DELAYED DIAGNOSIS OF TUBERCULOUS LEPTOMENINGITIS COMPLICATED BY MULTISYSTEMIC MORBIDITIES IN A KENYAN HOSPITAL
Abstract
Tuberculous meningitis (TBM) is the most severe and uniformly fatal form of extrapulmonary tuberculosis without treatment. HIV co-infection is the most serious risk factor of TBM in sub-Saharan Africa. The diagnosis of TBM is fraught with many patient and health system challenges, leading to treatment delays and serious TBM-related morbidity and mortality. These include a lack of resources for adequate TB diagnostics, lack of adequate knowledge on typical and atypical TB presentations, over-reliance on bacteriological methods to confirm TB diagnosis, and failure to consider TB in the absence of available diagnostic methods in the face of compatible clinical characteristics. The World Health Organization (WHO) recommended the use of Xpert/MTB/Rif as the initial diagnostic test for TBM in 2013, but the sensitivity rates for cerebrospinal fluid diagnosis of TBM vary from 59% to 72% depending on the methodology used. In this study, we report on the case of a young high school student in rural Kenya whose TBM diagnosis and treatment were delayed by 2 years, leading to significant disease-related morbidity. Her subsequent presumptive diagnosis of TBM and treatment with anti-TB drugs, adjunctive corticosteroids, and supportive care led to the resolution of almost all her complications. We emphasize the need for empirical TBM treatment in appropriate clinical circumstances
Keywords:
Tuberculous meningitis, TBM, TB Leptomeningitis, TBM diagnostics, Xpert/MTB/Rif, Kenya.Downloads
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Copyright (c) 2024 Onyango C. Vonwicks; MBChB, MMed, FCP (SA), Auma Nicholas; Diploma Clinical Medicine MBChB, Malalu P. Collins; B. Com, MBChB, Mutiso Boniface; Diploma Clinical Medicine, MBChB(c), , Mutuma M. Nicholas; Diploma Clinical Medicine, Certificate (Public Health, Mutua Dominic; Diploma Clinical Medicine, BSc. Clinical Medicine, Fryda C. William; MD

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References
CDC), C. f. D. P. a. C. (2021, June 13, 2024). HIV and TB Overview: Kenya. CDC. Retrieved September 20 from https://www.cdc.gov/global-hiv-tb/php/where-we-work/kenya.html?CDC_AAref_Val=https://www.cdc.gov/globalhivtb/where-we-work/kenya/kenya.html
Anderson, N. E., Somaratne, J., Mason, D. F., Holland, D., & Thomas, M. G. (2010). Neurological and systemic complications of tuberculous meningitis and its treatment at Auckland City Hospital, New Zealand. J Clin Neurosci, 17(9), 1114-1118. https://doi.org/10.1016/j.jocn.2010.01.006
Bagcchi, S. (2023). WHO's Global Tuberculosis Report 2022. The Lancet Microbe, 4(1), e20. https://doi.org/10.1016/S2666-5247(22)00359-7
Bahr, N. C., & Boulware, D. R. (2014). Methods of rapid diagnosis for the etiology of meningitis in adults. Biomark Med, 8(9), 1085-1103. https://doi.org/10.2217/bmm.14.67
Chin, J. H. (2014). Tuberculous meningitis: Diagnostic and therapeutic challenges. Neurol Clin Pract, 4(3), 199-205. https://doi.org/10.1212/cpj.0000000000000023
Enos, M., Sitienei, J., Ong'ang'o, J., Mungai, B., Kamene, M., Wambugu, J., Kipruto, H., Manduku, V., Mburu, J., Nyaboke, D., Ngari, F., Omesa, E., Omale, N., Mwirigi, N., Okallo, G., Njoroge, J., Githiomi, M., Mwangi, M., Kirathe, D., . . . Weyenga, H. (2018). Kenya tuberculosis prevalence survey 2016: Challenges and opportunities of ending TB in Kenya. PLoS One, 13(12), e0209098. https://doi.org/10.1371/journal.pone.0209098
