BACKGROUND

Loss of polarization of proximal tubular epithelial cells (PTECs) with detachment is known as an early response of PTEC to acute ischemia during acute tubular necrosis. However, the early morphologic changes of PTECs to chronic ischemic injury are not clear. We previously reported that rat renal microembolism induced chronic tubulointerstitial ischemia and extensive proximal tubular atrophy. Among atrophic tubules, some tubules showed a peculiar pattern mixed with intact and atrophic epithelial cells, which was thought to be the earliest feature leading to atrophic tubules.

METHODS

Chronic ischemic injury was induced by the left renal perfusion of microspheres after removal of the right kidney in rats. The ultrastructual changes, especially focusing on the process of tubular atrophy, are examined by electron microscopy after 4, 8 and 12 weeks.

RESULTS

Early changes in PTECs showed slight simplification or dedifferentiation such as loss or diminution of basolateral infolding and microvilli. Moderately simplified PTECs were partially detached from the tubular basement membrane (TBM) with matrix production in the detached spaces but maintained cell-cell contacts between PTECs. In the advanced stage, severely simplified PTECs showed complete detachment from TBM and more atrophic features characterized by cobblestone appearance with a uniform attachment between cells. In concert with these PTEC changes, accumulation of interstitial fibroblast-like cells (FLCs) with collagenous matrices could be found first in the interstitial spaces and later in the spaces where PTECs detached from TBM.

CONCLUSIONS

Our results suggest that microembolism-induced chronic ischemic injury induces PTEC dedifferentiation and detachment from TBM with matrix production in concert with FLC activation, resulting in tubulointerstitial damage characterized by tubular atrophy and renal fibrosis.

To determine the clinical utility of the tuberculin purified protein derivative (PPD) skin test in patients suspected of having tuberculous meningitis (TBM), the test was applied on admission to 180 patients suspected of having tuberculous meningitis and to 50 patients with proven bacterial meningitis admitted to the Abbassia Fever Hospital, Cairo, Egypt, during the period 1987 to 1989. Admission tuberculin positivity in evaluated groups revealed the following: overall suspect TBM cases--17% (31/180), culture-confirmed TBM cases--19% (16/83), and culture-confirmed acute bacterial meningitis cases--14% (7/50). Repeat PPD skin test at 60 days in surviving presumptive/confirmed TBM cases revealed a significant increase in tuberculin positivity to 62% (58/93) from admission (p < 0.001). Evaluation of PPD positivity by clinical stage of TBM revealed 36% positivity in alert patients as compared to 12% positivity in comatose patients (p = 0.01). Admission tuberculin skin testing as a diagnostic aid for clinical management of tuberculous meningitis is of limited utility in our study population because of the high prevalence of tuberculin positivity in the Egyptian population (potential false positive correlation with the acute presentation) and the advanced stage of TBM at presentation to Egyptian public hospitals (potential false negative correlation).

OBJECTIVE

Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibroinflammatory disorder affecting nearly all organs, including the kidney. Tubulointerstitial nephritis (IgG4-TIN) is the most common form of IgG4-related kidney disease (IgG4-RKD) and is the focus of this concise review.

OBJECTIVE

The study aims to describe when IgG4-TIN should be suspected and to summarize the diagnosis, treatment, and natural history of the disease.

METHODS

Ovid MEDLINE, Google Scholar, and PubMed were searched for full-text English language articles up to January 2016. References included in the manuscript were chosen at the authors' discretion based on their relevance to the subject of the review.

RESULTS

IgG4-TIN should be considered in patients presenting with abnormal urinalysis, abnormal kidney function, renal lesions on imaging, and elevated IgG, IgE, or hypocomplementemia. Diagnosis of IgG4-TIN requires a combination of histologic features (plasma cell-enriched TIN with >10 IgG4+ plasma cells/hpf, +/- TBM immune complex deposits in many cases) and at least one of the following:Characteristic radiologic findings (small peripheral low-attenuation cortical nodules, round or wedge-shaped lesions, or diffuse patchy involvement)Elevated serum IgG4 levelCharacteristic findings of IgG4-RD in other organs Other conditions such as lupus, vasculitis, diabetic nephropathy, and lymphoma must be excluded, as these can also present with IgG4+ plasma cells in the renal parenchyma. IgG4-TIN is generally responsive to steroids and B cell depletion with rituximab, but relapses are common and patients require close long-term follow-up.

CONCLUSIONS

Available data on IgG4-TIN are from retrospective observational studies.

