OBJECTIVE

To compare yields of cerebrospinal fluid (CSF) studies in the diagnosis of tuberculosis meningitis (TBM).

METHODS

Prospective laboratory study, Kenyatta National Hospital, Kenya.

METHODS

Consecutive patients with 1) headache, neck stiffness and altered consciousness for more than 14 days, 2) above features plus evidence of tuberculosis elsewhere in the body, and 3) on standard antimeningitic drugs for one week without response, were included. Those with contraindications to lumbar puncture, confirmed causes of meningitis (except TB) and on anti-tuberculosis treatment were excluded.

METHODS

CSF cell counts, glucose and protein were assayed. CSF was stained on ZN, cultured on LJ and BACTEC and subjected to PCR and LCR for Mycobacterium tuberculosis DNA sequences. Positive tests for M. tuberculosis were classified as definite and the rest as probable TBM.

RESULTS

Fifty-eight patients with a mean age of 33.0 years were recruited. Mean CSF cell count was 71/microl and CSF lymphocyte count up 67%. Mean CFS protein and glucose were 2.10 g/l and 2.05 mmol/l, respectively. BACTEC was positive in 20 cases, LJ 12, LCR eight, and PCR and ZN one each. Twenty-six patients had definite and 32 probable TBM. Patients with definite TBM had significantly higher CSF protein, lower CSF glucose, higher CSF cell count and lower CSF lymphocytes.

CONCLUSIONS

TBM can be confirmed in half of clinically suspected cases. More sensitive tests for confirmation of TBM are required.

OBJECTIVE

To design a fast and accurate semi-automated segmentation method for spinal cord 3T MR images and to construct a template of the cervical spinal cord.

METHODS

A semi-automated double threshold-based method (DTbM) was proposed enabling both cross-sectional and volumetric measures from 3D T2-weighted turbo spin echo MR scans of the spinal cord at 3T. Eighty-two healthy subjects, 10 patients with amyotrophic lateral sclerosis, 10 with spinal muscular atrophy and 10 with spinal cord injuries were studied. DTbM was compared with active surface method (ASM), threshold-based method (TbM) and manual outlining (ground truth). Accuracy of segmentations was scored visually by a radiologist in cervical and thoracic cord regions. Accuracy was also quantified at the cervical and thoracic levels as well as at C2 vertebral level. To construct a cervical template from healthy subjects' images (n=59), a standardization pipeline was designed leading to well-centered straight spinal cord images and accurate probability tissue map.

RESULTS

Visual scoring showed better performance for DTbM than for ASM. Mean Dice similarity coefficient (DSC) was 95.71% for DTbM and 90.78% for ASM at the cervical level and 94.27% for DTbM and 89.93% for ASM at the thoracic level. Finally, at C2 vertebral level, mean DSC was 97.98% for DTbM compared with 98.02% for TbM and 96.76% for ASM. DTbM showed similar accuracy compared with TbM, but with the advantage of limited manual interaction.

CONCLUSIONS

A semi-automated segmentation method with limited manual intervention was introduced and validated on 3T images, enabling the construction of a cervical spinal cord template.

Tubular basement membrane (TBM) was prepared from normal human kidneys and solubilized with various enzymes. Collagenase digestion released antigenic moieties from the TBM. All four anti-TBM antibodies we studied, three from patients with idiopathic tubulo-interstitial nephritis (TIN) and one from a renal allograft recipient, distinctively reacted with collagenase-digested (CD) TBM during enzyme-linked immunoassay and could discriminate among sera of normal controls or of other nephritis patients, including anti-glomerular basement membrane (anti-GBM) nephritis. When digested with pronase, trypsin, or pepsin, antigenicity of the TBM decreased. We studied the TBM antigens with immunoprecipitation and immunoblotting. After incubation of radio-iodinated CDTBM with anti-TBM sera, immunoprecipitates were identified by single-dimension SDS polyacrylamide gel electrophoresis or two-dimension gel electrophoresis, followed by autoradiography. All four antibodies had identical results on immunoprecipitation; under nonreducing conditions, they gave two protein bands with m.w. of 54,000 and 48,000 and with pI 7.0 to 8.0 and 6.5 to 7.0. Electrophoresis performed under reducing conditions disclosed only one band at the m.w. of 48,000 and pI of 6.5, suggesting that the 54-kDa component is composed of peptides linked by interchain disulfide bonds. Immunoblot analysis showed that the anti-TBM antibodies were heterogeneous; three antibodies from the idiopathic TIN patients reacted with the 54-kDa band, but the one from the renal allograft recipient reacted with neither band. This finding suggests that there are two antigenic determinants on the 54-kDa component. One such determinant that was resistant to denaturation with SDS was detected by the first three antibodies, and the other that was sensitive to such denaturation bound to the last antibody. The 48-kDa component seemed not to be immunoreactive after incubation with SDS. We studied TBM antigens reactive with anti-GBM antibodies. By immunoblotting, all four sera from patients with anti-GBM nephritis stained TBM proteins of 45 to 50 kDa and 25 to 27 kDa at pH 8.0 to 9.0; this was similar to the staining pattern of CDGBM with the same sera, but the highly cationic (pH greater than 9.0) components were specifically detected in the CDGBM. By inhibition ELISA, the binding of the anti-GBM sera to denatured CDTBM decreased with preincubation of the sera with CDGBM, suggesting that the anti-GBM antibodies recognize the same epitope(s) on the GBM and the TBM.

