Elsevier

Journal of Critical Care

Volume 30, Issue 6, December 2015, Pages 1365-1369
Journal of Critical Care

Clinical Potpourri
Outcome of tuberculous meningitis patients requiring mechanical ventilation

https://doi.org/10.1016/j.jcrc.2015.08.017Get rights and content

Abstract

Purpose

There is paucity of information about the outcome of tuberculous meningitis (TBM) patients on mechanical ventilation (MV). In this communication, we report the clinical characteristics, predictors of MV, and outcome of TBM patients requiring MV.

Method

Thirty-eight (18%) of 205 patients with TBM requiring MV were included; and their demographic, clinical, cerebrospinal fluid, and magnetic resonance imaging finding at admission and follow-up were noted. The ventilator-related and systemic complications, hospital death, and 3-month functional outcome were noted. The predictors of need of MV were derived by multivariate regression analysis.

Results

There were 38 MV and 36 non-MV TBM patients who were matched for age, sex, and stage of meningitis on admission. The requirement of MV was independently related to leukocytosis, seizure, and cerebrospinal fluid pleocytosis on admission. Patients on MV had higher frequency of septicemia (9 vs 2), bedsores (6 vs 0), and gastric hemorrhage (4 vs 0) compared with non-MV patients. Only 29% of MV patients survived and had poor outcome at 3 months; but in the non-MV group, all the patients survived, and only 11% had poor outcome.

Conclusion

Mechanical ventilation was needed in 18% TBM patients because of TBM-related or systemic complications. Those requiring MV had high mortality and may be categorized separately.

Introduction

Tuberculosis is an important public health problem. It is estimated that more than 2 billion people are infected with Mycobacterium tuberculosis, and 10% of them develop active tuberculosis [1]. Tuberculosis results in 2 million deaths annually, and 90% of these deaths occur in the developing countries of Asia and Africa. About 50% of new cases are from Bangladesh, Pakistan, India, China, Indonesia, and the Philippines [2]. Tuberculous meningitis (TBM) constitutes about 5% of extrapulmonary tuberculosis and is the most severe form of tuberculosis with high mortality and morbidity. About 10% to 30% of patients with TBM die, one third of the surviving patients have long-term functional deficit, and 78% have neurological sequelae [3], [4], [5], [6], [7]. In TBM, there may be vasculitis, exudates, hydrocephalous, and tuberculoma which contribute to increased intracranial pressure, altered sensorium, and brain herniation with ominous consequences [4], [8]. Intensive care management of these patients can be challenging but lifesaving. There is a paucity of information regarding intensive care unit (ICU) management of TBM patients. In this communication, we report our experience of management of TBM patients in a neurology ICU and evaluate the predictors of mechanical ventilation (MV) and their outcome.

Section snippets

Subjects and methods

Patients with TBM admitted to neurology ICU during 2010-2014 were included. These patients were retrospectively analyzed from a prospectively maintained TBM registry. The diagnosis of TBM was based on clinical, cerebrospinal fluid (CSF), and magnetic resonance imaging (MRI) findings. The essential diagnostic criteria were symptoms of meningitis (fever, headache, vomiting) for at least 2 weeks in which malaria, septic meningitis, and fungal meningitis were excluded. The supportive criteria

Results

During the study period, 205 patients with TBM were admitted and 38 (18.5%) of them needed MV. The median age of the MV patients was 32.5 (range, 17-65) years, and 15 (39.5%) were female. On admission, the majority of the patients belonged to stage II (15) and stage III (22) meningitis; and only 1 patient was admitted in stage I TBM. The diagnosis of TBM was definite in 14 (36.8%) patients and probable in 24 (63.2%). The median duration of illness before hospitalization was 60 (range, 7-241)

Discussion

In the present study, 18.5% of patients with TBM needed MV because of associated sepsis and pneumonia in 55.3% and because of TBM-related complications such as raised intracranial pressure and venticuloperitoneal shunt in the remaining 44.7% of patients. Presence of sepsis, seizures, and CSF pleocytosis on admission predicted MV. Thirty percent patients with MV survived but had major neurological deficit at 3 months.

This study for the first time reports the outcome of mechanically ventilated

Acknowledgement

We thank Mr Rakesh kumar Nigam and Mr Deepak Kumar Anand for secretarial help.

Funding support: none.

Conflict of interest: There is no conflict of interest to declare.

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