Intraspinal and Intracranial Neurotuberculosis, Clinical and Imaging Characteristics and Outcomes in Hospitalized Patients: A Cohort Study (2000–2022)
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design and Population
2.2. Data Collection and Diagnostic Methods
- One level: With paradiscal morphology, when a complex is affected (vertebra-disc-vertebra). If the morphology is central or appendiceal (2 contiguous vertebrae involved).
- Two levels: With paradiscal morphology when there are two complexes (each complex formed by a disc with 2 vertebrae involved). If the morphology is central or appendiceal (2 complexes, each complex formed by 2 contiguous vertebrae involved).
- Three or more levels: For paradiscal morphology when there are 3 or more complexes (vertebra–intervertebral disc–vertebra). For central or appendiceal morphology, there would be 3 or more complexes of 2 contiguous vertebral involved.
- Continuous multilevel involvement: patients with involvement of ≥3 continuous paradiscal, central, or appendiceal levels.
- Non-contiguous multifocal involvement/skipped lesion: Patients with involvement of ≥3 non-contiguous or skipped lesions of any morphology (paradiscal, central, or appendiceal) [18].
2.3. Statistic Analysis
3. Results
3.1. Intraspinal NeuroTB
3.2. Intracranial Neurotuberculosis
3.3. Mortality
4. Discussion
4.1. Intraspinal NeuroTB
4.2. Intracranial NeuroTB
4.3. Limitations
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- World Health Organization. Tuberculosis Profile: WHO Global. 2021. Available online: https://worldhealthorg.shinyapps.io/tb_profiles/?_inputs_&lan=%22ES%22&entity_type=%22group%22&-group_code=%22global%22 (accessed on 28 May 2023).
- CENAPRECE. Casos Nuevos de Tuberculosis Todas Formas Estados Unidos Mexicanos 1990–2016. Available online: http://www.cenaprece.salud.gob.mx/programas/interior/micobacteriosis/descargas/pdf/8CasosTbTodas16.pdf (accessed on 28 May 2022).
- Thakur, K.; Das, M.; Dooley, K.E.; Gupta, A. The Global Neurological Burden of Tuberculosis. Semin. Neurol. 2018, 38, 226–237. [Google Scholar] [CrossRef] [PubMed]
- Khanna, K.; Sabharwal, S. Spinal tuberculosis: A comprehensive review for the modern spine surgeon. Spine J. 2019, 19, 1858–1870. [Google Scholar] [CrossRef] [PubMed]
- Wilkinson, R.J.; Rohlwink, U.; Misra, U.K.; van Crevel, R.; Mai, N.T.H.; Dooley, K.E.; Caws, M.; Figaji, A.; Savic, R.; Solomons, R.; et al. Tuberculous Meningitis International Research Consortium. Tuberculous meningitis. Nat. Rev. Neurol. 2017, 13, 581–598. [Google Scholar] [CrossRef] [PubMed]
- Zunt, J.R. Tuberculosis of the Central Nervous System. Continuum 2018, 24, 1422–1438. [Google Scholar] [CrossRef]
- Glassman, I.; Nguyen, K.H.; Giess, J.; Alcantara, C.; Booth, M.; Venketaraman, V. Pathogenesis, Diagnostic Challenges, and Risk Factors of Pott’s Disease. Clin. Pract. 2023, 13, 155–165. [Google Scholar] [CrossRef]
- Rajasekaran, S.; Soundararajan, D.C.R.; Shetty, A.P.; Kanna, R.M. Spinal Tuberculosis: Current Concepts. Glob. Spine J. 2018, 8, 96S–108S. [Google Scholar] [CrossRef] [Green Version]
- Park, M.; Gupta, R.K. Central Nervous System Mycobacterium Infection: Tuberculosis and Beyond. Neuroimag. Clin. N. Am. 2023, 33, 105–124. [Google Scholar] [CrossRef]
- Patkar, D.; Narang, J.; Yanamandala, R.; Lawande, M.; Shah, G.V. Central nervous system tuberculosis: Pathophysiology and imaging findings. Neuroimag. Clin. N. Am. 2012, 22, 677–705. [Google Scholar] [CrossRef] [Green Version]
- Duarte, R.M.; Vaccaro, A.R. Spinal infection: State of the art and management algorithm. Eur. Spine J. 2013, 22, 2787–2799. [Google Scholar] [CrossRef] [Green Version]
- Berbari, E.F.; Kanj, S.S.; Kowalski, T.J.; Darouiche, R.O.; Widmer, A.F.; Schmitt, S.K.; Hendershot, E.F.; Holtom, P.D.; Huddleston, P.M., 3rd; Petermann, G.W.; et al. 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. Clin. Infect. Dis. 2015, 61, e26–e46. [Google Scholar] [CrossRef] [Green Version]
- Marais, S.; Thwaites, G.; Schoeman, J.F.; Török, M.E.; Misra, U.K.; Prasad, K.; Donald, P.R.; Wilkinson, R.J.; Marais, B.J. Tuberculous meningitis: A uniform case definition for use in clinical research. Lancet Infect. Dis. 2010, 10, 803–812. [Google Scholar] [CrossRef] [PubMed]
- Medical Research Council. Streptomycin treatment of Tuberculous Meningitis. Lancet 1948, 1, 582–596. [Google Scholar]
- Thwaites, G.E.; Tran, T.H. Tuberculous meningitis: Many questions, too few answers. Lancet Neurol. 2005, 4, 160–170. [Google Scholar] [CrossRef] [PubMed]
- Viswanathan, V.K.; Subramanian, S. Pott Disease. In StatPearls; StatPearls Publishing: Treasure Island, FL, USA, 2022; Available online: https://www.ncbi.nlm.nih.gov/books/NBK538331 (accessed on 30 May 2023).