METHODS

Experimental, controlled study.

OBJECTIVE

To examine the effects of whole-body vibration (WBV) on bone mass and trabecular bone microstructure (TBMS) during the early stage in juvenile rats with spinal cord injury (SCI).

METHODS

Studied at the Kio University in Japan.

METHODS

Thirty-four 8-week-old male Wistar rats were divided into 3 groups: the SCI group, the sham-operation group (SHAM) and the SCI+WBV group. WBV started on the 8th day after SCI. After 1 or 2 weeks of WBV treatment, measurements of tissue mineral density, trabecular bone mineral content (BMC) and parameters of TBMS were obtained by scanning the proximal tibias with x-ray micro-computed tomography. Serum levels of osteocalcin (OC) and of tartrate-resistant acid phosphatase 5b (TRACP 5b) were measured with ELISA.

RESULTS

BMC, volume bone mineral density, bone volume (BV), BV fraction (BV/tissue volume) and connectivity density (Conn.D) of TBMS parameters were significantly higher in SCI+WBV rats than in SCI rats after 2-week WBV. The BMC and BV/TV of bone mass index correlated well with Conn.D, suggesting the preservation of Conn.D. induced by WBV. SCI+WBV rats showed a decrease in serum OC after 1-week WBV, but a quick recovery from that after 2-week WBV. There was no difference in serum TRACP 5b among the 3 groups throughout the experimental period.

CONCLUSIONS

WBV treatment could attenuate the bone deterioration that occurs during the early stage in juvenile rats with SCI. In a clinic, this early WBV intervention may be an effective rehabilitation modality for preventing bone fragility in SCI patients.

BACKGROUND

Tracheobronchomegaly (Mounier-Kuhn Syndrome) is a rare disease characterized by tracheal enlargement and associated loss of elastic fibers in the trachea and main bronchi.

METHODS

MEDLINE, Index Medicus, and other databases were searched with pre-defined criteria to identify cases of tracheobronchomegaly (TBM). Two new cases of TBM were also identified from the Provincial Medical Genetics Program of British Columbia.

RESULTS

We identified 166 publications describing 365 occurrences of TBM. We observed that affected individuals could be grouped into subgroups according to clinical features. Type 1A (105 individuals) consists of infants who developed TBM after having undergone fetoscopic tracheal occlusion, and Type 1B patients (24 individuals) are infants and children who developed TBM after prolonged intubation. Type 2 individuals developed TBM following recurrent pulmonary infections (2A) (14 individuals) or pulmonary fibrosis (2B) (10 individuals). Type 3 represents TBM with evidence of extra-pulmonary elastolysis (18 individuals), and Type 4 denotes the development of TBM with no clear predisposing factors (196 individuals). Both of our patients had TBM and evidence of extra-pulmonary elastolysis. As well, one patient had a mildly dilated aortic root, which is a previously unreported co-occurrence.

CONCLUSIONS

We introduce a novel classification scheme, which may sort patients into etiologically distinct groups, furthering our understanding of its pathogenesis and potentially, prevention or therapy. We also hypothesize that TBM and generalized elastolysis may have etiological commonalities, suggesting a need for further study.

