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Published online January 7, 2009
PEDIATRICS Vol. 123 No. 1 January 2009, pp. e1-e8 (doi:10.1542/peds.2008-1353)
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ARTICLE

Twenty Years of Pediatric Tuberculous Meningitis: A Retrospective Cohort Study in the Western Cape of South Africa

Gijs T. J. van Well, MDa,b, Berbe F. Paes, MSca, Caroline B. Terwee, PhDc, Priscilla Springer, FCPd, John J. Roord, MD, PhDa, Peter R. Donald, MD, PhDd, A. Marceline van Furth, MD, PhDa, Johan F. Schoeman, MD, PhDd

a Departments of Pediatrics and Infectious Diseases
c Epidemiology and Biostatistics, EMGO Institute, VU University Medical Center, Amsterdam, Netherlands
d Department of Pediatrics and Child Health, Tygerberg Children's Hospital, University of Stellenbosch, Cape Town, South Africa
b Department of Pediatrics, Maastricht University Medical Center, Maastricht, Netherlands

OBJECTIVE. Tuberculous meningitis is the most severe extrapulmonary complication of tuberculosis, with high morbidity and mortality rates. The objective of this study was to assess the relationship between presenting clinical characteristics and outcome of pediatric tuberculous meningitis.

PATIENTS AND METHODS. We present a retrospective cohort study of all of the children diagnosed with tuberculous meningitis in a large university hospital in South Africa between January 1985 and April 2005. We compared demographic, clinical, and diagnostic characteristics with clinical outcome after 6 months of treatment.

RESULTS. We included 554 patients. Common characteristics on admission were young age (82%; <5 years), stage II or III tuberculous meningitis (97%), nonspecific symptoms existing for >1 week (58%), poor weight gain or weight loss (91%), loss of consciousness (96%), motor deficit (63%), meningeal irritation (98%), raised intracranial pressure (23%), brainstem dysfunction (39%), and cranial nerve palsies (27%). Common features of tuberculous meningitis on computed tomography scan of the brain were hydrocephalus (82%), periventricular lucency (57%), infarctions (32%), and basal meningeal enhancement (75%). Clinical outcome after 6 months was as follows: normal (16%), mild sequelae (52%), severe sequelae (19%), and death (13%). All of the patients diagnosed with stage I tuberculous meningitis had normal outcome. Factors associated with poor outcome in univariate analyses were as follows: African ethnicity, young age, HIV coinfection, stage III tuberculous meningitis, absence of headache and vomiting, convulsions, decreased level of consciousness, motor deficits, cranial nerve palsies, raised intracranial pressure, brainstem dysfunction and radiographic evidence of hydrocephalus, periventricular lucency, and infarction. Ethnicity, stage of disease, headache, convulsions, motor function, brainstem dysfunction, and cerebral infarctions were independently associated with poor outcome in multivariate logistic regression analysis.

CONCLUSIONS. Tuberculous meningitis starts with nonspecific symptoms and is often only diagnosed when brain damage has already occurred. Earlier diagnosis will improve outcome significantly. We were able to identify presenting variables independently associated with poor clinical outcome.

Key Words: tuberculosis • meningitis • hydrocephalus • neurologic outcome

Abbreviations: TBM—tuberculous meningitis • CSF—cerebrospinal fluid • CT—computed tomography • GCS—Glasgow Coma Scale • VP ratio—ratio between ventricular and biparietal diameters • CH—communicating hydrocephalus • NCH—noncommunicating hydrocephalus • VPS—ventriculoperitoneal shunt • AUC—area under the curve • MDR—multidrug resistant

Accepted Sep 25, 2008.


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