Late Radiological Findings after Recovery from Tuberculous Meningitis

The results of skull x-ray examinations of 101 children recovered from tuberculous meningitis are reported. The roentgenological re-examinations were performed 6—12 1/2 years after the disease, and were repeated later in several cases. Intra-cranial calcifications were found in 26 per cent. Of these, 4 children showed extensive calcified plots, including 1 with intracerebral calcifications. The occurrence of intracranial calcified plots was not correlated with the sex, the duration of meningeal symptoms prior to hospitalization, or the treatment of the patients; nor was it correlated with increased intracranial pressure during the disease or with the late mental and otological sequelae of the disease. Positive correlations were, however, found between the development of intracranial calcifications and the age at the onset of the disease, the state on admission, trephination, occurrence of convulsions and late neurological, EEG and ophthalmological sequelae.     

Late Otological Sequelae of Tuberculous Meningitis

An otological follow-up study in 1956 and 1959—62 of 103 children treated for and cured of tuberculous meningitis in 1949—54 is presented. Impaired hearing was observed in 63 per cent, severe loss of hearing in 15 per cent and total deafness in 7 per cent. In 36 per cent there was a hearing loss of more than 10 dB in the speech range (500—2,000 cps). The initial and the follow-up results of otological investigations were in close accordance with each other — only in 3 cases was there some improvement and in 11 some deterioration of hearing. The cases with hearing loss were evenly distributed between the different age groups excepting the youngest one — 0—12 months — which displayed a considerably lower frequency of impaired hearing as a whole but a much higher frequency of severe hearing loss. There was no correlation between hearing sequelae and the duration of meningeal symptoms prior to hospitalization or the severity of the disease on admission. There was, however, a correlation between the frequency of hearing sequelae and the daily and total doses of streptomycin given: the frequency of hearing loss was 49 per cent (severe hearing loss 22 per cent) when 50 mg/kg daily was used compared with an incidence of 15 per cent (severe hearing loss in 4 per cent) when 10—20 mg/kg of streptomycin was used intramuscularly and 1—3 mg/kg intrathecally daily.
No correlation was found between loss of hearing and neurological, mental, eye or EEG disturbances.
Disturbances of vestibular function were found in 54 per cent altogether and they were severe in 31 per cent.
Five of the 15 children with severe hearing loss used hearing aids with considerable success, 3 got along without them in ordinary schools and 10 children attended schools for the deaf.     

Late Neurological Sequelae of Tuberculous Meningitis

The neurological findings in a follow-up study of 103 children treated for and cured of tuberculous meningitis in 1949—54, are presented. Fifty children were found to be free of late neurological sequelae, 29 had minor neurological sequelae including 2 with cranial nerve palsies, nystagmus, and ataxia, 13 with mild disturbances of coordination and 10 with symptoms of upper motor neuron lesion without subjective complaints. Gross neurological sequelae were found in 22 cases, including 8 with spastic palsies, 9 with spastic palsies and convulsions, and 5 with convulsions without spastic palsies. Two children were found to have sequelae of spinal lesions; one had paraplegia and the other disturbance of sensation on the dorsum of the left foot. Fourteen children had convulsions.     

Late Ophthalmological Sequelae of Tuberculous Meningitis

One hundred and three patients who had recovered from tuberculous meningitis in 1949—54 were thoroughly re-examined ophthalmologically an average of 8 1/2 years (range 6—12 1/2 years) after recovery. One blind patient and one with severe visual impairment were found. In addition to these, a number of cases with ophthalmological sequelae of minor importance were found; partial structural and functional lesions of the optic nerve were found in 17 cases (including 1 case with associated abducens nerve palsy), nystagmus was found in 2, pupillary disturbances in 6 and scars of choroidal tubercles in 16 cases. Thus 36 cases (35 per cent) showed ophthalmological sequelae of the past illness. Permanent visual disability was found in the 2 cases mentioned above, both of them being late cases with a high block treated with trephination. Of the other sequelae of the disease only intracranial calcification showed some degree of correlation with the ophthalmological sequelae.     

Modern Treatment and Late Prognosis of Tuberculous Meningitis

Certain controversial subjects in the treatment of tuberculous meningitis are analyzed, amongst them intrathecal administration of streptomycin, the toxicity of isoniazid, long-term treatment with INH, and the etiological role of the primarily resistant strains of tubercle bacilli. The corticoid problem is given special consideration and the possibility of iatrogenic late sequelae due to corticoids is discussed at length. The importance of proper neurosurgical management in cases with increased intracranial pressure and signs of block formation and the value of preventive measures, like BCG vaccination, chemoprophylaxis and isolation are also stressed.
In addition, the methods of treatment presently employed at the Children's Hospital are presented in detail and certain therapeutical problems are discussed in this connection. The recent results, from the years 1956—62, are outlined. Finally, in the late prognosis of the survivors of tuberculous meningitis the emphasis is laid upon certain sociomedical aspects and the children are grouped into: Group A — 50 –60 per cent — fully recovered individuals with no handicaps; Group B – 30—40 per cent — individuals with minor handicaps requiring efficient rehabilitation and special training but with a favourable socio-medical prognosis when given these; and Group C — 10 per cent — severely handicapped individuals at the mercy of the domestic environment and or the community.     

Late Psychological and Psychiatric Sequelae of Tuberculous Meningitis

The psychological and psychiatric sequelae of tuberculous meningitis in 103 children were studied by thorough clinical follow-up examinations at the Children's Hospital, University of Helsinki, and extensive correspondence with the parents and teachers of the children. Forty five per cent of the series were found to be of subnormal or borderline intelligence. The achievements of those attending school were, on the whole, comparable with those of the siblings and classmates. Only 4 children were found to be severely mentally disturbed — of these 1 has greatly improved in the last 2 years — and 17 were slightly disturbed. Mental retardation was found to be more frequent in the youngest age groups (under 3 years of age) and social re-adjustment problems more frequent in the older age groups, particularly the school-age children. The latter seemed to pose the major problems in this series, especially the cases with major intellectual, sensory or motor handicaps.     