We assayed 229 CSF samples from 180 adults with meningitis of different etiologies for adenosine deaminase activity (ADA) and evaluated the usefulness of this assay in the differential diagnosis of aseptic meningitis. Cases of meningitis were classified as tuberculous meningitis (TBM), pyogenic meningitis, viral meningitis, self-resolving aseptic meningitis without a specific diagnosis, meningitis associated with other infections, and neoplastic meningitis. We also tested 117 CSF specimens for which parameters were normal. We chose a cutoff point of 10 IU/L on the basis of our results and found elevated ADA levels in 50% of the patients with TBM (no differences between patients with AIDS and those who did not have AIDS were observed). Among samples from patients with aseptic meningitis, we observed high ADA levels in only two of five of the patients with neurobrucellosis. Therefore, we concluded that in cases of aseptic meningitis, a CSF ADA level of>> or = 10 IU/L has a sensitivity of 48%, a specificity of 100%, a positive predictive value of 1, and a negative predictive value of 0.91 as a diagnostic criterion for TBM or neurobrucellosis. ADA levels were also>> 10 IU/L in 30% of the patients with pyogenic meningitis, but this diagnosis was easily excluded on other grounds.

Radioimmunoassay (RIA) techniques have been evaluated to detect specific tubercular antigen (TB Ag) and antitubercular antibody (TB Ab) in CSF and serum of patients with tuberculous meningitis (TBM). A solid-phase RIA using H37RV sonicate antigen of Mycobacterium tuberculosis, anti-BCG antibody, and staphylococcal protein A was standardized. TB Ag and TB Ab levels were noted to be significantly elevated in cerebrospinal fluid (CSF) as well in circulating immune complexes (CIC) isolated from serum samples of TBM patients as compared to control group (P less than 0.01). Detectability of disease by demonstrating elevated TB Ag and/or TB Ab levels in either CSF or CIC or both was 95%. There was no correlation between individual levels of TB Ag and TB Ab in CSF and in circulation. A follow-up study in patient over a period of 4-12 weeks revealed that TB antigen and/or TB Ab persisted in the majority of the cases for several weeks despite chemotherapy.

Tuberculous meningitis (TBM) is a serious complication of tuberculosis that affects the central nervous system. Present methods to diagnose TBM are not suitable for early diagnosis. Molecular markers and sensitive methods to identify them in the early stage of infection of TBM are critically needed for efficient management. We have done the proteomic analysis of TBM cerebrospinal fluid (n=20) with 2-dimensional difference gel electrophoresis (2D-DIGE) and mass spectrometry. We identified 11 human proteins and 8 mycobacterial proteins with changed expression levels in comparison to controls. Arachidonate 5-lipoxygenase and glial fibrillary acidic protein, two of the identified proteins, were validated with western blot technique on a larger set of disease and control samples (n=40). These two proteins were also analyzed in fungal meningitis samples. We suggest that arachidonate 5-lipoxygenase can be considered for validation as a potential marker for diagnosis of TBM.

BACKGROUND

The long-term neurologic sequelae of childhood tuberculous meningitis (TBM) mainly result from ischemia owing to cerebral vasculitis. Deep vein thrombosis occurs in adults with pulmonary tuberculosis owing to hypercoaguability. The present study aimed to investigate coagulation status during acute childhood TBM.

METHODS

Coagulation status, including the natural anticoagulants, antithrombin, protein C and protein S; procoagulant FVIII; fibrinolytic factors, tissue plasminogen activator and plasminogen activator inhibitor-1 (PAI-1) as well as anticardiolipin antibodies (ACA), was determined in 16 children with TBM before and during treatment.

RESULTS

A prothrombotic profile was found as expressed by a decrease of anticoagulant (protein S) and increase of the procoagulant (factor VIII) activity. Raised PAI-1 and normal tissue plasminogen activator values indicated deficient fibrinolysis. This hypercoagulable state was more pronounced in stage 3 patients than in stage 2 patients. The bleeding time on admission ranged from 1.2 to 10 minutes [mean 4.2 minutes]. The mean platelet count on admission was 577.9 +/- 188.6 x 10/L and increased further during the course of the treatment.

CONCLUSIONS

The hypercoagulable state in childhood TBM is comparable to that described in adults with pulmonary tuberculosis and may further increase the risk for infarction. Therapeutic measures that reduce the risk for thrombosis could therefore be potentially beneficial in childhood TBM.