CONCLUSIONS

IgG4-TIN is a distinct and emerging subtype of interstitial nephritis. Nephrologists must be aware of this entity and how to definitively diagnose and treat it. Prospective studies and ideally multi-center clinical trials are needed to study the epidemiology, treatment, and natural history of this disease.

BACKGROUND

Aerosol delivery is a cornerstone of CF airways disease management. New nebulisers have reduced treatment times by utilising mesh technology for aerosol production. We have evaluated a further modification (target inhalation mode (TIM)) that may reduce treatment delivery times further.

METHODS

Following a baseline period on tidal breathing mode (TBM), children with CF on long-term aerosol therapy were randomly allocated to either TIM, which optimises patient inhalations through a direct feedback mechanism, or to continue TBM. The primary outcome was nebuliser treatment times with secondary outcomes being adherence and patient preference.

RESULTS

The ten children allocated TIM reduced their mean (SD) treatment times from 6.9(2.9) to 3.7(2.3) minutes (p<0.001). In contrast, treatment times were unchanged in the ten children allocated TBM. Mean adherence was maintained in the TIM group but declined in patients allocated TBM by >5%. All children preferred TIM to TBM.

CONCLUSIONS

TIM reduces nebuliser treatment times and may positively impact on adherence, although longer duration studies are required to examine this. (ISRCTN65617839).

The most successful protein structure prediction methods to date have been template-based modeling (TBM) or homology modeling, which predicts protein structure based on experimental structures. These high accuracy predictions sometimes retain structural errors due to incorrect templates or a lack of accurate templates in the case of low sequence similarity, making these structures inadequate in drug-design studies or molecular dynamics simulations. We have developed a new physics based approach to the protein refinement problem by mimicking the mechanism of chaperons that rehabilitate misfolded proteins. The template structure is unfolded by selectively (targeted) pulling on different portions of the protein using the geometric based technique FRODA, and then refolded using hierarchically restrained replica exchange molecular dynamics simulations (hr-REMD). FRODA unfolding is used to create a diverse set of topologies for surveying near native-like structures from a template and to provide a set of persistent contacts to be employed during re-folding. We have tested our approach on 13 previous CASP targets and observed that this method of folding an ensemble of partially unfolded structures, through the hierarchical addition of contact restraints (that is, first local and then nonlocal interactions), leads to a refolding of the structure along with refinement in most cases (12/13). Although this approach yields refined models through advancement in sampling, the task of blind selection of the best refined models still needs to be solved. Overall, the method can be useful for improved sampling for low resolution models where certain of the portions of the structure are incorrectly modeled.

The ammonia-oxidizing bacterium Nitrosomonas europaea (ATCC 19718) was shown to degrade low concentrations (50 to 800 mug/liter) of the four trihalomethanes (trichloromethane [TCM], or chloroform; bromodichloromethane [BDCM]; dibromochloromethane [DBCM]; and tribromomethane [TBM], or bromoform) commonly found in treated drinking water. Individual trihalomethane (THM) rate constants (k1THM) increased with increasing THM bromine substitution, with TBM>> DBCM>> BDCM>> TCM (0.23, 0.20, 0.15, and 0.10 liters/mg/day, respectively). Degradation kinetics were best described by a reductant model that accounted for two limiting reactants, THMs and ammonia-nitrogen (NH3-N). A decrease in the temperature resulted in a decrease in both ammonia and THM degradation rates with ammonia rates affected to a greater extent than THM degradation rates. Similarly to the THM degradation rates, product toxicity, measured by transformation capacity (Tc), increased with increasing THM bromine substitution. Because both the rate constants and product toxicities increase with increasing THM bromine substitution, a water's THM speciation will be an important consideration for process implementation during drinking water treatment. Even though a given water sample may be kinetically favored based on THM speciation, the resulting THM product toxicity may not allow stable treatment process performance.

OBJECTIVE

Autologous bone grafting (BG) remains the standard reconstruction strategy for large craniofacial defects. Calcium phosphate (CaP) biomaterials, such as biphasic calcium phosphate (BCP), do not yield consistent results when used alone and must then be combined with cells through bone tissue engineering (BTE). In this context, total bone marrow (TBM) and bone marrow-derived mesenchymal stem cells (MSC) are the primary sources of cellular material used with biomaterials. However, several other BTE strategies exist, including the use of growth factors, various scaffolds, and MSC isolated from different tissues. Thus, clinicians might be unsure as to which method offers patients the most benefit. For this reason, the aim of this study was to compare eight clinically relevant BTE methods in an "all-in-one" study.

