AUCTORES
Globalize your Research
Research Article
*Corresponding Author: Ildefonso Rodriguez-Leyva, Neurology Service, Hospital Central
Citation: Katia Mabiael MC, Rodolfo Manuel RG, Ortiz-A. Arturo, Hector Gerardo HR, Rodriguez-L. Ildefonso, (2024), Clinical and Radiological Characteristics of Tuberculous Meningitis in the Central Hospital "Dr. Ignacio Morones Prieto," a Public Institution in Mexico, J. Neuroscience and Neurological Surgery, 14(9); DOI:10.31579/2578-8868/345
Copyright: ©, 2024, Ildefonso Rodriguez-Leyva. This is an open-access article distributed under the terms of The Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Received: 30 October 2024 | Accepted: 08 November 2024 | Published: 18 November 2024
Keywords: tuberculous meningitis; meningitis; mycobacterium tuberculosis
Background: Tuberculosis (TB) manifests as tuberculous meningitis (TBM) in up to 5% of extrapulmonary cases, causing significant morbidity and mortality. In Mexico, the prevalence is 0.35 cases per 100,000. Diagnosis is challenging due to the gradual onset and low TB levels in CSF. Mortality is around 20%, higher in HIV patients.
Material and Methods: A cross-sectional, retrospective, descriptive study was performed with patients treated at the Central Hospital "Dr. Ignacio Morones Prieto" who were diagnosed with TBM from 2018 to 2023. Patient records that met the following criteria were included: a) age over 18 years, b) any gender, c) confirmed diagnosis of TBM through staining, bacteriological culture, molecular studies, or biopsy, and d) brain imaging study using CT or MRI.
Results: Thirty-three patient files were evaluated. GeneXpert PCR, which was positive (only) in 17 of the cases (51.5%), culture (Lowenstein-Jensen) positive (only) in 6 patients (18.2%), cranial meninges biopsy (only) in 2 of the cases (6.1%) and bacilloscopic study in 1 patient (3.0%). Two positive results (GeneXpert and culture) were obtained in 7 patients (21.2%). There was a statistically significant correlation for mortality in those patients who presented stupor (100%) vs. those who did not present drowsiness only (33.0%) or remained awake (0%) (p<0.001). On the other hand, the statistically significant correlation between the presentation of cerebral edema and mortality was very striking since 93.8% of the patients who did not present edema survived, and 100% of those who presented edema died (p=0.001). Lumbar puncture findings included pleocytosis, hypoglycorrhachia (<30 mg/dL), and elevated protein (0.2 to 5 g/dL). Severe hypoglycorrhachia (<25 mg/dL) was associated with hydrocephalus and altered consciousness.
Conclusions: This study provides a clinical and demographic overview of TBM in San Luis Potosí, Mexico, highlighting the need for more comprehensive data collection and larger sample sizes to better characterize the disease.
Tuberculosis, caused by Mycobacterium tuberculosis, manifests as tuberculous meningitis (TBM) in up to 5% of extrapulmonary cases[1]. The prevalence of TBM varies between 1% and 10%, depending on the country of study[2]. It is a significant cause of morbidity and mortality, with neurological sequelae and complications occurring in up to 50% of patients[1]. In Mexico, the prevalence is 0.35 cases per 100,000 inhabitants, according to a 2017 study conducted in Tijuana—one of the few demographic studies on meningeal tuberculosis in the country. The study concluded that TBM's clinical, imaging, and laboratory characteristics in Mexico are similar to those observed globally[3].
The risk of developing central nervous system (CNS) tuberculosis is higher in children and adults with human immunodeficiency virus (HIV) infection and other causes of immunosuppression, such as chronic steroid use or treatment with tumor necrosis factor-alpha (TNF-α) inhibitors[4].