The main functions of spermatozoa required for fertilization are dependent on the energy status and metabolism. AMP-activated kinase, AMPK, acts a sensor and regulator of cell metabolism. As AMPK studies have been focused on somatic cells, our aim was to investigate the expression of AMPK protein in spermatozoa and its possible role in regulating motility. Spermatozoa from boar ejaculates were isolated and incubated under different conditions (38,5°C or 17°C, basal medium TBM or medium with Ca(2+) and bicarbonate TCM, time from 1-24 hours) in presence or absence of AMPK inhibitor, compound C (CC, 30 µM). Western blotting reveals that AMPK is expressed in boar spermatozoa at relatively higher levels than in somatic cells. AMPK phosphorylation (activation) in spermatozoa is temperature-dependent, as it is undetectable at semen preservation temperature (17°C) and increases at 38,5°C in a time-dependent manner. AMPK phosphorylation is independent of the presence of Ca(2+) and/or bicarbonate in the medium. We confirm that CC effectively blocks AMPK phosphorylation in boar spermatozoa. Analysis of spermatozoa motility by CASA shows that CC treatment either in TBM or in TCM causes a significant reduction of any spermatozoa motility parameter in a time-dependent manner. Thus, AMPK inhibition significantly decreases the percentages of motile and rapid spermatozoa, significantly reduces spermatozoa velocities VAP, VCL and affects other motility parameters and coefficients. CC treatment does not cause additional side effects in spermatozoa that might lead to a lower viability even at 24 h incubation. Our results show that AMPK is expressed in spermatozoa at high levels and is phosphorylated under physiological conditions. Moreover, our study suggests that AMPK regulates a relevant function of spermatozoa, motility, which is essential for their ultimate role of fertilization.

BACKGROUND

Renal injury of anti-glomerular basement membrane (GBM) disease is defined by the linear deposition of IgG along GBM and rapidly progressive glomerulonephritis. To date, the distribution of anti-GBM IgG subclasses on renal tissue is still unclear. In the current study, we investigated the deposition of the four IgG subclasses using immunohistochemistry in the renal biopsy specimens from 46 patients with anti-GBM disease.

RESULTS

All four IgG subclasses can be detected within the GBM. Anti-GBM IgG3 was detected in all patients (100%), with 39 (84.8%) patients presenting with weak segmental staining and 7 (15.2%) patients with strong linear deposition. Anti-GBM IgG2 was detected in 22 (47.8%) patients, with 20 (90.9%) patients having weak segmental deposition and 2 (9.1%) patients presenting strong linear staining. Anti-GBM IgG1 and IgG4 were detected in 9 (19.6%) and 7 (15.2%) patients, respectively. IgG deposition along tubular basement membrane (TBM) was also detected in 31 (67.4%) patients. Among them, the IgG subclass distribution was similar to that of the deposition within the GBM: IgG1 6.5% (2/31), IgG2 45.2% (14/31), IgG3 100% (31/31) and IgG4 9.7% (3/31). We observed increased inflammatory cell infiltration into the interstitium in patients with increased anti-TBM IgG3 deposits (P=0.031).

CONCLUSIONS

Anti-GBM IgG3 predominantly deposits along GBM and TBM on renal biopsy specimens from patients with anti-GBM disease, which may be involved in the development of renal injury of the disease.

Berberine (BB) is a protoberberine alkaloid derived from various representatives of the Berberidaceae family. Although used as a therapeutic agent, it has not been applied in the treatment of immune-mediated disorders. In the present study, BB was administered at a daily dose of 10 mg/kg for 3 consecutive days before the induction of tubulointerstitial nephritis (TIN) by injection of bovine tubular basement membrane (TBM) antigen in BALB/c mice. The animals were investigated 2 months after TBM inoculation. The intensity of pathological injuries in animals with TIN+BB decreased significantly, an effect that correlated with the improvement of renal function. Flow cytometric analysis of peripheral blood cells showed that BB caused a decrease in the number of CD3(+), CD4(+), CD8(+), and sIg(+) lymphocytes in comparison with TIN mice. The same tendency was noticed in the lymphocytes from kidney infiltrates of treated animals. The control animals treated only with BB showed a decrease in the number of CD3(+), CD4(+), CD8(+) T-lymphocytes in comparison with control nontreated mice. Our results, thus, indicate that BB has an immunosuppressive effect in the TIN model, which is an analogue of various human kidney autoimmune diseases.