METHODS

We used a transgenic rat strain expressing green fluorescent protein (GFP), from which BG, TBM, and MSC were harvested. Progenitor cells were then mixed with CaP materials and implanted subcutaneously into nude mice. After eight weeks, bone formation was evaluated by histology and scanning electron microscopy, and GFP-expressing cells were tracked with photon fluorescence microscopy.

CONCLUSIONS

Bone formation was observed in only four groups. These included CaP materials mixed with BG or TBM, in which abundant de novo bone was formed, and BCP mixed with committed cells grown in two- and three-dimensions, which yielded limited bone formation. Fluorescence microscopy revealed that only the TBM and BG groups were positive for GFP expressing-cells, suggesting that these donor cells were still present in the host and contributed to the formation of bone. Since the TBM-based procedure does not require bone harvest or cell culture techniques, but provides abundant de novo bone formation, we recommend consideration of this strategy for clinical applications.

BACKGROUND

A delay in the diagnosis and treatment of tuberculosis meningitis (TBM) may lead to increased mortality and morbidity. The aim of this study was to describe the clinical, radiological and laboratory findings of TBM on a cohort of 185 pediatric patients at a single centre over a 10 year period and to investigate relationship between the stage of the disease.

METHODS

The hospital records of 185 TBM children that presented to the Pediatric Clinics of Dicle University Hospital were retrospectively evaluated. The age, gender, family history of tuberculosis, result of Mantoux skin test, status of BCG vaccination, stage of TBM at hospitalization, and clinical, laboratory and radiological features were recorded. Clinical staging of TBM was defined as follows: Stage I, no focal neurological findings and Glasgow Coma Scale (GCS) score 15; Stage II, GCS 15 presenting with focal neurological deficit or all the patients with GCS 10-14; Stage III, all the patients with GCS < 10. Relationships between results and stages of TBM were investigated.

RESULTS

The mean age of the patients was 53.5 ± 44.9 months (4 months-18 years). 121 (65.4 %) of the patients were male and 64 (34.6 %) female. Family history of tuberculosis was defined in 62 (33.5 %) patients. Forty five (24.3 %) children had BCG vaccination scar. Mantoux skin test was interpreted as positive in 35 (18.9 %) patients. Sixty-eight (36.8 %) children were at stage I TBM, 57 (30.8 %) at stage II and 60 (32.4 %) were at stage III on admission. Mean duration of hospitalization was 23.9 ± 14.1 days. Totally, 90 patients (48.6 %) had abnormal chest X-ray findings (parenchymal infiltration in 46 (24.9 %), mediastinal lymphadenopathy in 36 (19.5 %), miliary opacities in 25 (13.5 %), pleural effusion in 2 (1.1 %), and atelectasis in 2 (1.1 %) patients). One hundred sixty seven (90.3 %) patients had hydrocephalus in cranial computerized tomography. There were 24 (13.0 %) patients with positive culture for Mycobacterium tuberculosis and 3 (1.6 %) patients with positive acid-fast bacilli in cerebrospinal fluid. Overall mortality rate was 24 (13.0 %). Among the findings; patients at Stage III had less frequent positive chest X-ray abnormality, miliary opacities and BCG vaccination scar when compared with patients at Stage I and II (p = 0,005; p = 0,007, p = 0.020, respectively).

CONCLUSIONS

Children with TBM and positive chest X-ray findings at hospital admission were more frequently diagnosed at Stage I, and BCG vaccination might be protective from the Stage III of the disease.

BACKGROUND

Diagnosis of tuberculous meningitis (TBM) is complicated and outcome is poor especially in resource limited settings. Early diagnosis and prompt treatment are vital in effective treatment. We set out to describe experiences in the management and immediate outcome of TBM a tertiary-level children's hospital in a high HIV and tuberculosis co-infection setting.

METHODS

This retrospective study included children who were diagnosed with TBM in the year 2009. A pre-coded questionnaire was used to extract data on presentation, diagnostics, treatment and outcome at the time of hospital discharge. Data was analyzed using STATA statistical package (StataCorp, Version 11).

RESULTS

Of the 40 children diagnosed with TBM, 6 (15%) had definitive TBM, 17 (42.5%) had probable TBM and 17 (42.5%) had possible TBM. The cerebrospinal fluid (CSF) chemistry and cells were abnormal in 39/40 (98%). Mantoux test was reactive in 16/29 (55%) and 17/30 (57%) had Chest X-rays suggestive of tuberculosis. Only 3/21 (14%) had positive sputum tuberculosis culture and 89% (32/36) had neuro-imaging abnormalities. Outcome at discharge was; 8% died, 49% improved with neurological sequelae and 43% improved without sequelae. Having TBM stage 3 at admission was associated with mortality (p=0.001).