Diagnostic criteria for Tuberculous Meningitis

Objective : Tuberculous Meningitis is associated with a high morbidity and mortality if there is a delay in diagnosis. The diagnosis is based on clinical evaluation since the bacteriological diagnosis takes time and has a low yield. This study attempts to validate these criteria in children with TBM.Methods : Forty-two children clinically suspected to have TBM were enrolled in the study. History, examination, CT scan and CSF findings were utilized to categorize patients into “definite”, “highly probable”, “probable” and “possible” TBM based on the criteria laid down by Ahuja et al. The validity of these criteria was tested against bacterial isolation and response to treatment.Results : Thirty one children, with complete data, were included for analysis. Using “improvement on therapy” as a criterion for definite TBM, we analyzed the sensitivity and specificity of the Ahuja criteria in diagnosing TBM. Using the criteria of “highly probable” TBM, the sensitivity was 65% with a specificity of 75%. When the criteria of “probable” TBM were used, the sensitivity increased to 96% while the specificity dropped to 38%. In an attempt to make these criteria more appropriate for children, we modified the criteria by including mantoux reaction, and family history of exposure in the criteria. The modified criteria gave a sensitivity of 83% and a specificity of 63%.Discussion : A sensitivity of 65% (highly probable group) implies that 35% of TBM patients will be missed, while the probable criteria gave a 63% false positive rate suggesting that the trade-off for a higher sensitivity makes the criteria very unreliable. Our modification of the criteria gave us a reasonable sensitivity of 83% with a higher specificity of 63%. The false positive rate was also reduced to 38%. Thus the modified Ahuja criteria worked better for children with TBM.Conclusion : The modified Ahuja criteria are better applicable for use in pediatric patients with TBM. Since the number of patients was small in this study, the study needs to be validated with a larger sample size     

Comparison of Scrub Typhus Meningitis with Acute Bacterial Meningitis and Tuberculous Meningitis

Objective

To compare scrub typhus meningitis with bacterial and tuberculous meningitis.

Methods

Children aged<15 years admitted with meningitis were screened and those who fit criteria for diagnosis of scrub typhus meningitis (n=48), bacterial meningitis (n=44) and tuberculous meningitis (n=31) were included for analysis. Clinical features, investigations and outcomes were compared between the three types of meningitis.

Results

Mean age, duration of fever at presentation, presence of headache and, altered sensorium and presence of hepatomegaly/splenomegaly were statistically significantly different between the groups. Scrub typhus had statistically significant thrombocytopenia, shorter hospital stay and a better neurological and mortality outcome.

Conclusions

Sub-acute presentation of meningitis in older age group children, and good outcome is associated with scrub typhus when compared to bacterial and tuberculous meningitis.

     

儿童结核性脑膜炎的诊断和治疗

结核性脑膜炎是严重威胁儿童生命健康的神经系统感染性疾病.在小儿肺外结核病中结核性脑膜炎是最常见的,尽管目前开展了足量的化疗,结核性脑膜炎仍有高发病率和病死率的特点.虽然近年来研究者从细菌学、分子生物学及免疫学等方面对小儿结核性脑膜炎的诊断进行了研究,但均末获得突破性进展,对小儿结核性脑膜炎的诊断仍依靠综合分析患儿的临床特点以及通过辅助检查的结果判断.早期及时诊断和完善的治疗是降低结核性脑膜炎病死率及后遗症发生率的关键.     

以呕吐为首发症状的结核性脑膜炎16例

目的探讨以呕吐为首发症状的结核性脑膜炎的临床特点,提高对结核性脑膜炎的认识。方法回顾分析1997～2005年天津市儿童医院就诊的16例以呕吐为首发症状的结核性脑膜炎患儿的临床资料,包括病史、血液及脑脊液检测、影像学检查、治疗及转归。结果以呕吐首发的结核性脑膜炎入院前误诊率高,小婴儿呕吐发生率低,当以呕吐为突出症状就诊时,多数病程已在中至晚期。较大年龄组呕吐症状出现较早,预后较婴幼儿好。结论对于有呕吐症状的患儿,要引起足够的重视,其中部分患儿是由结核性脑膜炎所致,避免漏诊、误诊。     

Initial Electroencephalographic Findings in Children with Acute Lymphoblastic Leukaemia

ABSTRACT. Electroencephalography (EEG) was performed on 66 children with acute lymphoblastic leukaemia, 45 before treatment and 21 during the first 5 days of chemotherapy. The patients, aged 7 months to 16 years, 33 boys and 33 girls, had been admitted to the Department of Paediatrics, University of Oulu, between March 1976 and January 1987. The EEG findings were compared with those in 66 age and sex-matched control children chosen at random from the local population. The patients had significantly more frequent and more severe disturbances in background activity ( p < 0.001) than the controls and increased slow waves in the occipital ( p < 0.001) and temporal regions ( p < 0.01). The patients who had received chemotherapy before the EEG recording had EEG disturbances significantly more frequently than the other patients ( p < 0.01), but the latter still had EEG abnormalities significantly more frequently than their matched controls, although they did not have severe changes (grade 3). The results suggest that chemotherapy increases EEG changes during the early days of induction therapy and possibly induces long-term disturbances in brain function. The associations between EEG changes and clinical findings were also analysed and the results show that a long duration of leukaemic symptoms or an aggressive disease may lead to EEG abnormalities.