BACKGROUND

Previous studies have identified regions within alpha3(IV) collagen in human antiglomerular basement membrane (anti-GBM) disease, however, information pertaining to the nature of the pathogenic human autoantibodies has been limited by a lack of a relevant disease model. Availability of engineered mice that produce antibodies (that is, XenoMouse II strains) provides an ideal opportunity to examine the human antibody response.

METHODS

XenoMouse II mice that produce human IgG2 (gamma2kappa) in response to antigenic challenge were immunized with various forms of alpha3(IV)NC1 GBM collagen, including native bovine alpha3(IV) NCl collagen, E. coli expressed r alpha3(IV)NCl, and mammalian fetal kidney 293 cell expressed r alpha3(IV)NC1 preparations. The mice were evaluated for autoantibody (Ab) production and nephritis.

RESULTS

All immunized XenoMouse II animals produced human anti-GBM Ab associated with proliferative glomerulonephritis, linear IgG deposits along the murine GBM and tubular basement membrane (TBM), C3 deposits (weaker). A fully human mAb (Ig gamma2kappa), produced from a mouse immunized with native bovine alpha3(IV)NCl collagen produced basement membrane deposits, nephritis and proteinuria on transfer to normal XenoMouse II. Furthermore, monoclonal antibodies (mAb) shared idiotypic properties with polyclonal autoantibodies derived from patients with anti-GBM disease, supporting a structural relationship among the antibodies.

CONCLUSIONS

The results further support the importance of alpha3(IV)NCl collagen in the pathogenesis of anti-GBM disease. Moreover, to our knowledge this is the first demonstration that experimentally induced, pathogenic human autoantibodies result in disease. This new model of anti-GBM disease, therefore, provides the means and unique reagents to both decipher the molecular basis of the human anti-GBM autoantibody response and the opportunity to test specific therapies aimed at modulation of either B cells producing human autoantibodies or the human pathogenic antibodies themselves, in vivo, prior to trial in patients with the spontaneous form of the disease.

The radioactive 82Br partition test was performed on 83 children with suspected tuberculous meningitis. Three of 51 patients with a final diagnosis of TBM had a false negative serum to CSF bromide partition ratio of more than 1.6. Four of the 32 patients in whom TBM was excluded had a false positive ratio of less than 1.6; three of these had sever purulent bacterial meningitis. The test distinguishes TBM from viral meningitis. Antituberculous therapy does not affect the diagnostic value of the bromide partition test in the first few weeks of treatment of TBM.

OBJECTIVE

To assess the utility of interferon gamma (INF-gamma) levels in cerebrospinal fluid (CSF), for the diagnosis of tuberculous meningitis (TBM), and compare these results with aPCR technique.

METHODS

We studied CSF samples from patients with proven or probable TBM and a control group, composed by patients with other causes of meningitis and without meningitis. INFgamma levels were measured by radioimmunoassay. A PCR technique was performed using IS6110 primers.

RESULTS

Of the 127 patients studied, 20 (15.6%) had TBM, 59 (46%) had meningitis of another aetiology and 49 (38.4%) had were HIV and non-HIV patients with normal CSF. The area below the ROC curve for interferon gamma levels in the diagnosis of TBM was 0.94. A cut-off of 6.4 IU/mL yielded a sensitivity of 70% and a specificity of 94%. False positive results were observed in 7 of the 59 patients (11.8%) with non-TB meningitis, (patients with herpetic meningoencephalitis and meningitis due to intracellular microorganisms). INF-gamma sensitivity was higher than PCR (70% vs. 65%). Both tests performed together showed higher sensitivity (80%) and specificity (92.6%).

CONCLUSIONS

CSF INF-gamma levels >> 6.4 IU/mL) are very valuable in TBM diagnosis. PCR and INF-gamma could be simultaneously used to increase the diagnostic yield.

BACKGROUND

Much epidemiological evidence suggests that hydrocarbon exposure may induce glomerulonephritis and worsen its course in many patients. The mechanisms are unknown, however, no specific microscopic pattern has been identified, and it has also been argued that hydrocarbon exposure causes tubular damage mainly. Studying experimental animals may best answer these questions, and as no systematic review of glomerulonephritis produced experimentally by hydrocarbon exposure has been performed previously, I found it relevant to search for and analyse such studies.

