Tuberculosis meníngea: reporte de casos años 2005-2017 / Meningeal tuberculosis: cases report years 2005-2017

INTRODUCCIÓN: La tuberculosis (TBC) continúa siendo un problema de salud pública mundial; su forma meníngea conlleva mayor letalidad y secuelas, en particular si se asocia a la infección por VIH/SIDA. OBJETIVO: Describir las características demográficas, presentación clínica, laboratorio y de las imágenes de los pacientes con TBC meníngea (aislamiento de Mycobacterium tuberculosis en LCR), analizando diferencias entre pacientes con y sin infección por VIH/SIDA. PACIENTES Y MÉTODOS: Estudio observacional y descriptivo, retrospectivo, de una serie de casos atendidos en el Hospital Dr. Alejandro Posadas de Buenos Aires, Argentina, desde enero de 2005 hasta diciembre de 2017. RESULTADOS: Se analizaron 36 pacientes, 22 de ellos mujeres, con una mediana de edad de 36,5 años. Veintidós pacientes presentaron co-infección por VIH, todos en estadio SIDA. El tiempo de inicio de síntomas tuvo una mediana 11 días. predominando fiebre, estado de conciencia alterado y cefalea. En el LCR se hallaron linfocitosis, hipoglucorraquia, hiperproteinorraquia y ácido láctico elevado. Se realizó tomografía computada de encéfalo a 34 pacientes, 16 sin alteraciones. En otros 16 se realizó resonancia magnética (RM) cerebral, 9 presentaban trastornos vasculares. La RM fue más sensible para identificar refuerzo meníngeo, trastornos de tipo vasculares, y lesiones de tipo granulomatosas. La mediana de inicio de tratamiento fue de 1 día, con 72,2% recibiendo co-adyuvancia con corticosteroides. La mortalidad observada fue de 27,7% y secuelas hubo en 36,1%. Sólo 5 pacientes requirieron intervención neuro-quirúrgica. CONCLUSIÓN: Siendo la TBC meníngea una afección de alta morbimortalidad, es imperioso asegurar un diagnóstico temprano en su evolución mediante la incorporación de la biología molecular e imagenología (RM) al amplio uso clínico.

BACKGROUND. Tuberculosis (TB) continues to be a global public health problem; its meningeal form leads to greater lethality and sequelae, particularly if it is associated with HIV / AIDS infection. AIM: To describe the demographic characteristics, clinical presentation, laboratory and images of patients with meningeal TB (isolation of Mycobacterium tuberculosis in CSF), analyzing differences between HIV and non-HIV patients. METHODS: We performed an observational and descriptive study, with retrospective analysis of patients attending at the Dr. Alejandro Posadas Hospital, Buenos Aires, since January 2005 to December 2017. RESULTS: Thirty-six patients were analyzed, with 22 women with a median age of 36.5 years. Twenty two patients had HIV coinfection, all in the AIDS stage. The symptom onset time was median 11 days. The predominant ones were fever, altered consciousness and headache. In the cerebrospinal fluid were lymphocitosis, hypoglycorrhachia, hyperproteinorrhachia and high lactic acid, according to previously described findings. Of 34 patients who underwent brain scan, 16 patients had no significant pathological findings. MRI was performed in 16 patients, 9 had vascular disorders. Brain MRI was more sensitive to identify meningeal reinforcement than computerized tomography, vascular disorders, and granulomatous lesions. The median onset of treatment was 1 day, with 72.2% of the total receiving coadjuvants with corticosteroids. Mortality of 27.7% and sequelae in 36.1% were observed. Only 5 patients required neurosurgical intervention. CONCLUSION: Since meningeal TB is a disease with high morbidity and mortality, it is imperative to ensure an early diagnosis in its evolution by incorporating molecular biology and imaging (MRI) into broad clinical use.