- Gupta, M.; Munakomi, S. CNS Tuberculosis. In StatPearls; StatPearls Publishing: Treasure Island, FL, USA, 2023; Available online: https://www.ncbi.nlm.nih.gov/books/NBK585138 (accessed on 30 May 2023).
- Garg, B.; Mehta, N.; Mukherjee, R.N.; Swamy, A.M.; Siamwala, B.S.; Malik, G. Epidemiological Insights from 1,652 Patients with Spinal Tuberculosis Managed at a Single Center: A Retrospective Review of 5-Year Data. Asian Spine J. 2022, 16, 162–172. [Google Scholar] [CrossRef] [PubMed]
- Batirel, A.; Erdem, H.; Sengoz, G.; Pehlivanoglu, F.; Ramosaco, E.; Gülsün, S.; Tekin, R.; Mete, B.; Balkan, I.I.; Sevgi, D.Y.; et al. The course of spinal tuberculosis (Pott disease): Results of the multinational, multicentre Backbone-2 study. Clin. Microbiol. Infect. 2015, 21, e9–e1008. [Google Scholar] [CrossRef] [Green Version]
- Modi, M.; Sharma, K.; Prabhakar, S.; Goyal, M.K.; Takkar, A.; Sharma, N.; Garg, A.; Faisal, S.; Khandelwal, N.; Singh, P.; et al. Clinical and radiological predictors of outcome in tubercular meningitis: A prospective study of 209 patients. Clin. Neurol. Neurosurg. 2017, 161, 29–34. [Google Scholar] [CrossRef] [PubMed]
- Cantier, M.; Morisot, A.; Guérot, E.; Megarbane, B.; Razazi, K.; Contou, D.; Mariotte, E.; Canet, E.; De Montmollin, E.; Dubée, V.; et al. Functional outcomes in adults with tuberculous meningitis admitted to the ICU: A multicenter cohort study. Crit. Care 2018, 22, 210. [Google Scholar] [CrossRef]
- Kanna, R.M.; Babu, N.; Kannan, M.; Shetty, A.P.; Rajasekaran, S. Diagnostic accuracy of whole spine magnetic resonance imaging in spinal tuberculosis validated through tissue studies. Eur. Spine J. 2019, 28, 3003–3010. [Google Scholar] [CrossRef]
- Kubihal, V.; Sharma, R.; Krishna Kumar, R.G.; Chandrashekhara, S.H.; Garg, R. Imaging update in spinal tuberculosis. J. Clin. Orthop. Trauma 2021, 25, 101742. [Google Scholar] [CrossRef]
- Garg, R.K. Tuberculous meningitis. Acta Neurol Scand. 2010, 122, 75–90. [Google Scholar] [CrossRef]
- Salvador, G.L.O.; Basso, A.C.N.; Barbieri, P.P.; Leitao, C.A.; Teixeira, B.C.A.; Neto, A.C. Central nervous system and spinal cord tuberculosis: Revisiting an important disease. Clin. Imaging 2021, 69, 158–168. [Google Scholar] [CrossRef] [PubMed]
- Liu, Z.; Wang, J.; Chen, G.Z.; Li, W.W.; Wu, Y.Q.; Xiao, X.; Zhang, Y.L.; Yang, Y.; Hu, W.K.; Sun, Z.C.; et al. Clinical Characteristics of 1378 Inpatients with Spinal Tuberculosis in General Hospitals in South-Central China. Biomed. Res. Int. 2019, 2019, 9765253. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Kim, J.H.; Ahn, J.Y.; Jeong, S.J.; Ku, N.S.; Choi, J.Y.; Kim, Y.K.; Yeom, J.S.; Song, Y.G. Prognostic factors for unfavorable outcomes of patients with spinal tuberculosis in a country with an intermediate tuberculosis burden: A multicentre cohort study. Bone Jt. J. 2019, 101-B, 1542–1549. [Google Scholar] [CrossRef]
- Chen, C.H.; Chen, Y.M.; Lee, C.W.; Chang, Y.J.; Cheng, C.Y.; Hung, J.K. Early diagnosis of spinal tuberculosis. J. Med. Assoc. 2016, 115, 825–836. [Google Scholar] [CrossRef] [Green Version]
- Manyelo, C.M.; Solomons, R.S.; Walzl, G.; Chegou, N.N. Tuberculous Meningitis: Pathogenesis, Immune Responses, Diagnostic Challenges, and the Potential of Biomarker-Based Approaches. J. Clin. Microbiol. 2021, 59, e01771-20. [Google Scholar] [CrossRef]