METHODS

Animal experiments having mimicked human glomerulonephritis by hydrocarbon exposure were sought on Medline and Toxnet

RESULTS

Twenty-six experiments using thirteen different hydrocarbons were identified. Several human subtypes were observed including IgA nephritis, mesangial, proliferative and extracapillary glomerulonephritis, focal and focal-segmental sclerosis, minimal change nephropathy, anti-GBM and anti-TBM nephritis, and glomerulonephritis associated with peiarteritis nodosa. Glomerular proteinuria was seen in 10/12 experiments that included urine analyses, and renal failure in 5/8 experiments that included measurements of glomerular function. All experiments resulted in various degrees of tubular damage as well. In most studies, where the animals were examined at different times during or after the exposure, the renal microscopic and functional changes were seen immediately, whereas deposits of complement and immunoglobulins appeared late in the course, if at all.

CONCLUSIONS

These experiments are in accord with epidemiological evidence that hydrocarbon exposure may cause glomerulonephritis and worsen renal function. Probable mechanisms include an induction of autologous antibodies and a disturbance of normal immunological functions. Also, tubular damage may increase postglomerular resistance, resulting in a glomerular deposition of macromolecules. In most models a causal role of glomerular immune complex formation was unlikely, but may rather have been a secondary phenomenon. As most glomerulonephritis subgroups were seen and as some of the hydrocarbons produced more than one subgroup, the microscopic findings in a patient cannot be used as a clue to the causation of his disease. By the same reason, the lack of a specific histological pattern in patients with glomerulonephritis assumed to have been caused by hydrocarbon exposure is not contradictive.

The diagnostic potential for detection of IgG to Mycobacterium tuberculosis excretory secretory (ES) antigen in childhood pulmonary and extrapulmonary tuberculosis was explored. IgG antibody to M. tuberculosis ES antigen was detected by indirect penicillinase ELISA. Twenty (80%) out of 25 pulmonary tuberculosis cases (clinically diagnosed and/or AFB-positive), five of nine tuberculous pleural effusion cases and only six of 69 cases in the control group were positive for IgG antibody to M. tuberculosis ES antigen. All CSF and sera were positive for IgG antibody in 12 cases of clinically diagnosed tuberculous meningitis (TBM). Out of 35 cases in the control group for TBM, all five cases of pyogenic meningitis but none of the 13 cases of viral encephalitis, five cases of enteric encephalopathy and 12 cases with no CNS infection were positive for anti-tubercular IgG antibody in CSF samples. Only two of them, i.e. one case of pyogenic meningitis and the other with no CNS infection, were positive for antibody in sera. The study demonstrated the potential of this assay in the diagnosis of tuberculosis in children where bacteriological confirmation is very difficult.

OBJECTIVE

To document the clinical and diagnostic features of tuberculous meningitis (TBM) in young children with and without concomitant miliary tuberculosis (TB).

METHODS

A retrospective comparative study.

RESULTS

Of 104 children with TBM, 32 (31%), median age 17.0 months, had a miliary appearance on chest radiograph; 72 (69%), median age 30.5 months, had TBM only (P = 0.04). Mediastinal adenopathy was noted in 27 (84%) of the children with miliary TB and 33 (46%) of those with TBM only (P = 0.0005). The mean cerebrospinal fluid (CSF) lymphocyte and polymorphonuclear counts of all children (no significant differences between groups) were 137 x 10(6)/l and 38 x 10(6)/l and the mean protein and glucose concentrations were 1.45 g/l and 0.72 mmol/l, respectively. Polymorphonuclear leukocytes were predominant in the CSF of 17% of children, in 16% the CSF glucose was>> 2.2 mmol/l and in 26% the CSF protein was < 0.8 g/l. On Mantoux testing 37 (65%) of 57 children with TBM only and 12 (48%) of 25 children with TBM and miliary TB had an induration of>> or = 10 mm (P = 0.23). Ten children (10%) died, five (7%) who had TBM only and five (16%) who had TBM and miliary TB.

CONCLUSIONS

Children with TBM and miliary TB were younger and more likely to have mediastinal adenopathy on chest radiography than those with TBM only. Diagnostic features and investigations in both groups may be misleading at times.