Diagnostic characteristics of Xpert MTB/RIF assay for the diagnosis of tuberculous meningitis and rifampicin resistance in Southern Brazil / Características diagnósticas do Xpert MTB/RIF para o diagnóstico de meningite tuberculosa e resistência à rifampicina no Sul do Brasil

ABSTRACT Background: The timely diagnosis of tuberculous meningitis (TBM) is challenging. Molecular diagnostic tools are necessary for TBM, particularly in low- and middle-income countries. Objectives: We aimed to calculate the diagnostics characteristics of Xpert MTB/RIF for the detection of Mycobacterium tuberculosis in the cerebrospinal fluid (CSF) and the frequency of rifampicin (RIF)-resistance in the CSF samples. Methods: A total of 313 consecutive CSF samples were studied and categorized into TBM definite, probable, possible, or not TBM cases based on the clinical, laboratory, and imaging data. Results: For the definite TBM cases (n=7), the sensitivity, specificity, efficiency, and positive likelihood ratio were 100, 97, 97, and 38%, respectively. However, for the TBM definite associated with the probable cases (n=24), the sensitivity decreased to 46%. All CSF samples that were Xpert MTB/RIF-positive were RIF susceptible. Conclusion: Xpert MTB/RIF showed high discriminating value among the microbiology-proven TBM cases, although the values for the probable and possible TBM cases were reduced. Xpert MTB/RIF contributes significantly to the diagnosis of TBM, mainly when coupled with the conventional microbiological tests and clinical algorithms.

RESUMO Introdução: O diagnóstico da meningite tuberculosa (TBM) é desafiador. Ferramentas de diagnóstico molecular são necessárias para esse diagnóstico, particularmente em países de baixa e média renda. Objetivos: Calcular as características diagnósticas do Xpert MTB/RIF para a detecção de Mycobacterium tuberculosis no líquido cefalorraquidiano (LCR) e a frequência de resistência à rifampicina (RIF) nas amostras do LCR. Métodos: Um total de 313 amostras consecutivas de LCR foram estudadas e categorizadas em casos de TBM definida, provável, possível ou não TBM, com base nos dados clínicos, laboratoriais e de imagem. Resultados: Para os casos definidos de TBM (n=7), sensibilidade, especificidade, eficiência e razão de verossimilhança positiva foram de 100, 97, 97 e 38%, respectivamente. No entanto, para os casos de TBM definidos associados aos prováveis (n=24), a sensibilidade diminuiu para 46%. Todas as amostras de LCR que foram positivas para Xpert MTB/RIF foram suscetíveis a RIF. Conclusão: O Xpert MTB/RIF mostrou alto valor discriminante entre os casos TBM comprovados por microbiologia, porém o valor nos casos prováveis e possíveis de TBM foram reduzidos. O Xpert MTB/RIF contribui significativamente para o diagnóstico de TBM, principalmente quando associado aos testes microbiológicos convencionais e algoritmos clínicos.

Aspectos associados à drogarresistência em pessoas com Tuberculose/HIV: revisão integrativa / Aspectos relacionados con la drogorresistencia en personas con tuberculosis/VIH: revisión integradora / Aspects associated with drug resistance in people with tuberculosis/HIV: an integrative review