Following inhalation of M. tuberculosis, an inflammatory reaction occurs, leading to the formation of a granuloma. This structure encapsulates the infected cells, slowing the bacilli replication and resulting in a latent infection. This immune response can progress to active primary tuberculosis in immunosuppressed patients, causing the bacilli to disseminate to other systems through lymphatic and blood routes. Once Mycobacterium tuberculosis enters the central nervous system, the limited innate immunity in this environment permits the bacillus to survive and replicate, resulting in latent tuberculous lesions. Known as Rich foci, these lesions are primarily located beneath the subcortical pia and adjacent to the ventricular system. When these lesions rupture, M. tuberculosis bacilli are released into the subarachnoid space, leading to granulomatous infection of the meninges and subsequent inflammation[5]. In the brain, microglial cells become infected and, along with infiltrating cells, produce inflammatory chemoattractants that damage the blood-brain barrier (BBB). This damage facilitates the penetration of innate immune system cells and specific B and T lymphocytes.[6]
The clinical presentation includes a prodromal period with nonspecific symptoms such as fatigue, malaise, myalgia, and fever. TBM consists of a subacute to a chronic process characterized by headache, fever, vomiting, photophobia, and nuchal rigidity, typically progressing slowly[6,7]. Among the main complications are cranial neuropathies, which occur in 25-50% of patients, primarily affecting cranial nerves VI and III[8]. Inflammatory infiltration in the subarachnoid space or ventricular system disrupts cerebrospinal fluid (CSF) flow, producing hydrocephalus, particularly of the communicating type[9]. Other causes of intracranial hypertension include encephalitis and obliterative vasculitis, which lead to cytotoxic and vasogenic edema[7]. Hyponatremia, due to cerebral salt-wasting or the syndrome of inappropriate antidiuretic hormone secretion (SIADH), is present in 40-50% of cases[10]. Another complication of TB infection in the CNS is the formation of tuberculomas. Tuberculomas may occur with or without TBM, presenting symptoms such as epileptic seizures, focal neurological deficits, or intracranial hypertension[11]. Cerebral infarction occurs in 15-57% of patients with TBM, predominantly affecting deep gray matter structures such as the caudate nucleus, anterior thalamus, genu, and anterior limb of the internal capsule. The mechanism of infarction involves vasculitis with direct inflammatory involvement from the meningitis[12]. Epileptic seizures occur in up to 34% of patients[13]. Other central nervous system manifestations include tuberculous abscesses, tuberculous spondylitis, and intradural spinal tuberculosis[4].
Diagnosing TBM is more challenging compared to other forms of bacterial meningitis. This difficulty arises partly because the symptoms usually develop more gradually than those of classic bacterial meningitis. TB leads to a paucibacillary infection that is hard to detect in the CSF. When detecting M. tuberculosis in CSF is not feasible, a presumptive diagnosis of TBM is often made based on a combination of clinical presentation and CSF findings.[14] Cerebrospinal fluid findings include pleocytosis (50 to 500 cells per microliter, with 50% or more being lymphocytes), increased protein levels (up to 1000 mg/L), and low glucose levels (<40>
Microbiological diagnostic methods include Ziehl-Neelsen staining of cerebrospinal fluid, a rapid and readily available technique, but its sensitivity varies between 10% and 20%. Mycobacterial cultures are currently the gold standard for diagnosis, with a sensitivity of up to 70%, although mycobacterial growth is slow and takes more than two weeks[16]. Detection of M. tuberculosis DNA is possible with molecular biology techniques such as GeneXpert MTB/RIF and GeneXpert MTB/RIF Ultra, which offer similar sensitivity to bacteriological culture but produce results more quickly. However, up to 50% of cases may lack bacteriological confirmation[14,17]. Adenosine deaminase determination has also been used as a marker of the disease, as its levels in cerebrospinal fluid are elevated in patients with the infection. However, false positives are common in patients with HIV infection[17]. Next-generation metagenomic sequencing is a recently developed technique with a sensitivity of 70% for detecting meningeal tuberculosis[18].
The most common radiological findings in tuberculosis meningitis are meningeal enhancement, tuberculomas, and hydrocephalus[19]. More extensive findings correlate with more significant clinical complications and cerebrospinal fluid abnormalities. Approximately 75% of patients present with hydrocephalus, 38% with basal meningeal enhancement, and 15-26% with cerebral infarcts4. The most sensitive feature is basal enhancement on CT or MRI with contrast. Advanced techniques like magnetization transfer imaging are also used. Basal enhancement is more common in HIV patients and advanced disease stages[20]. Hydrocephalus, usually communicating, is linked to basal exudates, tuberculomas, infarcts, and cranial nerve palsies and is the primary cause of intracranial hypertension in these patients[9].