BACKGROUND

Rapid and specific diagnosis of tubercular meningitis (TBM) is of utmost importance.

OBJECTIVE

To evaluate polymerase chain reaction (PCR) using protein b primers directed against M. tuberculosis for the diagnosis of tuberculous meningitis.

METHODS

PCR using protein b primers was performed in ten patients with confirmed TBM (culture positive), 60 patients with clinically suspected TBM and 40 patients with no TBM (control group).

RESULTS

Protein b PCR had a sensitivity of 90% and a specificity of 100% in patients with confirmed TBM. In 60 clinically diagnosed TBM patients, protein b PCR was positive in 49 (81.7%) patients. The overall sensitivity of microscopy, culture and PCR using protein b primers was 1.4%, 14.3%, and 82.8% and specificity was 100%, 100%, and 100% respectively.

CONCLUSIONS

Protein b PCR is valuable in rapid diagnosis of TBM.

Literature dealing with antituberculosis chemotherapy of tuberculous meningitis (TBM) in adults and children is reviewed and recommendations made for the chemotherapy of TBM. Publications relating to the chemotherapy of TBM were reviewed which contribute to understanding the efficacy of different drugs and regimens in TBM treatment. The established classification of disease severity into stages I (no neurological signs and fully conscious), II (patients conscious but with neurological signs) and III (comatose or stuporous or with severe pareses) was used to compare regimens of isoniazid (INH), para-amino salicylic acid and streptomycin (INH regimens) used up to approximately 1970 with those using INH and rifampicin (RMP), supported by pyrazinamide and ethambutol or streptomycin (RMP regimens). Mortality in studies at all disease stages in adults or adults and children, with the children not distinguished, following INH regimens (12.4%, 25.2% and 55% at stages I, II and III respectively) did not differ significantly from that following introduction of RMP regimens (9.7%, 22.2% and 56% at stages I, II and III respectively), In studies of children only, mortality fell significantly following the introduction of RMP to 0%, 5.9% and 28.2% in children at stage I, II and III having been 10.2%, 22.3% and 49.4% respectively with INH regimens (P = 0.006). Following RMP regimens of 6 months duration, only 2 (1%) relapses occurred amongst 197 patients, after RMP regimens of 9-24 months only 1 (0.16%) relapse was recorded amongst 632 patients. Where INH resistance rates are <4% a directly observed INH, RMP, pyrazinamide and ethambutol for 2-months followed by INH and RMP for 4 months is recommended. If directly observed therapy cannot be practiced treatment duration should be extended to at least 9 months; if the risk of INH resistance or multidrug resistance is higher, the use of ethionamide and a fluoroquinolone and possibly cycloserine is recommended and pyrazinamide should be continued for full treatment duration. The penetration of RMP, ethambutol and streptomycin into cerebrospinal fluid is poor; higher dosages of RMP should be considered.

OBJECTIVE

To evaluate the role of the radiometric BACTEC 460TB system and the conventional Lowenstein-Jensen (LJ) medium for isolation of M. tuberculosis from cerebrospinal fluid (CSF) samples of tuberculous meningitis (TBM) patients.

METHODS

CSF specimens (n=2325) from suspected TBM patients were processed for isolation of mycobacteria by inoculating BACTEC 12B medium and the LJ medium. The isolation of mycobacteria in both media was confirmed by microscopy and biochemical identification. Drug sensitivity testing for the anti-TB drugs was carried out by BACTEC radiometric method.

RESULTS

Among the total 2325 CSF specimens processed by both methods, M. tuberculosis was isolated from 256 specimens. The isolation rates were 93% and 39% for the BACTEC system and LJ medium respectively. Both the media supported growth in 32% of the culture-positive specimens. BACTEC system alone yielded growth in 61% and LJ alone in 7%, of the culture-positive specimens. Among 205 isolates tested for drug susceptibility 81% were sensitive to all the drugs tested and 19% were resistant.

CONCLUSIONS

The BACTEC 460TB system provides a highly sensitive and rapid tool for the isolation and drug susceptibility testing of M. tuberculosis, from CSF of TBM patients. Use of a solid medium in conjunction with the BACTEC 12B medium is essential for optimal recovery for M. tuberculosis from CSF specimens.