- Vinnard, C.; Macgregor, R.R. Tuberculous meningitis in HIV-infected individuals. Curr. HIV/AIDS Rep. 2009, 6, 139–145. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Navarro-Flores, A.; Fernandez-Chinguel, J.E.; Pacheco-Barrios, N.; Soriano-Moreno, D.R.; Pacheco-Barrios, K. Global morbidity and mortality of central nervous system tuberculosis: A systematic review and meta-analysis. J. Neurol. 2022, 269, 3482–3494. [Google Scholar] [CrossRef] [PubMed]
- Boubaker, K.; Gargah, T.; Abderrahim, E.; Abdallah, T.B.; Kheder, A. Mycobacterium tuberculosis infection following kidney transplantation. Biomed. Res. Int. 2013, 2013, 347103. [Google Scholar] [CrossRef] [Green Version]
- Huang, H.J.; Ren, Z.Z.; Dai, Y.N.; Tong, Y.X.; Yang, D.H.; Chen, M.J.; Huang, Y.C.; Wang, M.S.; Zhang, J.J.; Song, W.Y.; et al. Old age and hydrocephalus are associated with poor prognosis in patients with tuberculous meningitis: A retrospective study in a Chinese adult population. Medicine 2017, 96, e7370. [Google Scholar] [CrossRef]
- Hsu, P.C.; Yang, C.C.; Ye, J.J.; Huang, P.Y.; Chiang, P.C.; Lee, M.H. Prognostic factors of tuberculous meningitis in adults: A 6-year retrospective study at a tertiary hospital in northern Taiwan. J. Microbiol. Immunol. Infect. 2010, 43, 111–118. [Google Scholar] [CrossRef] [Green Version]
- Chaudhary, V.; Bano, S.; Garga, U.C. Central Nervous System Tuberculosis: An Imaging Perspective. Can. Assoc. Radiol. J. 2017, 68, 161–170. [Google Scholar] [CrossRef] [PubMed]
- Shridhar, A.; Garg, R.K.; Rizvi, I.; Jain, M.; Ali, W.; Malhotra, H.S.; Kumar, N.; Sharma, P.K.; Verma, R.; Uniyal, R.; et al. Prevalence of primary immunodeficiency syndromes in tuberculous meningitis: A case-control study. J. Infect. Public Health 2022, 15, 29–35. [Google Scholar] [CrossRef] [PubMed]
Demographic Characteristics, Risk Factors and Comorbidities | Intraspinal NeuroTB | Intracranial NeuroTB | ||
---|---|---|---|---|
n = 103 (%) | n = 82 (%) | OR (95%CI) | p | |
Male gender | 62 (60.2) | 53 (64.6) | ||
Mean age (years), median (IQR), range | 53 (41–62), (19–79) | 41 (29–50), (17–80) | 0.000 | |
Age groups (years) | n = 103 (%) | n = 82 (%) | ||
≤30 | 13 (12.6) | 24 (29.3) | 2.9 (1.6–6.1) | 0.005 |
>30 | 90 (87.4) | 58 (70.7) | ||
>40 | 78 (75.7) | 42 (51.2) | ||
White-collar workers | 2/73 (2.7) | 12/55 (21.8) | 9.9 (2.1–46.4) | 0.001 |
Blue-collar workers | 31/73 (42.5) | 26/55 (47.3) | ||
Diabetes mellitus (DM) | 37/100 (37.0) | 15/81 (18.5) | ||
Immunocompromise a | 50/100 (50.0) | 52/78 (66.7) | 2.0 (1.1–3.7) | 0.026 |
Immunosuppression b | 22/87 (25.3) | 44/72 (61.1) | 4.6 (2.4–9.1) | 0.000 |
Chronic kidney disease (CKD) | 13 (12.6) | 3 (3.7) | ||
Kidney transplant | 2 (1.9) | 10 (12.2) | 7.0 (1.5–32.9) | 0.006 |
Human Immunodeficiency Virus (HIV) Infection | 4 (3.9) | 22/79 (27.8) | 9.6 (3.1–29.1) | 0.000 |
History of tuberculosis | 13 (12.6) | 19 (23.2) | ||
Concomitant tuberculosis | ||||
Vertebral osteomyelitis | 101 (98.1) | - | ||
Pulmonary TB | 21 (20.4) | 28 (34.1) | ||
Disseminated tuberculosis (TB) | 21 (20.4) | 24 (41.5) | 2.8 (1.4–5.3) | 0.002 |
Pleural tuberculosis/empyema | 16 (15.5) | 5 (6.1) | ||
Extraspinal osteomyelitis * | 11 (10.7) | - | ||
Vertebro-cutaneous sinus tracts | 9 (8.7) | - | ||
TB in the pericardium and mediastinum | 7 (6.8) | 1 (1.2) | ||
Gastrointestinal and peritoneal tuberculosis | 3 (2.9) | 6 (7.3) | ||
Genitourinary tuberculosis | 1 (1.0) | 5 (6.1) | ||