In TBM, strokes are frequent and primarily affect the perforating and cortical branches[21]. It has been reported that up to 75% of cerebral infarctions occur in areas supplied by the lenticulostriate and thalamic-perforating arteries, with a smaller proportion in regions supplied by the lateral lenticulostriate, anterior choroidal, and thalamogeniculate arteries. However, findings vary across different studies, with some reporting different percentages and including other vascular territories, such as the cortical branches[22]. The pathogenesis is related to vasospasm in the early stages and an inflammatory reaction in the lumen of blood vessels, known as tuberculous vasculitis, in the later stages [23,24].
Treatment of tuberculosis involves a two-month intensive phase with isoniazid, rifampicin, ethambutol or streptomycin, and pyrazinamide, followed by a maintenance phase with rifampicin and isoniazid. Regimens last 6 to 9 months, but individualized management is recommended due to similar mortality rates. Intravenous or high-dose rifampicin with fluoroquinolones has not improved outcomes over standard therapy. Management is more complex with drug-resistant TB. For isoniazid resistance, levofloxacin and higher doses of rifampicin are suggested[25]. Second-line drugs include ethionamide, cycloserine, and linezolid[26]. Corticosteroids, like dexamethasone, are recommended to reduce brain and vessel inflammation, intracranial pressure, and mortality risk[27]. A Cochrane meta-analysis found reduced mortality but no impact on turning off neurological deficits[28].
Ventriculoperitoneal shunts and endoscopic ventriculostomies manage complications such as hydrocephalus. Intracranial hypertension may require mannitol or hypertonic solutions. Antiepileptic drugs treat symptomatic epileptic seizures. The treatment of hyponatremia depends on its cause: either a salt-losing brain or SIADH. Despite no therapeutic consensus, antiplatelet drugs are used for cerebral vasculitis and infarcts[29].
Approximately 20% of meningeal tuberculosis patients die, with higher risks in those over 18 and those co-infected with HIV[30].
A cross-sectional, retrospective, descriptive study was performed with patients treated at the Central Hospital "Dr. Ignacio Morones Prieto" who were diagnosed with TBM from 2018 to 2023. The study was approved by the Research Committee (COFEPRIS Registration Number 17 CI 24 028 093) and the Research Ethics Committee of the Central Hospital "Dr. Ignacio Morones Prieto" (Registration Number CONBIOETICA-24-CEI-001-20160427) with Registration Number 45-23.
Patient records that met the following criteria were included: a) age over 18 years, b) any gender, c) confirmed diagnosis of TBM through staining, bacteriological culture, molecular studies, or biopsy, and d) brain imaging study using computed tomography (CT) or magnetic resonance imaging (MRI). Exclusion criteria were: a) records that met the inclusion criteria, b) lack of a confirmatory study of the infection, and c) lack of a brain imaging study.
Statistical analyses were performed using IBM SPSS Statistics V.25 for Mac. The arithmetic mean, median (measures of central tendency), standard deviation, minimum, and maximum (measures of dispersion) were used for quantitative variables. For qualitative variables, relative frequency (percentages) and absolute frequency were used. Chi-square (X2) was used for qualitative variables. The student’s T-test (in cases of normal distribution) or Wilcoxon signed-rank test (in cases of abnormal distribution) was used for quantitative variables. A 95% confidence b) interval was determined, with a p-value less than or equal to 0.05 in two directions for statistically significant values.
The records of CSF samples sent for M. tuberculosis detection were obtained from the Epidemiology area of the hospital, with 147 suspected patients. Subsequently, the results were corroborated, obtaining 38 patients with a positive test for tuberculosis; 5 were discarded because they did not have a clinical record. Of the rest of the patients, 107 had a negative result, and 2 had a diagnosis of tuberculous meningitis due to cerebrospinal fluid findings and clinical correlation; however, they did not have a confirmatory test. Thirty-three patient files were evaluated (see Figure 1). Population characteristics are shown in table 1.