Arachnoiditis involving optic nerve and the optic chiasm can occur as a complication of tuberculous meningitis (TBM). This study evaluates the clinical features, cerebrospinal fluid (CSF) and laboratory parameters and imaging findings of optochiasmatic arachnoiditis (OCA) and also tried to identify any factors which can predict this complication in patients with TBM. Patients admitted with TBM in the neurology wards of a tertiary care teaching hospital over a period of 6 years formed the material for this study. Student's "t" test and univariate analysis were done to identify any predictors for this complication and the variables found to be significant were further analyzed by multivariate logistic regression analysis. One hundred sixty-three patients with TBM, admitted over a 6-year period, were studied. Twenty-three (14%) patients developed OCA. Eighteen out of 23 (78%) developed this complication while on antituberculous treatment (ATT) and 5/23 (22%) were newly diagnosed cases of TBM. Of those already on treatment, 12/23 (52%) were receiving only ATT, the remaining 6/23 (26%) had received steroids along with ATT in varying doses and duration. The average period from diagnosis of TBM to visual symptoms was 6.4 months. On the multivariate logistic regression analysis, female sex (P < 0.037), age less than 27 (P < 0.008) years and protein content in the CSF>> 260 mg% (P < 0.021) were the factors predisposing toward this complication. At 6 months follow-up, on treatment with steroids and ATT, 17% had improvement and no further deterioration was noted in visual acuity in 52%. OCA can develop even while on treatment with ATT. Young women with a high CSF protein content seem to be more prone for this complication.

OBJECTIVE

Tuberculous meningitis (TBM) and its complications continue to have devastating neurological consequences for patients. Budgetary constraints, especially in developing countries, have made it necessary to select patients for shunting who are likely to experience good recoveries. To date, the value of cerebrospinal fluid shunting for human immunodeficiency virus (HIV)-positive patients with TBM has not been clearly established.

METHODS

Thirty patients with TBM and hydrocephalus were prospectively evaluated. Coincidentally, one-half of the patients were HIV-positive. All patients underwent uniform treatment, including ventriculoperitoneal shunt placement and antituberculosis treatment. CD4 counts were measured for all patients. Outcomes were assessed at 1 month.

RESULTS

No complications related to shunt insertion were noted. The HIV-positive group fared poorly (death, 66.7%; poor outcome, 64.7%), compared with the HIV-negative group (death, 26.7%; poor outcome, 30.8%). Despite cerebrospinal fluid shunting, no patient in the HIV-positive group experienced a good recovery (Glasgow Outcome Scale score of 5). This is in contrast to the six patients (40%) in the HIV-negative group who, with the same treatment, experienced good recoveries (Glasgow Outcome Scale scores of 5) at discharge (P<0.14). No patient (either HIV-positive or HIV-negative) who presented in TBM Grade 4 survived, whereas no HIV-positive patient who presented in TBM Grade 3 survived. A significant relationship was noted between CD4 counts and patient outcomes (P<0.031).

CONCLUSIONS

In the absence of obvious clinical benefit, HIV-positive patients with TBM should undergo a trial of ventricular or lumbar cerebrospinal fluid drainage, and only those who exhibit significant neurological improvement should proceed to shunt surgery.

OBJECTIVE

Squamous esophageal carcinoma is highly prevalent in developing countries, especially in China. Tu Bei Mu (TBM), a traditional folk medicine, has been used to treat esophageal squamous cell carcinoma (ESCC) for a long term. tubeimoside I (TBMS1) is the main component of TBM, exhibiting great anticancer potential. In this study, we investigated the mechanism of TBMS1 cytotoxic effect on EC109 cells.

METHODS

Comparative nuclear proteomic approach was applied in the current study and we identified several altered protein spots. Further biochemical studies were carried out to detect the mitochondrial membrane potential, cell cycle and corresponding proteins' expression and location.

RESULTS

Subcellular proteomic study in the nucleus from EC109 cells revealed that altered proteins were associated with mitochondrial function and cell proliferation. Further biochemical studies showed that TBMS1-induced molecular events were related to mitochondria-induced intrinsic apoptosis and P21-cyclin B1/cdc2 complex-related G2/M cell cycle arrest.

CONCLUSIONS

Considering the conventional application of TBM in esophageal cancer, TBMS1 therefore may have a great potential as a chemotherapeutic drug candidate for ESCC.