CONCLUSIONS

Most children had early diagnosis of TBM and mortality was lower than in previous studies. We recommend a larger prospective study to further understand the outcome of TBM.

Tuberculous meningitis (TBM) is a serious complication of tuberculosis that affects the central nervous system. As TBM may result in permanent sequelae and death, rapid, accurate diagnostic tests using novel biomarkers are required for the early diagnosis and treatment of TBM. A quantitative proteomic study was therefore performed to identify differential proteins in the cerebrospinal fluid (CSF) obtained from TBM patients (n=12) and healthy controls (n=12). CSF samples were labelled with iTRAQ™ and analyzed by LC-MS/MS. Gene ontology and Pathway analysis were conducted using DAVID bioinformatics resources. Neural epidermal growth factor-like like 2 (NELL2) with the largest fold-change value was selected for validation by western blotting. Proteomic phenotyping revealed over-representation in two inflammation-associated processes, complement and coagulation cascades as well as cell adhesion molecules. Western blotting showed a significant decrease in NELL2 levels in TBM subjects compared to healthy controls. The AUC analysis revealed NELL2 was able to distinguish TBM subjects from healthy controls with 83.3% sensitivity and 75% specificity. In conclusion, the results showed that CSF NELL2 is a potential diagnostic biomarker for TBM. Further evaluation of these findings in larger studies including anti-tuberculosis medicated and unmedicated patient cohorts with other intracranial infectious diseases is required for clinical translation.

There are few data on morphology of light-chain deposition disease (LCDD) of kidney with coexistent light-chain cast nephropathy (LCCN). Here, the authors report the morphology in 23 cases of LCDD and LCCN. They retrospectively evaluated 23 renal biopsies with light (LM), immunofluorescence (IF), and electron microscopy (EM). Twenty-one patients had myeloma, 1 had a monoclonal gammopathy, and in 1 no illness was found. Nodular glomerulosclerosis, the LM lesion suggestive of LCDD, was noted in only 3 of 23 cases. Glomeruli were unremarkable in 16 (69%) cases. The diagnostic casts of LCCN were seen in all biopsies. Linear light chain (LC) immunoreactivity was observed in 23 (100%) cases (18 kappa, 5 lambda); GBM + TBM in 13, TBM only in 7, GBM only in 1, TBM and interstitium in 1, GBM, TBM and mesangium in 1. Casts were positive with same LC in all cases (100%). Fifteen cases (65%) showed granular electron-dense deposits; GBM only in 5, TBM only in 5, GBM and TBM in 4, mesangium in 1. In 8 patients without EM deposits, the diagnosis of LCDD was rendered by IF. Fifteen (65%) had deposits detectable by IF and EM, 8 (37%) had deposits with IF only. LCCN dominated the LM findings in all patients. There were minimal or no glomerular changes by LM. This study shows the lack of characteristic LM findings of LCDD in combined cases of LCDD and LCCN and emphasizes the difficulty for-definitive diagnosis-without IF and EM.

Tracheobronchomalacia (TBM) and hyperdynamic airway collapse (HDAC) can be debilitating diseases associated with decreased functional capacity and poor quality of life, although there is no standard definition of this complex condition, and there are numerous terms used to describe it. The diverse etiology associated with TBM and HDAC can obscure and delay an accurate diagnosis for years. A thorough medical history is important in understanding possible causes and in guiding diagnostic testing. Medical history may also suggest what treatments may be most beneficial.

OBJECTIVE

Do cleavage-stage embryos obtained from oocytes matured in vitro after pre-incubation with a phosphodiesterase inhibitor (IBMX) carry more chromosomal abnormalities than those generated from oocytes matured in vivo?

CONCLUSIONS

The rate and type of chromosomal abnormalities in normally developing cleavage-stage embryos generated with an in vitro maturation (IVM) system including pre-incubation with IBMX are not different from those observed in supernumerary embryos obtained from oocytes matured in vivo.

BACKGROUND

Very limited information is available about the chromosomal constitution of IVM embryos. Previous studies were carried out using FISH on single biopsied blastomeres or arrested whole embryos and only provided fragmentary information on chromosomal abnormalities in IVM embryos. There is no systematic study of chromosomal abnormalities in all blastomeres of human Day 3 embryos with good morphology.

METHODS

Between July 2012 and December 2012, 16 young (age <35 years old) egg donors underwent 18 IVM cycles for the generation of research embryos. Eighteen embryos developed to Day 3 and were analysed using array comparative genomic hybridization (aCGH).