Figure 1: Patient selection
| Table 1. Population characteristics | Total (n = 33) |
Sex Male Female Age group, n (%) 21-30 31-40 41-50 51-60 61-70 71-80 81-90 |
23 (69.7%) 10 (30.3%)
10 (30.3%) 11 (33.3%) 8 (24.2%) 0 3 (9.1%) 0 1 (3.1%) |
The associated comorbidities in order of frequency were as follows: alcoholism 17 (51.5%), smoking 16 (48.5%), drug addiction 8 (24.2%), pulmonary tuberculosis 7 (21.2%), type 2 diabetes mellitus 6 (18.2%) and HIV 11 (33.3%). As for drug use, the most frequently used drugs were, in order of frequency: crystal meth, marijuana, and cocaine (see Table 2).
| Table 2. Associated comorbidities | Total (n = 33) |
Alcoholism Smoking Drug abuse
Pulmonary tuberculosis Diabetes mellitus type 2 HIV | 17 (51.5%) 16 (48.5%) 8 (24.2%)
7 (21.2%) 6 (18.2%) 11 (33.3%) |
Among the clinical manifestations, the frequency corresponded to the following: 21 patients presented headache (63.6%), 17 presented altered state of consciousness (51.5%), of which 15 corresponded to drowsiness (45.5%) and 2 to stupor (6.1%); fever was present in 17 patients (51.5%), nausea or vomiting (or both) in 10 patients (30.3%), epileptic seizures in 10 patients (30.3%).1%); fever was present in 17 patients (51.5%), nausea and vomiting in 10 patients (30.3%), epileptic seizures in 10 patients (30.3%), of which three patients presented focal status epilepticus, focal deficit in 3 patients (9.1%), nuchal rigidity in 2 patients (6.1%). Cranial nerve palsy was present in only one patient (3%), III cranial nerve palsy. General symptoms, such as asthenia, fatigue, and weight loss, were found in 12 patients (36.4%), and delirium was documented in 6 patients (18.1%), of which four were hyperactive (12.1%), and two were hypoactive (6.1%) ( see Table 3).
| Table 3. Clinical manifestations | Total (n = 33) |
Headache Fever Altered state of consciousness Drowsiness Stupor Coma Nausea or vomiting Epileptic seizures Focal deficit Nuchal rigidity Cranial nerve palsies General symptoms Delirium Hyperactive Hypoactive | 21 (63.6%) 17 (51.5%) 17 (51.5%) 15 (45.5%) 2 (6.1%) 0 10 (30.3%) 10 (30.3%) 3 (9.1%) 2 (6.1%) 1 (3%) 12 (36.4%) 6 (18.1%) 4 (12.1%) 2 (6.1%) |
The imaging studies reviewed were computed tomography of the brain, performed in 28 patients. CT was performed in 28 patients (84.8%), and MRI was performed only in 12 patients (36.4%). Of the diagnostic methods required for inclusion in the study, the following were included: GeneXpert PCR, which was positive (only) in 17 of the cases (51.5%), culture (Lowenstein-Jensen) positive (only) in 6 patients (18.2%), cranial meninges biopsy (only) in 2 of the cases (6.1%) and bacilloscopic study in 1 patient (3.0%). Two positive results (GeneXpert and culture) were obtained in 7 patients (21.2%) (Table 4).
| Table 4: Paraclinical studies | Total (n = 33) |
Imaging studies Computed tomography of the brain Magnetic resonance imaging of the brain Microbiological studies GeneXpert Culture Biopsy Bacilloscopy GeneXpert/Culture |
28 (84.8%) 12 (36.4%)
17 (51.5%) 6 (18.2%) 2 (6.1%) 1 (3.3%) 7 (21.2%) |
The findings on imaging studies, in order of frequency, were as follows: tuberculoma or microabscesses in 9 patients (27.3%), hydrocephalus in 8 patients (24.2%), meningeal enhancement in 8 patients (24.2%), vasculitis in 6 patients (18.2%), ischemia in 5 patients (15.2%), and cerebral edema in 1 case (3.0%) (Table 5).