Clinical and laboratory findings | ||||
Fever | 44/97 (45.4) | 69/81 (85.2) | 6.9 (3.3–14.4) | 0.000 |
Weight Loss | 39/96 (40.6) | 47/77 (61.0) | 2.3 (1.2–4.2) | 0.008 |
Pain spine (back/neck) | 102 (99.0) | - | ||
Paraparesis/paraplegia or hemiparesis | 103 (100.0) | 8 (9.8) | ||
Lymphopenia ≤ 0.900 cells/µL, n (%) | 14/64 (21.9) | 33/51 (64.7) | 6.5 (2.9–14.9) | 0.000 |
C-reactive protein > 10 (mg/L), n (%) | 46/65 (70.8) | - | ||
Delay in diagnosis | ||||
≤20 days | 2 (1.9) | 36 (43.9) | ||
≤40 days | 7 (6.8) | 58 (70.7) | ||
≥150 days (≥5 months) | 68 (66.0) | 6 (7.3) | ||
Diagnostic delay time (days), median (IQR), range | 214 (92–365), (6–3660) | 21 (13–48), (6–730) | ||
Diagnostic delay time (months), median (IQR), range | 7.0 (3–12), (0.2–120) | 0.7 (0.4–1.6), (0.03–24) | ||
Duration antituberculous drugs | ||||
Duration of treatment (months), median (IQR) | 12 (12–14) | 12 (3–12) | ||
Positive cultures in Löwenstein–Jensen | 21/43 (48.8) | 22/79 (27.8) | ||
Resistance to anti-tuberculosis treatment | 1/21 (4.8) | 6/22 (27.3) | ||
Isoniazid resistance | 1/21 (4.8) | 1/22 (4.5) | ||
Rifampicin resistance | 1/21 (4.8) | 2/22 (9.1) | ||
Pyrazinamide resistance | 0/21 (0.0) | 3/22 (13.6) | ||
Ethambutol resistance | 0/20 (0.0) | 1/22 (4.5) | ||
Outcomes | ||||
Kidney graft loss | 0/2 (0.0) | 5/10 (50.0) | ||
Favorable (improvement) | 34/99 (34.3) | 32/81 (39.5) | ||
Unfavorable (without improvement or death) | 65/99 (65.7) | 49/81 (60.5) | ||
Deaths (due to tuberculosis) | 3/99 (3.0) | 24/81 (29.6) | 13.5 (3.9–46.8) | 0.000 |
Patients who received ≤2 months of treatment for death due to TB | 2/99 (2.0) | 20/81 (24.7) | 15.9 (3.6–70.4) | 0.000 |
Intraspinal Neurotuberculosis | n = 103 (%) | Intracranial Neurotuberculosis | n = 82 (%) | ||||
---|---|---|---|---|---|---|---|
Imaging Findings | Lancet Score | ||||||
Spondylodiscitis (SD) | 101 (98.1) | Definitive meningeal tuberculosis or Lancet I a | 41 (50.0) | ||||
Regional distribution of vertebral involvement | Probable meningeal tuberculosis or Lancet II | 28 (34.1) | |||||
Cervical | 5/102 (4.9) | Possible meningeal tuberculosis or Lancet III | 13 (15.9) | ||||
Dorsal | 29/102 (28.4) | ||||||
Dorso-lumbar | 4/102 (3.9) | ||||||
Lumbar | 25/102 (24.5) | ||||||
Lumbo-sacral | 8/102 (7.8) | ||||||
Multilevel involvement | 31/102 (30.4) | Meningeal tuberculosis severity grades MRC b | |||||
Number of levels involved intraspinal neuroTB | Grade I meningitis | 7 (8.9) | |||||
1 level involved | 70/102 (68.6) | Grade II meningitis | 43 (54.4) | ||||
2 level involved | 16/102 (15.7) | Grade III meningitis | 29 (36.7) | ||||
≥3 levels involved | 16/102 (15.7) | ||||||
Contiguous multilevel involvement | 27/102 (26.5) | ||||||
Non-contiguous multilevel segments/skipped lesion | 10/102 (9.8) | ||||||
Pattern of vertebral involvement | |||||||
Paradiscal | 101/102 (99.0) | Imaging findings and/or complications | |||||
Central (C7 to T3/L5) | 1/102 (1.0) | Tuberculomas without meningitis or normal CSF | 3 (3.7) | ||||
Appendiceal | 5/102 (4.9) | Meningitis (M) + tuberculomas | 34 (41.5) | ||||
Complications and/or findings on admission | M + cranial neuropathy | 33 (40.2) | |||||
Motor deficit | 103 (100.0) | Cranial nerve palsy II | 5/33 (15.2) | ||||
Spinal instability | 95/101 (94.1) | Cranial nerve palsy III | 11/33 (33.3) | ||||
Pre/paravertebral abscess | 86/102 (84.3) | Cranial nerve palsy IV | 4/33 (12.1) | ||||