Resumo Objetivo: Analisar as produções científicas acerca dos aspectos associados à drogarresistência em pessoas com coinfecção Tuberculose/HIV. Métodos: Revisão integrativa de literatura, realizada nas bases de dados CINAHL, LILACS, SciELO, Web of Science, SCOPUS, MEDLINE e COCHRANE. Utilizaram-se dos descritores HIV, Tuberculose e Resistência a múltiplos medicamentos, em português, inglês e espanhol. Encontraram-se 1.177 artigos e selecionaram-se 19, excluíram-se 1.158, 41 duplicados e 1.117, por não atenderem à pergunta de pesquisa e abordarem outras temáticas, como: coinfecção do HIV e pneumonia; impacto da multirresistência na vida de pessoas com coinfecção, destacando-se a mortalidade; testes diagnósticos de multirresistência aos fármacos; e associação entre HIV e tuberculose meníngea. Resultados: Os dados obtidos foram organizados em três categorias temáticas: Aspectos clínicos, destacando-se: infecção pelo HIV, hipoalbuminemia, carga elevada do bacilo; Aspectos relacionados aos fármacos, incluindo abandono do tratamento, não adesão à terapia, tratamento prévio para tuberculose, má absorção de medicamentos, efeitos adversos causados pela terapia antirretroviral, interação entre os tratamentos de ambas as infecções; e Aspectos sociais, sinalizando-se hospitalizações, convivência com outras pessoas com bacilos multirresistentes, privação de liberdade, atraso no diagnóstico e início tardio do tratamento. Conclusão: Os principais aspectos identificados foram o abandono da terapêutica, tratamento prévio para tuberculose e intervenção inadequada, tais resultados, também, podem estender-se às pessoas que não apresentam coinfecção. Enfatiza-se a importância desta revisão para instigar novas pesquisas, com destaque para estratégias com foco na identificação precoce de pessoas com multirresistência, prevenção e incentivo à adesão ao tratamento.

Resumen Objetivo: Analizar las producciones científicas sobre los aspectos relacionados con la drogorresistencia en personas con coinfección tuberculosis/VIH. Métodos: Revisión integradora de literatura, realizada en las bases de datos CINAHL, LILACS, SciELO, Web of Science, SCOPUS, MEDLINE y COCHRANE. Se utilizaron los descriptores VIH, tuberculosis y resistencia a múltiples medicamentos, en portugués, inglés y español. Se encontraron 1.177 artículos, de los que se seleccionaron 19 y se excluyeron 1.158, 41 duplicados y 1.117 por no abordar la pregunta de la investigación y tratar otros temas, como: coinfección de VIH y neumonía; impacto de la multirresistencia en la vida de personas con coinfección, con énfasis en la mortalidad; pruebas diagnósticas de multirresistencia a los fármacos, y relación entre VIH y tuberculosis meníngea. Resultados: Los datos obtenidos fueron organizados en tres categorías temáticas: aspectos clínicos, con énfasis en: infección por VIH, hipoalbuminemia, carga del bacilo elevada; aspectos relacionados con los fármacos, como abandono del tratamiento, no adherencia al tratamiento, tratamiento previo para tuberculosis, mala absorción de medicamentos, efectos adversos causados por el tratamiento antirretroviral, interacción entre los tratamientos de ambas infecciones; y aspectos sociales, con foco en internaciones, convivencia con otras personas con bacilos multirresistentes, privación de la libertad, retraso en el diagnóstico e inicio tardío del tratamiento. Conclusión: Los principales aspectos identificados fueron el abandono del tratamiento, el tratamiento previo para tuberculosis y la intervención inadecuada. Estos resultados también pueden extenderse a las personas que no presentan coinfección. Se resalta la importancia de esta revisión para estimular nuevas investigaciones, con énfasis en estrategias centradas en la identificación temprana de personas con multirresistencia, prevención e incentivo para adherir al tratamiento.

Abstract Objective: To analyze scientific productions on aspects associated with drug resistance in people with tuberculosis (TB)/HIV coinfection. Methods: Integrative literature review performed in the CINAHL, LILACS, SciELO, Web of Science, SCOPUS, MEDLINE and COCHRANE databases. The following descriptors were used in Portuguese, English and Spanish: HIV, Tuberculosis and Multidrug resistance. In total, 1,177 articles were found and 19 were selected; 1,158 were excluded, of which 41 were duplicates and 1,117 did not answer the research question and addressed other topics, namely: HIV and pneumonia coinfection; impact of multidrug resistance on the lives of people with coinfection, with emphasis on mortality; diagnostic tests for multidrug resistance; and association between HIV and meningeal tuberculosis. Results: Data were organized into three thematic categories, as follows: Clinical aspects, highlighting: HIV infection, hypoalbuminemia, elevated bacillus load; drug-related aspects, including treatment abandonment, non-adherence to therapy, previous treatment for tuberculosis, drug malabsorption, adverse effects caused by antiretroviral therapy, interaction between treatments for both infections; and social aspects, including hospitalizations, living with other people with multidrug-resistant bacilli, deprivation of liberty, delayed diagnosis and late start of treatment. Conclusion: The main aspects identified were abandonment of therapy, previous treatment for tuberculosis and inadequate intervention, and these results may also extend to people who do not have coinfection. This review is important to instigate new research, with emphasis on strategies focused on the early identification of people with multidrug resistance, prevention and encouragement of adherence to treatment.