| Table 5. Radiological findings | Total (n = 33) |
Tuberculoma/micro abscess Hydrocephalus Meningeal enhancement Vasculitis Ischemia Cerebral edema | 9 (27.3%) 8 (24.2%) 8 (24.2%) 6 (18.2%) 5 (15.2%) 1 (3.3% |
In the secondary analysis, the Fisher exact Test was applied to establish the correlation between the patient's pre-existing conditions and the presentation of death (see Table 6). Similarly, using the Fisher exact Test (for variables with more than two items, Chi-squared was used), the clinical complications presented by the patients and their association with fatal outcomes were analyzed (See Table 7).
Table 6: Correlation of Pre-existing Conditions and Mortality A 2X2 table with percentages per row is presented. | ||||
FEATURES
|
n | NOT DEATH n (%) | DEATH n (%) |
p |
GENRE Male Woman |
23 10 |
20 (87.0%) 10 (100%) |
3 (13.0%) 0 (0%) |
0.536 |
DM2 NO YES |
27 6 |
24 (88.9%) 6 (100%) |
3 (11.1%) 0 (0%) |
1.000 |
HIV NO YES |
22 11 |
21 (95.5%) 9 (81.%8) |
1 (4.5%) 2 (18.2%) |
0.252 |
Pulmonary Tuberculosis NO YES |
26 7 |
23 (88.5%) 7 (100%) |
3 (11.5%) 0 (0.0%) |
1.00 |
Alcoholism NO YES |
16 17 |
15 (93.8%) 15 (88.2%) |
1 (6.2%) 2 (11.8%) |
1.00 |
Smoking NO YES |
17 16 |
16 (94.1%) 14 (87.5%) |
1 (5.9%) 2 (12.5%) |
0.601 |
Polydrug addictions NO YES |
25 8 |
22 (88.0%) 8 (100%) |
3 (12%) 0 (0%) |
0.560 |
Table 7: Correlation of clinical complications and mortality. A 2X2 table with percentages per row is presented. | |||||
FEATURE
|
n | NOT DEATH n (%) | DEATH n (%) |
p | |
Alterations in awake state NO YES |
16 17 |
16 (100%) 14 (82.4%) |
0 (0%) 3 (17.6%) |
0.227 | |
Nuchal Rigidity NO YES |
31 2 |
29 (93.5%) 1 (50%) |
2 (6.5%) 1 (50%) |
0.176 | |
Focal deficit NO YES |
30 3 |
28 (93.3%) 2 (66.7%) |
2 (6.7%) 1 (33.3%) |
0.256 | |
State of consciousness* Awake Drowsiness Stupor |
16 15 2 |
16 (100%) 14 (93.3%) 0 (0%) |
0 (0%) 1 (33.3%) 2 (100%) |
<0> | |
Delirium* No Delirium Hypoactive Hyperactive |
27 2 4 |
24 (88.9%) 2 (100%) 4 (100%) |
3 (11.1%) 0 (0%) 0 (0%) |
0.693 | |
Epileptic seizures NO YES |
23 10 |
22 (95.7%) 8 (80.0%) |
1 (4.3%) 2 (20%) |
0.212 | |
Hydrocephalus NO YES |
25 8 |
24 (96.0%) 6 (75.0%) |
1 (4.0%) 2 (25.0%) |
0.139 | |
Cerebral Edema NO YES |
32 1 |
30 (93.8%) 0 (0%) |
2 (6.3%) 1 (100%) |
0.091 | |
Tuberculomas NO YES |
24 9 |
23 (95.8%) 7 (77.8%) |
1 (4.2%) 2 (22.2%) |
0.174 | |
Vasculitis NO YES |
27 6 |
25 (92.6%) 5 (83.3%) |
2 (7.4%) 1 (16.7%) |
0.464 | |
Ischemia NO YES |
28 5 |
26 (92.9%) 4 (80.0%) |
2 (7.1%) 1 (20.0%) |
0.400 | |
*Chi-squared was applied due to more than two items.