Vertebral destruction | 80/102 (78.4) | Cranial nerve palsy VI | 17/33 (51.5) | ||||
Epidural abscess | 79/102 (77.5) | Cranial nerve palsy VII | 10/33 (30.3) | ||||
Myelopathy | 71/102 (69.6) | M + hydrocephalus | 26 (31.7) | ||||
Destruction as vertebra plana | 38/102 (37.3) | M + hydrocephalus + VPS | 20/26 (76.9) | ||||
Psoas abscess | 33/102 (32.4) | Leptomeningitis | 16 (19.5) | ||||
Destruction of vertebral bodies ≥ 2 levels involved | 36/102 (35.3) | Optochiasmatic arachnoiditis | 1/16 (6.3) | ||||
Destruction of vertebral bodies ≥ 3 levels involved | 20/102 (19.6) | M + cerebral infarction | 13 (15.9) | ||||
No. of levels with vertebral destruction, median (IQR), range | 0 (0–1), (0–8) | M + hydrocephalus + tuberculomas | 9 (11.0) | ||||
No. of destroyed vertebrae, median (IQR), range | 2 (1–2), (0–16) | M + cerebral infarction + hydrocephalus | 6 (7.3) | ||||
Wedge fracture | 28/102 (27.5) | M + tuberculous abscess | 1 (1.2) | ||||
Kyphosis | 25/99 (25.3) | ||||||
Anterior or posterior longitudinal ligament involvement | 15/101 (14.9) | Spinal arachnoiditis | 5 (6.1) | ||||
Intraosseous abscesses | 11/102 (10.8) | ||||||
Complete spinal cord syndrome | 5 (4.9) | ||||||
Spinal arachnoiditis | 4/102 (3.9) | ||||||
Intramedullary tuberculoma | 1 (1.0) |
Demographic Characteristics, Risk Factors and Comorbidities | Favorable n = 34 (%) | Unfavorable n = 65 (%) | OR | CI 95% | p |
---|---|---|---|---|---|
Male gender | 18 (52.9) | 44 (67.7) | 0.150 | ||
Median age (years), mean ± standard deviation (SD) | 45 ± 15 | 53 ± 13 | 0.006 ‡ | ||
>40 years | 21 (61.8) | 54 (83.1) | 3.0 | 1.2–7.8 | 0.019 |
Diabetes mellitus | 7 (20.6) | 29/62 (46.8) | 3.4 | 1.3–8.9 | 0.011 |
Chronic kidney disease | 4 (11.8) | 9 (13.8) | 1.000 | ||
Immunocompromise a | 14 (41.2) | 35/62 (56.5) | 0.152 | ||
Immunosuppression b | 7/30 (23.3) | 14/53 (26.4) | 0.756 | ||
History of tuberculosis | 5 (14.7) | 8 (12.3) | 0.760 | ||
Concomitant tuberculosis | |||||
Disseminated tuberculosis (TB) | 4 (11.8) | 16 (24.6) | 0.188 | ||
Pulmonary TB | 6 (17.6) | 15 (23.1) | 0.530 | ||
Pleural tuberculosis/empyema | 2 (5.9) | 14 (21.5) | 0.05 | ||
Extraspinal osteomyelitis | 2 (5.9) | 8 (12.3) | 0.487 | ||
Vertebro-cutaneous sinus tracts | 1 (2.9) | 8 (12.3) | 0.159 | ||
Clinical findings and diagnostic delay | |||||
Diagnostic delay ≥ 150 days | 17 (50.0) | 48 (73.8) | 2.8 | 1.2–6.7 | 0.018 |
Diagnostic delay time (months), median (IQR), range | 4.8 (3–12), (0.2–60) | 8 (4–17), (1–120) | 0.027 * | ||
Fever | 14/32 (43.8) | 28/61 (45.9) | 0.843 | ||
Weight loss | 12/32 (37.5) | 27/60 (45.0) | 0.488 | ||
Paraparesis/paraplegia | 34 (100.0) | 65 (100.0) | - | ||
Imaging findings | |||||
Cervical Spondylodiscitis (SD) | 5/33 (15.2) | 0 (0.0) | - | ||
Dorsal SD | 7/33 (21.2) | 19 (29.2) | 0.395 | ||
Dorso-lumbar SD | 1/33 (3.0) | 3 (4.6) | 1.000 | ||
Lumbar SD | 13/33 (39.4) | 12 (18.5) | NS | ||
Lumbo-sacral SD | 4/33 (12.1) | 4 (6.2) | 0.436 | ||
2 levels involved | 3/33 (9.1) | 13 (20.0) | 0.249 | ||
≥2 levels involved | 4/33 (12.1) | 27 (41.5) | 5.2 | 1.6–16.4 | 0.003 |
≥3 levels involved | 1/33 (3.0) | 14 (21.5) | 8.8 | 1.1–70.1 | 0.017 |
Multilevel lesions involvement | 3/33 (9.1) | 27 (41.5) | 7.1 | 2.0–25.7 | 0.001 |
Contiguous multilevel involvement | 3/33 (9.1) | 23 (35.4) | 5.5 | 1.5–19.9 | 0.007 |