Kioumehr, F., Dadsetan, M. R., Feldman, N., Mathison, G., Moosavi, H., Rooholamini, S. A., & Verma, R. C. (1995). Postcontrast MRI of cranial meninges: leptomeningitis versus pachymeningitis. J Comput Assist Tomogr, 19(5), 713-720. https://doi.org/10.1097/00004728-199509000-00005
Laborada, J., & Cohen, P. R. (2021). Tuberculosis-Associated Erythema Nodosum. Cureus, 13(12), e20184. https://doi.org/10.7759/cureus.20184
Mace, S. E. (2008). Acute Bacterial Meningitis. Emergency Medicine Clinics of North America, 26(2), 281-317. https://doi.org/https://doi.org/10.1016/j.emc.2008.02.002
Marx, G. E., & Chan, E. D. (2011). Tuberculous meningitis: diagnosis and treatment overview. Tuberc Res Treat, 2011, 798764. https://doi.org/10.1155/2011/798764
Navasardyan, I., Abdou, A., Kades, S., Misakyan, Y., Ochsner, J., Subbian, S., & Venketaraman, V. (2023). Tuberculosis meningitis coexisting with HIV Infection: a comprehensive review [Review]. Frontiers in Tuberculosis, 1. https://doi.org/10.3389/ftubr.2023.1242869
Nhu, N. T., Heemskerk, D., Thu do, D. A., Chau, T. T., Mai, N. T., Nghia, H. D., Loc, P. P., Ha, D. T., Merson, L., Thinh, T. T., Day, J., Chau, N., Wolbers, M., Farrar, J., & Caws, M. (2014). Evaluation of GeneXpert MTB/RIF for diagnosis of tuberculous meningitis. J Clin Microbiol, 52(1), 226-233. https://doi.org/10.1128/jcm.01834-13
Paramasivam, S., Thomas, B., Chandran, P., Thayyil, J., George, B., & Sivakumar, C. P. (2017). Diagnostic delay and associated factors among patients with pulmonary tuberculosis in Kerala. J Family Med Prim Care, 6(3), 643-648. https://doi.org/10.4103/2249-4863.222052
Patel, V. B., Theron, G., Lenders, L., Matinyena, B., Connolly, C., Singh, R., Coovadia, Y., Ndung'u, T., & Dheda, K. (2013). Diagnostic accuracy of quantitative PCR (Xpert MTB/RIF) for tuberculous meningitis in a high burden setting: a prospective study. PLoS Med, 10(10), e1001536. https://doi.org/10.1371/journal.pmed.1001536
Prasad, K., Singh, M. B., & Ryan, H. (2016). Corticosteroids for managing tuberculous meningitis. Cochrane Database Syst Rev, 4(4), Cd002244. https://doi.org/10.1002/14651858.CD002244.pub4
Seddon, J. A., Tugume, L., Solomons, R., Prasad, K., & Bahr, N. C. (2019). The current global situation for tuberculous meningitis: epidemiology, diagnostics, treatment and outcomes. Wellcome Open Res, 4, 167. https://doi.org/10.12688/wellcomeopenres.15535.1
Teo, A. K. J., Singh, S. R., Prem, K., Hsu, L. Y., & Yi, S. (2021). Duration and determinants of delayed tuberculosis diagnosis and treatment in high-burden countries: a mixed-methods systematic review and meta-analysis. Respiratory Research, 22(1), 251. https://doi.org/10.1186/s12931-021-01841-6
Thwaites, G. E., Nguyen, D. B., Nguyen, H. D., Hoang, T. Q., Do, T. T., Nguyen, T. C., Nguyen, Q. H., Nguyen, T. T., Nguyen, N. H., Nguyen, T. N., Nguyen, N. L., Nguyen, H. D., Vu, N. T., Cao, H. H., Tran, T. H., Pham, P. M., Nguyen, T. D., Stepniewska, K., White, N. J., . . . Farrar, J. J. (2004). Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults. N Engl J Med, 351(17), 1741-1751. https://doi.org/10.1056/NEJMoa040573
Treatment of tuberculosis. (2003). MMWR Recomm Rep, 52(Rr-11), 1-77.
Veltman, J. A., Bristow, C. C., & Klausner, J. D. (2014). Meningitis in HIV-positive patients in sub-Saharan Africa: a review. J Int AIDS Soc, 17(1), 19184. https://doi.org/10.7448/ias.17.1.19184
WHO Guidelines Approved by the Guidelines Review Committee. (2010). In Treatment of Tuberculosis: Guidelines. World Health Organization
Copyright © 2010, World Health Organization.
WHO Guidelines Approved by the Guidelines Review Committee. (2013). In Automated Real-Time Nucleic Acid Amplification Technology for Rapid and Simultaneous Detection of Tuberculosis and Rifampicin Resistance: Xpert MTB/RIF Assay for