Clinical and Radiological End Points to Stop Anti-Tubercular Treatment in Central Nervous System Tuberculoma and Predictors of Poor Outcome: A Retrospective Study

Overview

Journal Am J Trop Med Hyg

Specialty Tropical Medicine

Date 2023 Nov 2

PMID 37918003

Authors

Ankit Gupta

Vimal Kumar Paliwal

Swati Bharatveer

Prabhakar Mishra

Neeraj Jain

Affiliations

Soon will be listed here.

Abstract

The clinical and radiological end points to stop anti-tubercular treatment in central nervous system (CNS) tuberculoma are not known. This retrospective study was done to determine end points to stop anti-tubercular treatment and find the predictors of poor outcome in patients with CNS tuberculoma. Patients who were admitted with a diagnosis of brain/spine tuberculoma between January 2015 and December 2019 and who completed a minimum of 1-year follow-up were enrolled. Clinical and radiological end points to stop anti-tubercular treatment and predictors of death and poor outcome (modified Rankin scale > 2) were analyzed. One hundred and eight patients (male-to-female ratio, 47 [43.5%]:61 [56.5%]; brain tuberculoma, 102; spinal cord tuberculoma, 14; brain and spinal cord tuberculoma, 8) were included in the study. Median duration of anti-tubercular treatment was 24 months. Radiological resolution of tuberculoma (resolution of gadolinium-enhancing lesion, gliosis, calcification, cord atrophy, or syrinx formation) and radiological halt (no increase in size/number of tuberculoma on magnetic resonance imaging scans done 6 months apart) were used as end points to stop anti-tubercular treatment in 69 and 7 patients, respectively. Seven patients stopped their treatment by themselves, and 25 patients died. Altered sensorium, motor weakness, infarcts, hydrocephalus, and constitutional symptoms of tuberculous meningitis were predictors of poor outcome or death in CNS tuberculoma patients. Radiological resolution or radiological halt of brain/spinal cord tuberculoma was a reasonable end point to stop anti-tubercular treatment. However, this may require 24 months or more of anti-tubercular treatment. Associated tuberculous meningitis and its complications portend a poor prognosis.

References

Anupriya A, Sunithi M, Maya T, Goel M, Alexander M, Aaron S . Tuberculous optochiasmatic arachnoiditis. Neurol India. 2010; 58(5):732-5. DOI: 10.4103/0028-3886.72194. View

Ahuja G, Mohan K, Prasad K, Behari M . Diagnostic criteria for tuberculous meningitis and their validation. Tuber Lung Dis. 1994; 75(2):149-52. DOI: 10.1016/0962-8479(94)90045-0. View

Garg A, Kaur K, Devaranjan Sebastian L, Gaikwad S, Bhatia R, Singh M . Conglomerate Ring-Enhancing Lesions are Common in Solitary Neurocysticercosis and do not always Suggest Neurotuberculosis. Ann Indian Acad Neurol. 2019; 22(1):67-72. PMC: 6327694. DOI: 10.4103/aian.AIAN_221_18. View

Morales H, Alfaro D, Martinot C, Fayed N, Gaskill-Shipley M . MR spectroscopy of intracranial tuberculomas: A singlet peak at 3.8 ppm as potential marker to differentiate them from malignant tumors. Neuroradiol J. 2015; 28(3):294-302. PMC: 4757282. DOI: 10.1177/1971400915592077. View

Wasay M, Moolani M, Zaheer J, Kheleani B, Smego R, Sarwari R . Prognostic indicators in patients with intracranial tuberculoma: a review of 102 cases. J Pak Med Assoc. 2004; 54(2):83-7. View

Thakur K, Das M, Dooley K, Gupta A . The Global Neurological Burden of Tuberculosis. Semin Neurol. 2018; 38(2):226-237. DOI: 10.1055/s-0038-1651500. View

Ramappa V, Aithal G . Hepatotoxicity Related to Anti-tuberculosis Drugs: Mechanisms and Management. J Clin Exp Hepatol. 2015; 3(1):37-49. PMC: 3940184. DOI: 10.1016/j.jceh.2012.12.001. View

Poonnoose S, Rajshekhar V . Rate of resolution of histologically verified intracranial tuberculomas. Neurosurgery. 2003; 53(4):873-8. DOI: 10.1227/01.neu.0000083553.25421.6f. View

Awada A, Daif A, Pirani M, Khan M, Memish Z, Al Rajeh S . Evolution of brain tuberculomas under standard antituberculous treatment. J Neurol Sci. 1998; 156(1):47-52. DOI: 10.1016/s0022-510x(98)00024-0. View

10.

Metcalf T, Soria J, Montano S, Ticona E, Evans C, Huaroto L . Evaluation of the GeneXpert MTB/RIF in patients with presumptive tuberculous meningitis. PLoS One. 2018; 13(6):e0198695. PMC: 6005529. DOI: 10.1371/journal.pone.0198695. View

11.

Dastur H . A tuberculoma review with some personal experiences. I. Brain. Neurol India. 1972; 20(3):111-26. View

12.

Bagga A, Kalra V, GHAI O . Intracranial tuberculoma. Evaluation and treatment. Clin Pediatr (Phila). 1988; 27(10):487-90. DOI: 10.1177/000992288802701004. View

13.

Be N, Kim K, Bishai W, Jain S . Pathogenesis of central nervous system tuberculosis. Curr Mol Med. 2009; 9(2):94-9. PMC: 4486069. DOI: 10.2174/156652409787581655. View

14.

Sinha M, Garg R, Hk A, Agarwal A, Singh M, Verma R . Vision impairment in tuberculous meningitis: predictors and prognosis. J Neurol Sci. 2010; 290(1-2):27-32. DOI: 10.1016/j.jns.2009.12.012. View

15.

Dorjee K, Sadutshang T, Rana R, Topgyal S, Phunkyi D, Choetso T . High prevalence of rifampin-resistant tuberculosis in mountainous districts of India. Indian J Tuberc. 2020; 67(1):59-64. PMC: 9150926. DOI: 10.1016/j.ijtb.2019.08.005. View

16.

Prasad K, Sahu J . Duration of anti-tubercular treatment in tuberculous meningitis: challenges and opportunity. Neurol India. 2010; 58(5):723-6. DOI: 10.4103/0028-3886.72182. View

17.

Gupta M, Garg A, Kaur K, Joseph L, Goyal V, Srivastava A . A Neurocysticercosis Infestation Masquerading as Malignant Brain Tumour. Ann Indian Acad Neurol. 2022; 24(6):970-972. PMC: 8965918. DOI: 10.4103/aian.AIAN_725_20. View

18.

Thwaites G, Fisher M, Hemingway C, Scott G, Solomon T, Innes J . British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children. J Infect. 2009; 59(3):167-87. DOI: 10.1016/j.jinf.2009.06.011. View

19.

Khadilkar S, Kadam N, Kulkarni R, Meshram C, Meshram A, Patel B . Guidelines versus ground lines: Tuberculosis of the central nervous system. Neurol India. 2019; 67(3):787-791. DOI: 10.4103/0028-3886.263198. View

20.

ARSENI C . Two hundred and one cases of intracranial tuberculoma treated surgically. J Neurol Neurosurg Psychiatry. 1958; 21(4):308-11. PMC: 497336. DOI: 10.1136/jnnp.21.4.308. View