Non-contiguous multilevel involvement | 0 (0.0) | 10 (15.4) | - | ||
Paradiscal involvement | 33/33 (100.0) | 64 (98.5) | - | ||
Central involvement | 0/33 (0.0) | 1 (1.5) | - | ||
Appendiceal involvement | 1/33 (3.0) | 3 (4.6) | 1.000 | ||
Complications and/or findings pre-treatment | |||||
Motor deficit | 34 (100.0) | 65 (100.0) | - | ||
Pre/paravertebral abscess | 27/33 (81.8) | 55 (84.6) | 0.723 | ||
Epidural abscess | 23/33 (69.7) | 52 (80.0) | 0.255 | ||
Psoas abscess | 14/33 (42.4) | 19 (29.2) | 0.192 | ||
Intraosseous abscesses | 2/33 (6.1) | 8 (12.3) | 0.487 | ||
Complete spinal cord syndrome | 0 (0.0) | 5 (7.7) | - | ||
Spinal arachnoiditis | 1/33 (3.0) | 3 (4.6) | 1.000 | ||
Myelopathy | 19 (55.9) | 49 (75.4) | NS | ||
Anterior or posterior longitudinal ligament involvement | 3/33 (9.1) | 12/64 (18.8) | 0.252 | ||
Spinal instability | 31/33 (93.9) | 60/64 (93.8) | 1.000 | ||
Kyphosis | 2/32 (6.3) | 21/63 (33.3) | 7.5 | 1.6–34.4 | 0.004 |
Wedge fracture | 9/33 (27.3) | 18 (27.7) | 0.965 | ||
Destruction as vertebra plana | 9/33 (27.3) | 27 (41.5) | 0.166 | ||
Vertebral destruction | 24/33 (72.7) | 52 (80.0) | 0.415 | ||
Vertebral destruction (No. of vertebrae), median (IQR), range | 2 (0–2), (0–3) | 2 (1–3), (0–16) | 0.036 * | ||
Vertebral destruction ≥ 2 levels | 5/33 (15.2) | 30 (46.2) | 4.8 | 1.6–14.0 | 0.003 |
Vertebral destruction ≥ 3 levels | 1/33 (3.0) | 18 (27.7) | 12.3 | 1.6–96.5 | 0.003 |
≥3 destroyed vertebrae | 2/33 (6.1) | 19 (29.2) | 6.4 | 1.4–29.5 | 0.009 |
Peri or post treatment (post operative) complications | |||||
Motor deficit | 1 (2.9) | 52 (80.0) | 0.000 | ||
Residual abscess or lack spinal cord release by anterior surgical approach | 16 (47.1) | 49 (75.4) | 3.4 | 1.4–8.3 | 0.005 |
Instrumentation | 26/33 (78.8) | 47 (72.3) | 0.487 | ||
Removal of instrumentation | 0/33 (0.0) | 6/63 (9.5) | - | ||
Post-surgical spinal instability | 3/33 (9.1) | 26/64 (40.6) | 6.8 | 1.9–24.8 | 0.001 |
Duration antituberculous drugs | |||||
Duration of treatment (months), median (IQR), range | 12 (12–12) | 12 (12–18) | 0.712 * | ||
Deaths (due to tuberculosis) | 0 (0.0) | 3 (4.6) | - |
Demographic Characteristics, Risk Factors and Comorbidities | Favorable n = 32 (%) | Unfavorable n = 49 (%) | OR | CI 95% | p |
---|---|---|---|---|---|
Male gender | 24 (75.0) | 28 (57.1) | 0.101 | ||
Mean age (years), mean ± (SD) | 36.8 ± 16 | 42.5 ± 14 | 0.053 ‡ | ||
>40 years | 11 (34.4) | 30 (61.2) | 3.0 | 1.2–7.6 | 0.018 |
Immunocompromise a | 20/31 (64.5) | 31/46 (67.4) | 0.794 | ||
Immunosuppression b | 17/27 (63.0) | 17/44 (61.4) | 0.893 | ||
HIV infection | 7 (21.9) | 14/46 (30.4) | 0.402 | ||
Diabetes mellitus | 3/31 (9.7) | 12 (24.5) | 0.143 | ||
Kidney transplant | 6 (18.8) | 4 (8.2) | 0.182 | ||
Chronic kidney disease | 2 (6.3) | 1 (2.0) | 0.559 | ||
History of tuberculosis | 10 (31.3) | 9 (18.4) | 0.181 | ||
Concomitant tuberculosis | |||||
Disseminated tuberculosis (TB) | 11 (34.4) | 22 (44.9) | 0.346 | ||
Genitourinary TB | 1 (3.1) | 3 (6.1) | 1.000 | ||
Gastrointestinal and peritoneal TB | 1 (3.1) | 5 (10.2) | 0.395 | ||
Pulmonary TB | 11 (34.4) | 16 (32.7) | 0.872 | ||
Pleural tuberculosis/empyema | 1 (3.1) | 4 (8.2) | 0.643 | ||
Clinical, laboratory, microbiological and histological findings | |||||
Diagnostic delay ≥ 24 days | 10 (31.3) | 27 (55.1) | 2.7 | 1.1–6.9 | 0.035 |
Diagnostic delay time (days), median (IQR) | 16 (11–38) | 30 (13–58) | 0.328 * | ||
