Background: Tuberculous disease of spine (spinal TB) is under-recognized in tuberculous (TB) meningitis.
The objective of the study was to evaluate the frequency, clinical and neuroimaging changes, and
outcome in the patients with spinal TB.
Methods: All the patients with spinal TB admitted in the two
largest tertiary hospitals in Kuala Lumpur from 2009 to 2017 were recruited, the clinical features were
documented, the magnetic resonance imaging (MRI) of the spine was performed. Clinical outcome was
assessed with Modified Rankin scale (MRS).
Results: Twenty two patients were recruited. This was
out of 70 TB meningitis patients (31.4%) seen over the same period. Eighteen (81.8%) patients had
concomitant TB meningitis. The clinical features consisted of systemic symptoms with fever (63.6%),
meningitis symptoms with altered sensorium (45.5%), myelopathy with paraparesis (36.4%). The
findings on spinal MRI were discitis (36.4%), spinal meningeal enhancement (31.8%), spinal cord
compression (31.8%), psoas abscess (27.3%), osteomyelitis (22.7%), and cord oedema (22.7%). All
except two patients (90.9%) had involvement in psoas muscle, bone or leptomeningeal enhancement,
features that can be used to differentiate from myelopathy that affect the parenchyma only, such as
demyelination. Unusual manifestations were syringomyelia and paradoxical manifestations seen in 3
patients each. The outcome were overall poor, with 68% having MRS 3 or more.
Conclusion: Spinal TB is common in TB meningitis. The outcome is overall poor. A heightened
awareness is crucial to enable early diagnosis and treatment.
Background: Tuberculous meningitis is a life-threatening manifestation resulting from infection
by Mycobacterium tuberculosis, especially in the developing countries. The molecular aspects of
pathogenesis of tuberculous meningitis remain poorly understood. We evaluated the correlation of
cerebrospinal fluid (CSF) and serum cytokine levels with the clinical outcome of 15 HIV-negative
patients with tuberculous meningitis. We also assessed the association of CSF and serum cytokines
with neuroimaging of brain findings in the patients.
Methods: The prospective longitudinal study was
conducted at the University Malaya Medical Centre between 2012 and 2014. Neuroimaging of the
brain was performed and the findings of leptomeningeal enhancement, hydrocephalus, tuberculoma,
infarcts and vasculopathy were recorded. The CSF and serum specimens were analyzed for IL-1ß,
IL-8, IL-10, IL-18, IP-10, IFN-γ, MCP-1, TGF-ß, VEGF, TNF- α, IL-18BPa and MMP-9. The clinical
outcome was graded at 3 months based on Modified Rankin scale (mRS).
Results: On admission and
at one month of anti-tuberculosis treatment, the CSF levels of IL-8, IL-1β, IP-10, IFN-γ and VEGF
were elevated in all of the patients. Serum IP-10, MCP-1, IL-1β and IL-8 levels were increased on
admission and at one month of anti-tuberculosis treatment. There were statistically significant differences
between good and poor outcome (mRS at 3 months) for CSF IFN-γ (p=0.033), CSF IL-10 (p=0.033)
and serum VEGF (p=0.033) at one month of treatment. None of the patients showed any association
between CSF and serum cytokines on admission and at one month of anti-tuberculosis treatment with
neuro-radiological findings.
Conclusion: The CSF cytokine levels were not related to TBM disease severity on admission, and
changes on MRI/CT scans. CSF levels of IFN-γ and IL-10 at one month of anti-tuberculosis treatment
were associated with clinical outcome at 3 months. CSF cytokine levels on admission were not
associated with the clinical outcome.
Background. Since 2008, we have observed an increasing number of Myanmarese refugees in Malaysia being admitted for acute/subacute onset peripheral neuropathy. Most of them had a preceding history of starvation. Methods. We retrospectively studied the clinical features of all Myanmarese patients admitted with peripheral neuropathy from September 2008 to January 2014. Results. A total of 24 patients from the Chin, Rohingya, and Rakhine ethnicities (mean age, 23.8 years; male, 96%) had symmetrical, ascending areflexic weakness with at least one additional presenting symptom of fever, lower limb swelling, vomiting, abdominal pain, or difficulty in breathing. Twenty (83.3%) had sensory symptoms. Ten (41.6%) had cranial nerve involvement. Nineteen patients had cerebrospinal fluid examinations but none with evidence of albuminocytological dissociation. Neurophysiological assessment revealed axonal polyneuropathy, predominantly a motor-sensory subtype. Folate and vitamin B12 deficiencies were detected in 31.5% of them. These findings suggested the presence of a polyneuropathy related to nutrition against a backdrop of other possible environmental factors such as infections, metabolic disorders, or exposure to unknown toxin. Supportive treatment with appropriate vitamins supplementation improved functional outcome in most patients. Conclusion. We report a spectrum of acquired reversible neurological manifestations among Myanmarese refugees likely to be multifactorial with micronutrient deficiencies playing an important role in the pathogenesis.
Objective: The primary objective of this study was to describe the neuroimaging changes of tuberculous meningitis (TBM), and to determine the role of neuroimaging in the diagnosis of TBM.
Methods: Between January 2009 and July 2015, we prospectively recruited TBM patients in two hospitals in Malaysia. Neuroimaging was performed and findings were recorded. The control consists of other types of meningo-encephalitis seen over the same period.
Results: Fifty four TBM patients were recruited. Leptomeningeal enhancement was seen in 39 (72.2%) patients, commonly at prepontine cistern and interpeduncular fossa. Hydrocephalus was observed in 38 (70.4%) patients, 25 (46.3%) patients had moderate and severe hydrocephalus. Thirty four patients (63.0%) had cerebral infarction. Tuberculoma were seen in 29 (53.7%) patients; 27 (50.0%) patients had classical tuberculoma, 2 (3.7%) patients
had “other” type of tuberculoma, 18 (33.3%) patients had ≥5 tuberculoma, and 11 (20.4%) patients had < 5 tuberculoma. Fifteen (37.2%) patients had vasculitis, 6 (11.1%) patients had vasospasm. Close to nine tenth (88.9%) of the patients had ≥1 classical neuroimaging features, 77.8% had ≥ 2 classical imaging features of TBM (basal enhancement, hydrocephalus, basal ganglia / thalamic infarct, classical tuberculoma, and vasculitis/vasospasm). Only 4% with other types of meningitis/encephalitis had ≥1 feature, and 1% had two or more classical TBM neuroimaging features. The sensitivity of the imaging features of the imaging features for diagnosis of TBM was 88.9% and the specificity was 95.6%.
Conclusion: The classic imaging features of basal enhancement, hydrocephalus, basal ganglia/thalamic infarct, classic tuberculoma, and vasculitis are sensitive and specific to diagnosis of TBM.