METHODS

Immature oocytes were retrieved from 2 to 10 mm follicles after mild ovarian stimulation with gonadotrophins but without hCG ovulation trigger. At collection, oocytes were pre-incubated with 3-isobutyl-1-methylxanthine (IBMX), a phosphodiesterase inhibitor and matured in vitro. After IVM culture, mature oocytes were microinjected with sperm from a single donor. Embryos were cultured to Day 3 after ICSI and all blastomeres of 18 good-morphology embryos were collected individually for aCGH.

RESULTS

Oocyte maturation rate in vitro was 50.2% (120/239). The mean fertilization rate was 68.3% (82/120) and 30.5% (25/82) of fertilized oocytes developed into a morphologically good quality embryo on Day 3 after ICSI. Of these, 18 embryos that developed well up to Day 3 were analysed using aCGH. Eighty of the 123 blastomeres analysed showed at least one chromosomal abnormality. Three out of eighteen embryos had completely normal cells. A single embryo carried a meiotic abnormality, 11 embryos were mosaic and three were chaotic. Although the aneuploidy data of this study are too limited to allow statistical analysis, these data are comparable to our own published data on the chromosome constitution of whole day 3 and day 4 embryos after conventional ART.

CONCLUSIONS

Array CGH technology determines relative quantification of chromosomal domains but does not allow for the visualization of chromosomal rearrangements, assessment of ploidy or detection of uniparental isodisomy. Conclusions drawn on segmental abnormalities should be treated with caution. Although the limited number of embryos analysed here precludes firm conclusions, they provide valuable data on possible causes of the reduced potential of IVM embryos.

CONCLUSIONS

This is the first study to describe the complete chromosome complement of all single blastomeres of good-morphology day 3 embryos obtained with IVM (including the presence of IBMX in a pre-incubation medium). The results demonstrate that a high proportion of good-morphology embryos are aneuploid and that there is no obvious increase in aneuploidies as a result of IVM which seems to suggest that the reduced efficiency of IVM technology compared with standard IVF may be accounted for by factors other than aneuploidy, such as cytoplasmic defects or reduced endometrial receptivity.

BACKGROUND

This study was funded by the TBM (Applied Biomedical Research with Societal Finality) programme of the IWT (Agency for Innovation through Science and Technology - Flanders, 110680) and by a Methusalem grant of the Vrije Universiteit Brussel. C.S. is a post-doctoral fellow of the Fund for Scientific Research Flanders (FWO - Vlaanderen). K.J. is a PhD student funded by the FWO. The University of Adelaide owns a patent family associated with IVM technologies that is licensed to Cook Medical. R.B.G. and J.G.T. are inventors. The remaining authors have no conflict of interest to declare.

OBJECTIVE

The goal of this study was to monitor tuberculosis (TB)-specific T-cell responses in cerebrospinal fluid-mononuclear cells (CSF-MCs) and peripheral blood mononuclear cells (PBMCs) in patients with tuberculous meningitis (TBM) over the course of anti-TB therapy.

METHODS

Adult patients (≥ 16 years) with TBM admitted to Asan Medical Center, Seoul, South Korea, were prospectively enrolled between April 2008 and April 2011. Serial blood or CSF samples were collected over the course of the anti-TB therapy, and analyzed using an enzyme-linked immunosorbent spot (ELISPOT) assay.

RESULTS

Serial ELISPOT assays were performed on PBMCs from 17 patients (seven definite, four probable, and six possible TBM) and CSF-MC from nine patients (all definite TBM). The median number of interferon-gamma (IFN-γ)-producing T-cells steadily increased during the first 6 months after commencement of anti-TB therapy in PBMCs. Serial CSF-MC ELISPOT assays revealed significant variability in immune responses during the first 6 weeks of anti-TB therapy, though early increases in CSF-MC ELISPOT results were associated with treatment failure or paradoxical response.

CONCLUSIONS

Serial analysis of PBMCs by ELISPOT during the course of treatment was ineffective for predicting clinical response. However, increases in TB-specific IFN-γ-producing T-cells in CSF-MC during the early phase of anti-TB therapy may be predictive of clinical failure.

BACKGROUND

Tuberculous meningitis (TBM) is a common central nervous system infection in the Philippines; however it is difficult to diagnose as findings are non-specific. Hence we decided to determine if, among patients with chronic meningitis syndrome, the following are associated with the diagnosis: new-onset seizures; focal neurologic deficit; pulmonary tuberculosis (PTB) on chest X-ray; cerebrospinal fluid (CSF) pleocytosis with lymphocytic predominance; decreased CSF glucose; increased CSF protein.