Tuberculosis cerebral sin meningitis en un niño inmunocompetente / Cerebral tuberculosis without meningitis in a immunocompetent child

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.

Tratamiento de meningitis tuberculosa en paciente HIV negativo, posible reacción paradojal / Possible paradoxical reaction to treatment of tubercular meningitis in an HIV negative patient

La respuesta paradojal al tratamiento tuberculoso es la aparición de manifestaciones clínico-radiológicas nuevas, o el empeoramiento de las previas, luego de una mejoría inicial con el tratamiento específico. Se puede observar en 6-30% de los casos de tuberculosis meníngea. Es una reacción inmunológica exagerada y debe tenerse presente ya que su tratamiento se basa en el uso de inmunomoduladores y no en el cambio de las drogas antituberculosas. Presentamos el caso de una paciente adulta HIV negativa con meningitis tuberculosa que, luego de una adecuada respuesta inicial al tratamiento, intercurre a las 10 semanas con una reacción paradojal tratada satisfactoriamente con corticoides.

The paradoxical response to tuberculosis treatment consists in the appearance of new clinical or radiologic manifestations or worsening of previous injuries after an initial improvement with anti-tuberculosis therapy. It can be observed in 6 to 30 percent of the cases of tubercular meningitis. It is the consequence of an exaggerated immune reaction that should be considered since the treatment is based on the use of immunomodulators and not in the change of anti-tuberculous drugs. We present the case of an HIV negative adult with tuberculous meningitis with a good initial response to specific therapy who showed, 10 weeks later, a paradoxical reaction to treatment that responded successfully to corticosteroids.

Reacción paradojal al tratamiento antituberculoso en un paciente inmunocompetente: a propósito de un caso / Paradoxical reaction during tuberculosis treatment in immunocompetent children: case report

Tuberculosis is an important public health problem. It is estimated that around 5-10% of patients with tuberculosis present with central nervous system involvement; meningitis and tuberculoma being two of the most frequent manifestations. The paradoxical reaction in patients undergoing antituberculosis treatment is infrequent, nevertheless it is an important consideration in patients, who after an appropriate initial response to specific treatment, present with worsening clinical and radiological signs or the appearance of new lesions.

La tuberculosis (TBC) es un problema de importancia en salud pública. Se estima que alrededor de 5 a 10% de los pacientes con TBC presentan compromiso de sistema nervioso central, siendo la meningitis y el tuberculoma las manifestaciones más frecuentes. La reacción paradojal en pacientes con tratamiento antituberculoso es infrecuente, sin embargo, es importante considerarla en pacientes que durante la terapia, luego de una respuesta inicial apropiada, presentan un empeoramiento clínico y/o radiológico o aparición de nuevas lesiones.

Neurotuberculosis mimicking brain tumour; A case report.

