Clare Logan1, Claire Mullender2, Miriam Mirfenderesky2, Nicholas Feasey3, Catherine Cosgrove1, Peter Riley2, Angela Houston2, Tom Harrison1, Tihana Bicanic1, Phil Rich4, Paul Hart5, Síle F Molloy6, Derek C Macallan7. 1. Infection Care Group, St George's University Hospitals NHS Foundation Trust, London, UK; Institute for Infection & Immunity, St George's, University of London, London SW17 0RE, UK. 2. Infection Care Group, St George's University Hospitals NHS Foundation Trust, London, UK. 3. Infection Care Group, St George's University Hospitals NHS Foundation Trust, London, UK; Liverpool School of Tropical Medicine, Liverpool, UK. 4. Department of Neuroradiology, St George's University Hospitals NHS Foundation Trust, London, UK. 5. Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK; Department of Neurology, Epsom and St Helier Hospital, Epsom, UK. 6. Institute for Infection & Immunity, St George's, University of London, London SW17 0RE, UK. 7. Infection Care Group, St George's University Hospitals NHS Foundation Trust, London, UK; Institute for Infection & Immunity, St George's, University of London, London SW17 0RE, UK. Electronic address: macallan@sgul.ac.uk.
Abstract
OBJECTIVES: Most data for Central Nervous System Tuberculosis (CNS-TB) derive from high-incidence, resource-limited countries. We sought to determine the presentation, management and outcomes of CNS-TB in a low-incidence setting with accessible healthcare. METHODS: We undertook a retrospective, observational study of CNS-TB in adults at a single tertiary-referral London hospital (2001-2017). Cases were categorised as either TB meningitis (TBM) or TB mass lesions without meningitis (TBML), applying novel criteria for definite, probable, and possible TBML. RESULTS: We identified sixty-two cases of TBM (37% definite; 31% probable; 32% possible) alongside 14 TBML cases (36% definite; 29% probable; and 36% possible). Clinical presentation was highly variable. Among CSF parameters, hypoglycorrhachia proved most discriminatory for "definite" TBM. Neurosurgical intervention was required for mass-effect or hydrocephalus in 16%. Mortality was higher in TBM versus TBML (16% vs. 0%) but overall morbidity was significant; 33% of TBM and 29% of TBML survivors suffered persisting neurological disability at 12-months. In TBM, hydrocephalus, infarct, basal enhancement and low CSF white cell count were independently associated with worse neurological outcomes. CONCLUSION: Although mortality was lower than previously reported in other settings, morbidity was significant, highlighting the need for improved CNS-TB diagnostics, therapeutics and interventions to mitigate neurological sequelae.
OBJECTIVES: Most data for Central Nervous System Tuberculosis (CNS-TB) derive from high-incidence, resource-limited countries. We sought to determine the presentation, management and outcomes of CNS-TB in a low-incidence setting with accessible healthcare. METHODS: We undertook a retrospective, observational study of CNS-TB in adults at a single tertiary-referral London hospital (2001-2017). Cases were categorised as either TB meningitis (TBM) or TB mass lesions without meningitis (TBML), applying novel criteria for definite, probable, and possible TBML. RESULTS: We identified sixty-two cases of TBM (37% definite; 31% probable; 32% possible) alongside 14 TBML cases (36% definite; 29% probable; and 36% possible). Clinical presentation was highly variable. Among CSF parameters, hypoglycorrhachia proved most discriminatory for "definite" TBM. Neurosurgical intervention was required for mass-effect or hydrocephalus in 16%. Mortality was higher in TBM versus TBML (16% vs. 0%) but overall morbidity was significant; 33% of TBM and 29% of TBML survivors suffered persisting neurological disability at 12-months. In TBM, hydrocephalus, infarct, basal enhancement and low CSF white cell count were independently associated with worse neurological outcomes. CONCLUSION: Although mortality was lower than previously reported in other settings, morbidity was significant, highlighting the need for improved CNS-TB diagnostics, therapeutics and interventions to mitigate neurological sequelae.