infecciones oportunistas concurrentes, como meningitis tuberculosa, leucoencefalopatia multifocal progresiva y toxoplasmosis cerebral; conjuntamente presentó síndrome inflamatorio de reconstitución inmunológica (IRIS). El paciente al iniciar y mantener el TARGA se recuperó ¡ntegramente y manifestó buena evolución, actualmente es tratado ambulatoriamente y no se ha complicado. Interpretación: los episodios múltiples y concurrentes de infecciones oportunistas del SNC descritos as¡ como el IRIS, generalmente inducen a los pacientes a mal pronóstico, sin embargo, son pocos los casos que se recuperan copiosamente y muestran buen pronóstico. Este es un caso particular de recuperación después de seguir el TARGA correctamente. Se describe este reporte por su importancia para valorar una apropiada adherencia al TARGA.
In the context of severe immunosuppression, there is a marked difficulty in making a definitive diagnosis of opportunistic infections, which are leading causes of morbidity and mortality. The presence of CNS infections during the evolution of HIV patients is common, less common being multiple and concurrent presence of these. This situation undergoes patients with poor prognosis. For this reason we report the case of a patient who developed multiple opportunistic infections in the CNS, who after HAART initiation and continuation showed good performance. Clinical case: 51 year old male with a history of alcoholism, was admitted to hospital with intracranial hypertension syndrome. He was diagnosed with cryptococcal meningitis and HIV infection stage C without HAART. During treatment also showed concurrent opportunistic infections such as TB meningitis, progressive multifocal leukoencephalopathy and cerebral toxoplasmosis, jointly presented immune reconstitution inflammatory syndrome (IRIS). The patient, initiating and maintaining HAART, fully recovered and showed good performance. Currently he is treated as an outpatient and has no complications. Interpretation: The multiple concurrent episodes of opportunistic infections of the CNS described, as well as the IRIS, generally induce poor prognosis in patients. However, there are few cases that improve and show good prognosis. This is a particular case of recovery after HAART follow correctly. We describe this report because of its importance in assessing adherence to HAART.