Summary: Neurotuberculosis is one of the grave complications of primary tuberculous infection. Extensive BCG vaccination of children and inadequate antituberculous drug therapy have led to the emergence of newer complex clinical pictures and diagnostic dilemma. Here we report a case of right-sided hemiparesis with features of raised intracranial tension in a sixyear- old boy. Neuroimaging revealed presence of a high grade astrocytoma. On clinical examination, right-sided cervical lymphadenopathy with discharging sinus and tenderness over right hip joint were present. On further investigation, these were proved to be of tubercular origin. All preliminary findings were in favour of disseminated tuberculosis, but the nature of CNS lesion was creating diagnostic dilemma. Etiological diagnosis of the CNS lesion was necessary, as, if it was not of tubercular origin, the management protocol would be different and with any delay we could have lost the patient. Though on routine CSF study, no AFB were present, but we confirmed the presence of mycobacterial DNA by polymerase chain reaction. Patient showed considerable improvement after being put on Anti-tubercular Treatment (ATT) and steroids. Tuberculous brain abscess is rare. Very few cases have been reported even in adults. Most reported cases are in immunocompromised patients. This case highlights the fact that tuberculous brain abscess can have atypical presentation even in immunocompetent children mimicking CNS malignancy. Careful examination and thorough investigation are required to establish the diagnosis. Timely initiation of appropriate therapy can reduce mortality and neurological sequelae.

Tuberculous meningitis: a report of 60 adult cases / Meningitis tuberculosa: reporte de 60 casos adultos

OBJECTIVE: This was to evaluate the history, clinical and laboratory findings, outcome and prognosis of patients with tuberculous meningitis (TBM). METHOD: Between 1998 and 2009, 60 patients with TBM were evaluated, retrospectively. RESULT: Overall, 60 patients were selected, of which 33 (55%) were male. The patients' ages ranged from 14 to 62 years. In the majority of the patients, disease was in an advanced stage on admission (66% in stage III according to the British Research Council neurological criteria). The rate of complications was highest among patients in stages II and III with an overall mortality rate of 6.6% (n= 2 of stage II patients and n= 2 of stage III patients). CONCLUSIONS: Earlier admission of the patients with TBM could provide better outcomes with regard to sequelae and mortality. Fatal cases presented with rapid deterioration and were refractory to treatment.

OBJETIVO: El propósito de este trabajo fue evaluar la historia, los hallazgos clínicos y de laboratorio, la evolución, y la prognosis de pacientes con meningitis tuberculosa (MTB). MÉTODO: Entre 1998 y 2009, se evaluaron 60 pacientes con TBM, retrospectivamente. RESULTADOS: En general, se seleccionaron 60pacientes, de los cuales 33 (55%) fueron varones. La edad de los pacientes osciló de 14 a 62 años. En la mayoría de los pacientes, la enfermedad se encontraba en etapa avanzada al momento del ingreso (66% en la etapa III de acuerdo con los criterios neurológicos del Consejo Británico de Investigación). La tasa de complicaciones fue más alta entre los pacientes en las etapas IIy III con una tasa de mortalidad general de 6.6% (n = 2 en los pacientes de etapa IIy n = 2 en los pacientes de etapa III). CONCLUSIONES: El ingreso temprano de los pacientes con MTB podría proporcionar mejores resultados con respecto a las secuelas y la mortalidad. Los casos fatales se presentaron con deterioro rápido y fueron refractarios al tratamiento.

Meningitis tuberculosa: claves para su diagnóstico y propuestas terapéuticas / Tuberculous meningitis: tips for diagnosis and proposals for treatment

Diagnosis of tuberculous meningitis (TBM) is always a challenge. We must give importance for duration of clinical manifestations. Cerebrospinal fluid (CSF) has own characteristic and it have to be control several times during the treatment. Adenosin deaminase with cut off more than 15 UI/mL and M. tuberculosis polymerase chain reaction in CSF are the most relevant diagnostic tests. Radiologic test gives diagnostic clues but do not confirm the diagnosis. In the future we can structure a score with all these elements to support the clinician in the diagnostic process. The treatment of TBM because of its high morbidity and high mortality has to be necessarily more intensive and prolonged and we must select drugs with a good penetration into the central nervous system (SNC). A therapeutic scheme with duration of 12 months with two phases is proposed, the diary phase during the first three months of treatment includes isoniacid, rifampicin, pirazinamid and ethambutol or moxifloxacin. Streptomycin must not be included due to own erratic SNC penetration and its known toxicity. The second twice a week phase has to be changed by a three times per week phase during 9 months and it must include isoniacid, rifampicin and pirazinamide. Dexamethasone is added during the first 6 weeks of treatment. Patients with HIV infection than required treatment with antiretroviral drugs have to start ART treatment when diary phase has finished and must not include protease or integrase inhibitors.