METHODS

Adult patients with suspected TBM were enrolled after informed consent was obtained. Baseline physical examination and diagnostic tests including CT scan of the head with contrast and CSF analysis for acid fast bacilli (AFB) smear, TB culture and cryptococcal antigen detection were done and results collected. Definite TBM was defined as positive AFB smear or positive TB culture or positive basal meningeal enhancement on CT contrast study. Logistic regression was done to determine which were associated with a diagnosis of TBM.

RESULTS

91 patients were included. Using the gold standard criteria mentioned above, 44 had definite TBM; but if subsequent clinical course and response to anti-Koch's therapy are considered, 68 had a final diagnosis of TBM. After logistic regression was performed, only abnormal CSF (the combination of CSF pleocytosis with lymphocytic predominance, decreased CSF glucose, and increased CSF protein) was associated with the diagnosis of TBM.

CONCLUSIONS

In patients with chronic meningitis syndrome, only abnormal CSF was associated with the diagnosis of TBM.

In this study, a dot-immunobinding assay (Dot-Iba) was standardized to measure circulating antimycobacterial antibodies in the cerebrospinal fluid (CSF) specimens for the rapid laboratory diagnosis of tuberculous meningitis (TBM). Specific CSF-IgG antibody to Mycobacterium tuberculosis from a culture proven patient with TBM was isolated and coupled with activated Cynogen bromide-Sepharose 4B. Using an immunoabsorbent affinity chromatography, 14 kDa antigen present in the culture filtrates of M. tuberculosis was isolated and this antigen was used in the Dot-Iba, to quantitate specific antimycobacterial antibodies in CSF specimens. The Dot-Iba gave positive results in all the 5 culture proven patients with TBM and gave no false positive results in CSFs from patients with partially treated pyogenic meningitis. Dot-Iba developed in our laboratory is a simple, rapid and specific method and more importantly suited for the routine application in laboratories with limited resources.

Tuberculous meningitis (TBM) is one of the commonest chronic infections of the central nervous system (CNS). Diagnosis of TBM has been a problem as it causes various clinical manifestations which can be confused with those of other chronic infections of the CNS such as neurocysticercosis (NCC), neurobrucellosis and cryptococcal meningitis, that are prevalent in many underdeveloped and developing countries. Differential diagnosis of TBM can be made by detecting circulating mycobacterial antigens in CSF by immunoassays. In this study, a reverse passive hemagglutination (RPHA) has been developed using rabbit antimycobacterial IgG for detection of circulating mycobacterial antigens in CSFs from chronic infections of the CNS in order to develop a rapid, simple, sensitive and cost-effective method. Circulating mycobacterial antigens were characterized by immunoblot assay. The sensitivity limit of RPHA was 400 ng ml(-1). RPHA was specific as antimycobacterial IgG did not show any reaction with porcine Cysticercus cellulosae which was used as a control antigen. RPHA could detect mycobacterial antigens in CSF at a sensitivity level of 94.11% with a specificity of 99.0%. Immunoblot analysis of RPHA positive CSFs revealed predominantly 30-32 kDa and 71 kDa antigens whilst 6, 86, 120, 96 and 110 kDa showed varied degree of reactivity. Antigens of masses 30-32 and 71 kDa were absent in culture filtrate of Mycobacterium tuberculosis H37Rv grown in Proskeur-Beck liquid medium. RPHA is a rapid, simple and sensitive immunological method with a long shelf life of 6-8 weeks if stabilized coated erythrocytes are stored at +4 degrees C. RPHA could be used as an additional immunodiagnostic tool in both differential diagnosis and prognosis of TBM. Immunoblot results indicate that 30-32 kDa and 71 kDa antigens are cell wall derived.