Fever | 25 (78.1) | 43/48 (89.6) | 0.206 | ||
Weight loss | 15/30 (50.0) | 31/46 (67.4) | 0.129 | ||
Hemiparesis | 3 (9.4) | 26 (53.1) | 10.9 | 2.9–40.7 | 0.000 |
Drowsiness | 6 (18.8) | 28 (57.1) | 5.8 | 2.0–16.6 | 0.001 |
Stiff neck | 6 (18.8) | 25 (51.0) | 4.5 | 1.6–12.9 | 0.003 |
Alterations of consciousness | 17 (53.1) | 39 (79.6) | 3.4 | 1.3–9.2 | 0.012 |
Language alterations | 12 (37.5) | 31 (63.3) | 2.9 | 1.1–7.2 | 0.023 |
Total, lymphocytes/mm3, (No. lymphocytes), median (IQR) | 1.1 (0.8–2.6) | 0.5 (0.3–0.9) | 0.002 * | ||
Lymphopenia ≤ 0.900 cells (103/µL) | 5/15 (33.3) | 28/35 (80.0) | 8.0 | 2.1–31.0 | 0.003 |
HIV viral load copies/mL Log, median (IQR) | 6.1 (3.5–6.4) | 5.1 (1.7–5.8) | 0.349 * | ||
Helper lymphocytes CD4 cells/mm3, median (IQR) | 136 (58–323) | 47 (35–73) | 0.088 * | ||
Imaging findings and/or complications and Lancet Score | |||||
Definitive meningeal tuberculosis or Lancet I c | 7 (21.9) | 34 (69.4) | 8.1 | 2.9–22.8 | 0.000 |
Tuberculomas without meningitis or normal CSF | 3 (9.4) | 0 (0.0) | - | ||
Meningitis (M) + cranial neuropathy | 7 (21.9) | 26 (53.1) | 4.0 | 1.5–11.1 | 0.005 |
M + tuberculomas | 11 (34.4) | 22 (44.9) | 0.346 | ||
Leptomeningitis | 6 (18.8) | 10 (20.4) | 0.855 | ||
M + cerebral infarction | 2 (6.3) | 11 (22.4) | 0.066 | ||
M + hydrocephalus | 5 (15.6) | 21 (42.9) | 4.1 | 1.3–12.3 | 0.014 |
M + cerebral infarction and hydrocephalus | 0/32 (0.0) | 6/49 (12.2) | - | ||
Meningitis + hydrocephalus + tuberculomas | 3 (9.4) | 6 (12.2) | 1.000 | ||
Outcomes | |||||
Patients who received ≤2 months of treatment due to death | 0 (0.0) | 20 (40.8) | - | ||
Deaths due to TB | 0 (0.0) | 24 (48.9) | - |
Survivors n = 57 (%) | Deaths n = 24 (%) | OR | CI 95% | p | |
---|---|---|---|---|---|
Demographic characteristics, risk factors and comorbidities | |||||
Male gender | 39 (68.4) | 13 (54.2) | 0.222 | ||
Mean age (years), mean (SD) | 39 ± 15.1 | 43 ± 14.5 | 0.279 * | ||
>40 years | 28 (49.1) | 13 (54.2) | 0.678 | ||
Immunocompromise a | 34/56 (60.7) | 17/21 (81.0) | 0.112 | ||
Immunosuppression b | 29/48 (60.4) | 15/23 (65.2) | 0.697 | ||
HIV infection | 11 (19.3) | 10/21 (47.6) | 3.8 | 1.3–11.2 | 0.012 |
Diabetes mellitus | 1/56 (19.6) | 4 (16.7) | 1.000 | ||
Kidney transplant | 6 (10.5) | 4 (16.7) | 0.472 | ||
Chronic kidney disease | 2 (3.5) | 1 (4.2) | 1.000 | ||
History of tuberculosis | 13 (22.8) | 6 (25.0) | 0.832 | ||
Concomitant tuberculosis | |||||
Disseminated TB | 18 (31.6) | 15 (62.5) | 3.6 | 1.3–9.8 | 0.010 |
Genitourinary TB | 1 (1.8) | 3 (12.5) | 0.076 | ||
Gastrointestinal and peritoneal TB | 1 (1.8) | 5 (20.8) | 14.7 | 1.6–134.2 | 0.008 |
Pleural TB/empyema | 2 (3.5) | 3 (12.5) | 0.151 | ||
Clinical, laboratory, microbiological and histological findings | |||||
Diagnostic delay ≥ 20 days | 28 (49.1) | 17 (70.8) | 0.073 | ||
Diagnostic delay time (days), median (IQR), range | 16 (12–50), (6–730) | 30 (14–56), (6–336) | 0.395 * | ||
Diagnostic delay time (months), median (IQR), range | 0.5 (0.4–1.7), (0.03–24) | 1.0 (0.5–1.9), (0.2–11) | 0.335 * | ||
Fever | 46 (80.7) | 22/23 (95.7) | 0.164 | ||
Weight loss | 29/54 (53.7) | 17/22 (77.3) | 0.072 | ||
Language alterations | 24 (42.1) | 19 (79.2) | 5.2 | 1.7–15.9 | 0.003 |
Alterations of consciousness | 33 (57.9) | 23 (95.8) | 16.7 | 2.1–132.6 | 0.000 |
Stiff neck | 18 (31.6) | 13 (54.2) | 0.056 | ||