El diagnóstico de la meningitis tuberculosa (MTBC) es siempre un desafío. Debemos dar importancia a las manifestaciones clínicas y su duración. El análisis citoquímico del LCR tiene características propias y debe ser controlado varias veces durante el tratamiento. La adenosin deami-nasa con punto de corte > 15 UI/mL y la RPC para M. tuberculosis en LCR son las pruebas más relevantes. Las imágenes aportan elementos valiosos pero no establecen el diagnóstico por si solas. A futuro se puede estructurar un puntaje con todos estos elementos para apoyar al clínico en el proceso diagnóstico. El tratamiento de la MTBC, dada su alta morbilidad y mortalidad, necesariamente debe ser más intensivo y prolongado, y debemos seleccionar fármacos con buena penetración en el SNC. Se propone un esquema de 12 meses. La fase diaria debería durar tres meses e incluir isoniacida, rifampicina, pirazinamida y etambutol o moxifloxacina. Estreptomicina no debería ser incluida dada su mala penetración en el SNC y reconocida toxicidad. La fase de mantención debería ser trisemanal e incluir isoniacida, rifampicina y pirazinamida. Dexa-metasona debe administrarse durante las primeras seis semanas de tratamiento. En el caso de pacientes con infección por VIH que requieran iniciar TARV ésta debe ser aplazada para después de la fase diaria y no debería incluir inhibidores de proteasa e integrasa.

Evaluation of 121 adult cases of tuberculous meningitis

To evaluate serious complications of tuberculous meningitis [TBM], resulting from difficulties in diagnosis and treatment of the disease. Clinical and laboratory findings of 121 patients with TBM followed-up between the years 1998 and 2005 were evaluated retrospectively in Haseki Training and Research Hospital, Istanbul, Turkey. The patients were diagnosed by history, physical examination findings, CSF findings, CSF culture, and radiological imaging techniques, and were treated with isoniazid, rifampicin, ethambutol, pyrazinamide, and dexamethasone. The age distribution of 121 patients was 15-70 [31 +/- 14.0 years]. Most frequent complaint on admission was headache, and most frequent findings were nuchal rigidity, alteration in consciousness, and fever. Forty-four patients had active pulmonary tuberculosis, 33 had a history of pulmonary tuberculosis, 24 had a family member with active pulmonary tuberculosis, and one had HIV infection. Mycobacterium tuberculosis was isolated from CSF in 52 patients [43%]. At cranial imaging, basal meningitis, tuberculoma, and hydrocephalus were the most common findings. Of 121 patients who were treated, 69 recovered completely, 40 recovered with neurological sequels, and 12 patients died. Ten of the deceased had stage III TBM. Tuberculous meningitis is one of the most severe clinical forms of tuberculosis. Mortality is directly related with the stage of the disease

Prevalence of antitiuberculous drug-induced cytolytic hepatitis of tuberculous meningitises