A treatment protocol for long-term anticonvulsant therapy (ACT) in children with tuberculous meningitis (TBM) has been followed depending upon clinical characteristics and EEG/CT scan findings suggestive of the underlying cause of convulsions. Sixty-three children which included all patients with focal seizures (FS), and those with generalized tonic and clonic seizures (GTCS), and tonic spasms (TS) manifesting more than once during hospitalization and/or associated with abnormal CT/EEG findings were given long-term ACT (Group A). Thirty-eight cases with GTCS before hospitalization, and/or not more than one seizure during first week of hospitalization and without any specific CT/EEG abnormalities (Group B) and 35 cases without any seizures (Group C) did not receive any ACT. Forty-four patients who were finally discharged on long-term ACT, were given phenobarbitone (57 per cent), phenytoin (23 per cent), and a combination of phenobarbitone+phenytoin (14 per cent), and phenobarbitone+sodium valproate (7 per cent). Follow-up was continued for 4 years with 93, 84 and 81 per cent attendance, respectively, in groups A, B and C. Some of the side-effects observed with anti-convulsant drugs included gingival hypertrophy in 11 out of 16 cases (69 per cent) on phenytoin, hyperkinetic behaviour in 3 out of 34 (9 per cent) cases on phenobarbitone, hypocalcaemia in 3 out of 44 cases (7 per cent), hypophosphataemia in 10 out of 44 cases (23 per cent) and increase in alkaline phosphatase in 14 out of 44 cases (32 per cent). CT scan of brain repeated in six cases with multiple tuberculomas showed marked improvement. While 4 out of 41 (10 per cent) cases in group A had recurrence of seizures in the follow-up, only 2 out of 28 cases (7 per cent) in group B presented with GTCS during first 3 months after discharge which was successfully controlled by long-term ACT in later part of the follow-up. Two out of 21 cases (10 per cent) in group C also presented with myoclonic seizures 3 and 5 months after discharge. There was no statistically significant difference in the recurrence/appearance of seizures in the three groups (P =>> 0.05). Our results suggest that long-term ACT is not indicated in all cases of TBM with seizures. In view of the known side-effects of anticonvulsant drugs and danger of interaction with antitubercular drugs, it is mandatory to clinically evaluate the patients, identify the cause and restrict long-term ACT only to those cases who are likely to have some abnormal focus resulting in secondary epilepsy. All the cases with FS and some of the patients with GTCS and TS may need to be started on ACT. However, a close follow-up is necessary in all particularly in those for whom ACT has been withheld.

Three recent studies found that corticosteroids improve clinical outcome and mortality in tuberculous meningitis (TBM), although the exact mechanism of action of the drug remains speculative. A number of reports on the effect of corticosteroids on cerebrospinal fluid (CSF) findings in TBM have been published, often with conflicting results regarding serial cell counts and protein levels. As part of a controlled, randomized trial on the effect of oral prednisone on outcome in childhood TBM at our institution, CSF was collected and analysed weekly during the 1st month of treatment. We found no significant difference in serial CSF cell counts between the steroid and non-steroid groups in the study. However, the steroid group had significantly lower CSF protein and globulin levels after the 1st month of treatment, and a more steady rise in CSF glucose levels than the non-steroid group. Knowledge of the different CSF responses during the course of anti-tuberculosis therapy is important in clinical decision-making.

Genome sequencing plays a key role in understanding the genetic diversity of Mycobacterium tuberculosis (M.tb). The genotype-specific character of M. tb contributes to tuberculosis severity and emergence of drug resistance. Strains of M. tb complex can be classified into seven lineages. The Nonthaburi (NB) genotype, belonging to the Indo-Oceanic lineage (lineage 1), has a unique spoligotype and IS6110-RFLP pattern but has not previously undergone a detailed whole genome analysis. In addition, there is not much information available on the whole genome analysis of M. tb isolates from tuberculous meningitis (TBM) patients in public databases. Isolates CSF3053, 46-5069 and 43-13838 of NB genotype were obtained from the cerebrospinal fluids of TBM Thai patients in Siriraj Hospital, Bangkok. The whole genomes were subjected to high throughput sequencing. The sequence data of each isolate were assembled into draft genome. The sequences were also aligned to reference genome, to determine genomic variations. Single nucleotide polymorphisms (SNPs) were obtained and grouped according to the functions of the genes containing them. They were compared with SNPs from 1,601 genomes, representing the seven lineages of M. tb complex, to determine the uniqueness of NB genotype. Susceptibility to first-line, second-line and other antituberculosis drugs were determined and related to the SNPs previously reported in drug-resistant related genes. The assembled genomes have an average size of 4,364,461 bp, 4,154 genes, 48 RNAs and 64 pseudogenes. A 500 base pairs deletion, which includes ppe50, was found in all isolates. RD239, specific for members of Indo Oceanic lineage, and RD147c were identified. A total of 2,202 SNPs were common to the isolates and used to classify the NB strains as members of sublineage 1.2.1. Compared with 1,601 genomes from the seven lineages of M. tb complex, mutation G2342203C was found novel to the isolates in this study. Three mutations (T28910C, C1180580T and C152178T) were found only in Thai NB isolates, including isolates from previous study. Although drug susceptibility tests indicated pan-susceptibility, non-synonymous SNPs previously reported to be associated with resistance to anti-tuberculous drugs; isoniazid, ethambutol, and ethionamide were identified in all the isolates. Non-synonymous SNPs were found in virulence genes such as the genes playing roles in apoptosis inhibition and phagosome arrest. We also report polymorphisms in essential genes, efflux pumps associated genes and genes with known epitopes. The analysis of the TBM isolates and the availability of the variations obtained will provide additional resources for global comparison of isolates from pulmonary tuberculosis and TBM. It will also contribute to the richness of genomic databases towards the prediction of antibiotic resistance, level of virulence and of origin of infection.