Hemiparesis | 16 (28.1) | 13 (54.2) | 3.0 | 1.1–8.1 | 0.025 |
Drowsiness | 14 (24.6) | 20 (83.3) | 15.4 | 4.5–52.6 | 0.000 |
Total, lymphocytes/mm3, median (IQR) | 1.0 (0.5–1.6) | 0.3 (0.3–0.5) | 0.000 * | ||
Lymphopenia ≤ 0.900 cells (103/µL) | 13/28 (46.4) | 20/22 (90.9) | 11.5 | 2.3–59.0 | 0.001 |
≥50% Mononuclear cells in CSF | 31/52 (59.6) | 7/17 (41.2) | 0.185 | ||
CSF glucose ≤ 40 mg/dL | 24/44 (54.5) | 14/19 (73.7) | 0.175 | ||
HIV viral load copies/mL Log, mean (SD) | 4.7 ± 2.1 | 4.4 ± 2.1 | 0.859 * | ||
Helper lymphocytes CD4 cells/mm3, mean (SD) | 170 ± 170 | 45 ± 22.2 | 0.064 * | ||
Imaging findings and/or complications and Lancet Score | |||||
Definitive meningeal tuberculosis or Lancet I c | 21 (36.8) | 20 (83.3) | 8.6 | 2.6–28.5 | 0.000 |
Tuberculomas without meningitis or normal CSF | 3 (5.3) | 0 (0.0) | - | ||
Meningitis (M) + cranial neuropathy | 21 (36.8) | 12 (50.0) | 0.271 | ||
M + tuberculomas | 24 (42.1) | 9 (37.5) | 0.700 | ||
Leptomeningitis | 14 (24.6) | 2 (8.3) | 0.130 | ||
M + cerebral infarction | 4 (7.0) | 9 (37.5) | 7.9 | 2.1–29.5 | 0.002 |
M + hydrocephalus | 13 (22.8) | 13 (54.2) | 4.0 | 1.5–11.0 | 0.006 |
M + cerebral infarction + hydrocephalus | 1 (1.8) | 5 (20.8) | 14.7 | 1.6–134 | 0.008 |
M + hydrocephalus + tuberculomas | 6 (10.5) | 3 (12.5) | 1.000 | ||
Outcomes | |||||
Patients who received ≤2 months of treatment due to death | 0 | 20 (83.3) | - |
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Corona-Nakamura, A.L.; Arias-Merino, M.J.; Miranda-Novales, M.G.; Nava-Jiménez, D.; Delgado-Vázquez, J.A.; Bustos-Mora, R.; Cisneros-Aréchiga, A.G.; Aguayo-Villaseñor, J.F.; Hernández-Preciado, M.R.; Mireles-Ramírez, M.A. Intraspinal and Intracranial Neurotuberculosis, Clinical and Imaging Characteristics and Outcomes in Hospitalized Patients: A Cohort Study (2000–2022). J. Clin. Med. 2023, 12, 4533. https://doi.org/10.3390/jcm12134533
Corona-Nakamura AL, Arias-Merino MJ, Miranda-Novales MG, Nava-Jiménez D, Delgado-Vázquez JA, Bustos-Mora R, Cisneros-Aréchiga AG, Aguayo-Villaseñor JF, Hernández-Preciado MR, Mireles-Ramírez MA. Intraspinal and Intracranial Neurotuberculosis, Clinical and Imaging Characteristics and Outcomes in Hospitalized Patients: A Cohort Study (2000–2022). Journal of Clinical Medicine. 2023; 12(13):4533. https://doi.org/10.3390/jcm12134533
Chicago/Turabian StyleCorona-Nakamura, Ana Luisa, Martha Judith Arias-Merino, María Guadalupe Miranda-Novales, David Nava-Jiménez, Juan Antonio Delgado-Vázquez, Rafael Bustos-Mora, Aldo Guadalupe Cisneros-Aréchiga, José Francisco Aguayo-Villaseñor, Martha Rocio Hernández-Preciado, and Mario Alberto Mireles-Ramírez. 2023. "Intraspinal and Intracranial Neurotuberculosis, Clinical and Imaging Characteristics and Outcomes in Hospitalized Patients: A Cohort Study (2000–2022)" Journal of Clinical Medicine 12, no. 13: 4533. https://doi.org/10.3390/jcm12134533
APA StyleCorona-Nakamura, A. L., Arias-Merino, M. J., Miranda-Novales, M. G., Nava-Jiménez, D., Delgado-Vázquez, J. A., Bustos-Mora, R., Cisneros-Aréchiga, A. G., Aguayo-Villaseñor, J. F., Hernández-Preciado, M. R., & Mireles-Ramírez, M. A. (2023). Intraspinal and Intracranial Neurotuberculosis, Clinical and Imaging Characteristics and Outcomes in Hospitalized Patients: A Cohort Study (2000–2022). Journal of Clinical Medicine, 12(13), 4533. https://doi.org/10.3390/jcm12134533