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

OBJECTIVE. Tuberculous meningitis is the most severe extrapulmonary complication of tuberculosis, with high morbidity and mortality rates. The objective of this study was to assess the relationship between presenting clinical characteristics and outcome of pediatric tuberculous meningitis. PATIENTS AND METHODS.We present a retrospective cohort study of all of the children diagnosed with tuberculous meningitis in a large university hospital in South Africa between January 1985 and April 2005. We compared demographic, clinical, and diagnostic characteristics with clinical outcome after 6 months of treatment. RESULTS.We included 554 patients. Common characteristics on admission were young age (82%; 5 years), stage II or III tuberculous meningitis (97%), nonspecific symptoms existing for 1 week (58%), poor weight gain or weight loss (91%), loss of consciousness (96%), motor deficit (63%), meningeal irritation (98%), raised intracranial pressure (23%), brainstem dysfunction (39%), and cranial nerve palsies (27%). Common features of tuberculous meningitis on computed tomography scan of the brain were hydrocephalus (82%), periventricular lucency (57%), infarctions (32%), and basal meningeal enhancement (75%). Clinical outcome after 6 months was as follows: normal (16%), mild sequelae (52%), severe sequelae (19%), and death (13%). All of the patients diagnosed with stage I tuberculous meningitis had normal outcome. Factors associated with poor outcome in univariate analyses were as follows: African ethnicity, young age, HIV coinfection, stage III tuberculous meningitis, absence of headache and vomiting, convulsions, decreased level of consciousness, motor deficits, cranial nerve palsies, raised intracranial pressure, brainstem dysfunction and radiographic evidence of hydrocephalus, periventricular lucency, and infarction. Ethnicity, stage of disease, headache, convulsions, motor function, brainstem dysfunction, and cerebral infarctions were independently associated with poor outcome in multivariate logistic regression analysis. CONCLUSIONS. Tuberculous meningitis starts with nonspecific symptoms and is often only diagnosed when brain damage has already occurred. Earlier diagnosis will improve outcome significantly. We were able to identify presenting variables independently associated with poor clinical outcome. Pediatrics 2009;123:e1–e8 T BILLION PEOPLE are infected with Mycobacterium tuberculosis, and each year 9 million people develop tuberculosis.1 Although the incidence of tuberculosis is increasing, prevalence and mortality rates are declining. Annually, 2 million people die as a result of this disease.2 Tuberculous meningitis (TBM) is the most severe complication of tuberculosis and frequently occurs in childhood. Lymphohematogenous spread from a primary pulmonary focus leads to the development of a Rich focus in the brain. Rupturing of this caseous granuloma into the subarachnoid space causes 3 features responsible for the clinical www.pediatrics.org/cgi/doi/10.1542/ peds.2008-1353 doi:10.1542/peds.2008-1353