BACKGROUND

Cerebral infarction (CI) complicating tuberculous meningitis (TBM) is a major risk factor of permanent disability. The prevention of this complication is an important issue in the quality care of TBM patients.

OBJECTIVE

Our aim was to evaluate the clinical characteristics of TBM patients with CI.

METHODS

Ninety-one adult patients with TBM were studied between 1999 and 2007. Clinical, neuroradiological and cerebrospinal fluid data of patients with CI were compared with those without CI.

RESULTS

Thirty of the 91 patients had CI, including symptomatic CI occurring before admission in 10 patients, symptomatic CI occurring during hospitalisation in four and silent CI in 16 patients. When compared with non-CI patients, patients with CI were younger and associated with focal weakness on presentation, and had basal meningeal enhancement and hydrocephalus on brain images. Prolonged doctor delays of antituberculosis and steroid therapies, neurosurgical intervention, focal weakness and dementia as sequelae, and poor outcomes were associated with patients with CI than non-CI patients.

CONCLUSIONS

Contrast-enhanced brain imaging is helpful to explore the basal meningeal enhancement in CI patients, and contributes to early diagnosis and treatment of TBM. Early antituberculosis and steroid therapies may help prevent CI in TBM patients.

BACKGROUND

The Western Cape in South Africa has one of the highest incidences of tuberculous meningitis (TBM) in the world. Despite therapy, the outcome in children with advanced TBM remains dismal. Magnetic resonance imaging (MRI) has been shown to be superior to computed tomography (CT) in demonstrating ischemia in TBM, especially of the brainstem. The objective of this study was to characterize brainstem lesions and association with clinical findings in children with TBM by using MRI.

METHODS

CT and multiplanar MRI scans were performed in 30 children with proven TBM. From this group, a subgroup with radiological ischemic changes of the brainstem were identified. Radiological findings in these patients were then correlated with severity of disease, motor deficit, and outcome after 6 months.

RESULTS

Radiological brainstem abnormalities were identified in 14 out of 30 children. Thirty-eight brainstem lesions were confirmed to be ischemic. The severity of disease at presentation, degree of motor deficit, and developmental outcome after 6 months of the children with ischemic brainstem lesions was poorer compared to those children without brainstem involvement. However, both sensitivity and specificity of the MRI brainstem lesion detection for clinical outcome proved low.

CONCLUSIONS

A significant percentage of children with TBM have ischemic brainstem lesions. These are poorly visualized on conventional CT. MRI scanning is more sensitive in detecting these lesions and localizing them. There appears to be some association between MRI-detected brainstem lesions and clinical outcome. The exact meaning of these lesions and their implication for the patient's management require further clarification.

Twenty-seven patients with tuberculous meningitis (TBM) were treated with ethambutol, isonicotinic acid hydrazide, streptomycin and dexamethasone and 28 were treated with triple anti-tuberculous drugs only. Only two of the patients to whom steroids were given developed ocular complications as compared to seven of those not receiving dexamethasone. High dose dexamethasone apparently prevents optic atrophy in TBM. Controlled double-blind studies with and without dexamethasone are needed to confirm this postulation.

Folate and folic acid are forms of the B vitamin that are involved in the synthesis, repair, and functioning of DNA and are required for the production and maintenance of cells. Low levels of folate have been associated with several forms of cancer, including colon cancer. Aberrant crypt foci (ACF), identified as putative precursor lesions in the development of colon cancer, have been induced by the drinking water disinfection by-product, tribromomethane (TBM). To investigate whether ACF induced by TBM could be promoted by a diet devoid of dietary folate, male F344/N rats were exposed to 500 mg/l of TBM in drinking water and fed either a normal or no folate diet (NFD) for 26 weeks. At the conclusion of the study, colons were excised and examined for ACF. Rats exposed to TBM and fed a NFD, evident by significantly reduced serum folate concentrations and elevated serum homocysteine levels, had significant increases of ACF when compared to rats exposed to TBM and fed a normal diet. This study highlights the important role that diet, especially folate intake, represents in protecting the colon against TBM-induced ACF.