The aim of this work was to specify the prevalence and the description of scondary cytolytic hepatitis of the antituberculous drugs used in treatment of tuberculous meningitis in the intensive care units. Method: We have been included retro-spectively [January 1998 - December 2002] patients having a tuberculous meningitis treated with antituberculous drugs who developed a cytolytic hepatitis defined by an increase of the alanin-aminotransferase [ALAT] level more than two times of its normal upper limit. Six cases have been included among 74 patients [prevalence of 8,1%], three women and three men aged 17 to 45 years. The delay of apparition of cytolytic hepatitis varied from four days to five weeks. ALAT rates varied from two and half to 26 times the normal level. No other potentialy hepatotoxic medication has been prescribed. Three patients normalized their ALAT after reducing the rifam picin dose to half measure, in another case a definitive stoppage of isoniazid was required. Ytolytic hepatitis regressed spotaneously in one patient whereas another died as a result of a nosocomial infection. The prevalence of secondary cytolytic hepatitis of antituberculous drugs during treatment of tuberculous meningitis in the intensive care unit raised to 8,1%, the evolution is most often favourable after adaptation of doses

Effect of methyl prednisolone on sensory motor functions in tuberculous meningitis.

A prospective hospital based study was undertaken to study the effect of methyl prednisolone therapy on sensory and motor functions in tuberculous meningitis (TBM). The patients with TB meningitis seen during 1994-1998 were studied. CT scan, motor evoked potential (MEP) to upper and lower limbs; and median and tibial somatosensory evoked potentials (SEP) were carried out in all the patients. Outcome was defined at the end of 3 months into poor, partial or complete recovery on the basis of Barthel index score. Inj methyl prednisolone (MPS) 500 mg IV was given to 21 patients followed by oral tapering dose of prednisolone over one month in addition to 4 drug anti-tubercular treatment. The control group comprised of 16 patients who received 4 drugs anti-tubercular therapy without any corticosteroid. These groups were comparable with respect to their age, stage of meningitis, Glasgow coma scale score and radiological findings. In MPS group, CMCT was abnormal in 9 and SEPs in 7 patients. In the control group, these were abnormal in 9 and 5 patients respectively. Three months after the therapy the frequency of improvement, deterioration and stationary evoked potential (EP) changes were also noted in both the groups. Diversity of evoked potential changes were also noted. Evoked potential changes were neither significantly different between the groups nor there was any beneficial effect shown in MPS group at 3 months. On the contrary, the control group fared significantly better than the MPS group. Initial MEP and SEP abnormalities were however related to 3 months outcome (p<0.01).

Múltiplos tuberculomas intracerebrais na vigência de terapia específica para tuberculose pulmonar: a propósito de um caso / Multiple intracranial tuberculomas developing during specific treatment of pulmonary tuberculosis: case report

A forma clássica de apresentação da neurotuberculose é a meningite. Os tuberculomas cerebrais são formas raras de neurotuberculose e resultam da disseminação hematogênica de focos distantes de infecção pelo Mycobacterium tuberculosis. Aproximadamente 1 por cento dos pacientes com tuberculose do sistema nervoso central desenvolve tuberculomas intracranianos, poucas semanas ou meses após o início da quimioterapia tuberculostática. A involução das lesões é lenta e não necessariamente significa resistência medicamentosa ou falta de aderência ao tratamento. Descrevemos o caso, diagnosticado e tratado na 25ª Enfermaria da Santa Casa da Misericórdia do Rio de Janeiro, de um paciente imunocompetente que apresentou meningite e tuberculomas múltiplos do sistema nervoso central, durante o tratamento específico de tuberculose miliar. A literatura é revisada e o diagnóstico, terapêutica e possíveis mecanismos imunológicos são discutidos.

Treatment of tuberculosis.

Early diagnosis and prompt treatment of tuberculosis is important in order to minimise complications and sequelae. It is important to select the proper regimen and ensure that the patient is getting adequate number of drugs for adequate duration. The principles of short course chemotherapy and the rationale behind the currently recommended regimens are outlined in this article. Standard (daily or intermittent) 6-month short course regimens are sufficient to cure most forms of tuberculosis in children and only severe forms like miliary, meningitis and neurotuberculosis require a longer duration of treatment. Worldwide, the DOTS strategy is now recommended in order to ensure cure and cut down the transmission of disease in the community and wherever possible, should be employed in the treatment of tuberculosis in children also.