Tuberculous meningitis: Challenges in diagnosis and management: Lessons learnt from Prof. Dastur's article published in 1970.

It has been approximately five decades since Dastur et al., published their seminal work on pathology of tuberculous meningitis (TBM). Though most of their findings find relevance in today's era, there is an important difference; these findings can now be replicated during life using modern day technology. In this article, we review the seminal words of Professor Dastur and colleagues, analyse their findings, interpret how these revolutionized our understanding of TBM and highlight their relevance in today's era. We also discuss challenges in the management of TBM, which we continue to face today and the various options required to overcome these challenges.

First Homo erectus from Turkey and implications for migrations into temperate Eurasia.

Remains of fossil hominins from temperate regions of the Old World are rare across both time and space, but such specimens are necessary for understanding basic issues in human evolution including linkages between their adaptations and early migration patterns. We report here the remarkable circumstances surrounding the discovery of the first fossil hominin calvaria from Turkey. The specimen was found in the Denizli province of western Turkey and recovered from within a solid block of travertine stone as it was being sawed into tile-sized slabs for the commercial natural stone building market. The new specimen fills an important geographical and temporal gap and displays several anatomical features that are shared with other Middle Pleistocene hominins from both Africa and Asia attributed to Homo erectus. It also preserves an unusual pathology on the endocranial surface of the frontal bone that is consistent with a diagnosis of Leptomeningitis tuberculosa (TB), and this evidence represents the most ancient example of this disease known for a fossil human. TB is exacerbated in dark-skinned peoples living in northern latitudes by a vitamin D deficiency because of reduced levels of ultraviolet radiation (UVR). Evidence for TB in the new specimen supports the thesis that reduced UVR was one of the many climatic variables presenting an adaptive challenge to ancient hominins during their migration into the temperate regions of Europe and Asia.

Amedeo Modigliani and his "great secret": a brief history of medical and social aspects of tuberculosis in the nineteenth and early twentieth century.

The pathography of the famous painter and sculptor Amedeo Modigliani (1884-1920) shows that he had tuberculosis and died of tubercular meningitis aged 35. The nineteenth century was characterized by numerous milestones in the history of tuberculosis. In 1853, Hermann Brehmer, first used the term tuberculosis referred to at the time as "phthisis". In 1865, Jean Antoine Villemin demonstrated the infectious etiology of the disease. This was confirmed in 1882 by Robert Koch by identifying the tubercle bacillus. Koch also invented the diagnostic tuberculin test. Charles Mantoux and Florence Seibert improved this test. Identification of the infectious etiology of tuberculosis led to experiments of effective treatments for this disease. The most successful treatment for tuberculosis was by sanatorium regime. From the late nineteenth century, more invasive therapeutic approaches such as artificial pneumothorax were introduced. The advent of streptomycin in 1945 changed the social view of tuberculosis. This previously romanticized disease became a social stigma which was associated with poor social and moral standards; patients were kept in isolation. Fearing social ostracism, Modigliani refused treatment for tuberculosis and instead deliberately fostered his reputation as an alcoholic and addict in order to conceal the disease.

Robert Whytt (1714-1766): from dropsy in the brain to tuberculous meningitis.

Robert Whytt was born and educated in Edinburgh and served the City in the Royal Infirmary. A prolific author, his major work is usually said to be his Essay on the Vital and other Involuntary Movements of Animals (1751), based on his belief that a 'sentient principle' was not limited to the nervous system but was distributed throughout the body, a view that brought him into conflict with Albrecht von Haller, who held that the sentient and motor powers of the body were those of a machine. Whatever about the speculative nature of the sentient principle, Whytt was a clinician blessed with unusual clarity, and he is remembered today for his Observations on the Dropsy in the Brain (1768). Therein he described the clinical signs and symptoms of what later came to be recognised as tuberculous meningitis, the acute disease which appears early in the haemic spread of the infection in a child, and which was fatal until the discovery of chemotherapy and antimicrobials. John Cheyne, in describing two terminal cases, recognised the connexion between hydrocephalus and scrophula, and Dorothy Price provided a precise guide to the clinical picture in 1942. When streptomycin became available Christopher McSweeney used it to alter the bleak picture in Dublin, and was helped by the prevention resulting from neonatal BCG immunisation. Later antimicrobials have facilitated the avoidance of emergent bacillary resistance.

The first Brazilian neuropsychiatrist, José Martins da Cruz Jobim, tuberculous meningitis and mental disease.

The intersection between infectious diseases, poverty and mental disease was an important subject to the Brazilian Neuropsychiatry in the early 19th century. José Martins da Cruz Jobim (1802-1878) was engaged in a hygienist approach based on symptomatological and anatomopathological studies. He wrote "Insânia loquaz" (Loquacious insanity), 1831, the first written text about mental illness in Brazil, founded on clinical and pathological data, compatible with tuberculous meningitis. Thus, Jobim deserves the title of the first neuropsychiatrist in Brazil. The authors critically studied the clinical history and the autopsy findings of his cases, and the main health policies at the time.

The first Brazilian neuropsychiatrist, José Martins da Cruz Jobim, tuberculous meningitis and mental disease / O primeiro neuropsiquiatra brasileiro, José Martins da Cruz Jobim, meningite tuberculosa e doença mental

The intersection between infectious diseases, poverty and mental disease was an important subject to the Brazilian Neuropsychiatry in the early 19th century. José Martins da Cruz Jobim (1802–1878) was engaged in a hygienist approach based on symptomatological and anatomopathological studies. He wrote “Insânia loquaz” (Loquacious insanity), 1831, the first written text about mental illness in Brazil, founded on clinical and pathological data, compatible with tuberculous meningitis. Thus, Jobim deserves the title of the first neuropsychiatrist in Brazil. The authors critically studied the clinical history and the autopsy findings of his cases, and the main health policies at the time.

A intersecção entre as doenças infecciosas, a pobreza e a doença mental foi um assunto importante para a Neuropsiquiatria brasileira no início do século 19. José Martins da Cruz Jobim (1802–1878) estava engajado em uma abordagem higienista baseada em estudos sintomatológicos e anatomopatológicos. Escreveu “Insânia loquaz”, 1831, o primeiro texto escrito sobre doença mental no Brasil, baseado em dados clínicos e patológicos compatíveis com meningite tuberculosa. Assim, Jobim merece o título de primeiro neuropsiquiatra no Brasil. Os autores estudaram criticamente a história clínica e os resultados da autópsia dos seus casos, bem como as principais políticas de saúde da ocasião.

[Clinical and epidemiological changes in tuberculosis in children in the last 5 decades(1950-2000) ]. / Mutatii clinico-epidemiologice ale tuberculozei copilului în ultimele cinci decenii (1950-2000).

This study analyses over a 48 years period (1953-2000) the incidence of various clinical forms of TB in children aged 0-8, admitted in several ftizio-pediatric institutions. Follow-up included: primary complex, pleuro-pulmonary involvement, bronchial adenogenic involvement, extra-respiratory forms and major sequelae of primary tuberculosis. The results show a marked decrease of incidence of all TB forms in children and disappearance of chronic extensive primary tuberculosis and major sequelae of primary tuberculosis. The incidence tappered in steps: a sudden decrease in 1964-65, another in 1974, followed by a gradual decline. On contrary, the incidence of multiple sequela calcifications seems to be increasing after 1980. These clinical mutations, especially the one in 1974, may be attributed to strictly observed treatment, to reintroduction of national campaign of BCG vaccination and to the decrease of TB incidence in adults (diminished bacilli offer).