There was a statistically significant correlation for mortality in those patients who presented stupor (100%) vs. those who did not present drowsiness only (33.0%) or remained awake (0%) (p<0 p=0.001).>
During data collection, it was decided to capture the values of the first lumbar puncture performed on the first day of admission to the emergency room. However, only 27 patients were found to be analyzed in this item. The data collected are shown in Table 8. Because of a lack of information, only 24 cases were counted with protein information and only 25 with glucose levels.
| Table 8. CSF findings | Total (n = 27) (%) |
Leukocytes (range) (mm3 /ml) 10-100 100-300 300-500 >500 Mononuclear (range) (%) 10-50 50-100 Protein (range) (g/dL) 0-100 101-200 201-300 301-400 401-500 >500 Pandy + Glucose (range) (mg/dL) 0-10 11-20 21-30 31-40 41-50 >50 |
15 (55.5%) 9 (33.3%) 2 (5.4%) 1 (2.7%)
4 (14.8%) 23 (85.1%)
2 (7.4%) 7 (25.9%) 8 (29.6%) 2 (7.4%) 1 (2.7%) 4 (5.4%) 3 (11.1%)
3 (11.1%) 5 (18.5%) 11 (40.7%) 3 (11.1%) 1 (2.7%) 4 (5.4%) |
The Kolmogorov-Smirnov test assessed whether the CSF parameter results followed a normal distribution. The test indicated that the absolute leukocyte count (p=0.00), percentage of mononuclear cells (p=0.000), protein levels (p=0.000), and glucose levels (p=0.001) all exhibited a non-normal distribution. Based on this finding, the Mann-Whitney U test for independent samples was then utilized to analyze the association between these CSF parameters and specific clinical complications, including altered wakefulness, nuchal rigidity, focal deficits, epileptic seizures, hydrocephalus, cerebral edema, tuberculomas, vasculitis, and ischemia. Altered wakefulness and the development of hydrocephalus showed a significant correlation with low glucose levels (see Figures 2a and 2b). No significant correlation was found between CSF features and nuchal rigidity, focal deficits, epileptic seizures, cerebral edema, tuberculomas, vasculitis, or ischemia.
Therefore, taking these results into account, the decision was made to add a univariate analysis with a CSF glucose cutoff point ≤25 mg/dl (such cutoff comes out of the mean glucose associated with hydrocephalus <17> + 1 standard deviation <8>) to analyze its correlation with the different clinical complications, Fisher exact Test was applied, and the results of this are shown in Table 9.
Table 9: Correlation of clinical complications and CSF glucose level ≤25 mg/dl. A 2X2 table with percentages per row is presented. | ||||
FEATURE
|
n | Glucose >25 mg/dl n (%) | Glucose ≤25 mg/dl n (%) |
p |
Altered wakefulness NO YES |
12 13 |
9 (75%) 3 (23.1%) |
3 (25.0%) 10 (76.9%) |
0.017 |
Headache NO YES |
6 19 |
5 (83.3%) 7 (36.8%) |
1 (16.7%) 12 (63.2%) |
0.073 |
Fever NO YES |
11 14 |
8 (72.7%) 4 (28.6%) |
3 (27.3%) 10 (71.4%) |
0.047 |
Nuchal Rigidity NO YES |
23 2 |
12 (52.1%) 0 (0%) |
11 (47.8%) 2 (100%) |
0.480 |
Focal deficit NO YES |
23 2 |
11 (47.8%) 1 (50.0%) |
12 (52.2%) 1 (50.0%) |
1.00 |
State of consciousness* Awake Drowsiness Stupor |
12 11 2 |
9 (75.0%) 2 (18.2%) 1 (50.0%) |
3 (25.0%) 9 (81.8%) 1 (50.5%) |
0.024 |
Delirium* No Delirium Hypoactive Hyperactive |
21 1 3 |
11 (52.4%) 0 (0%) 1 (33.3%) |
10 (47.6%) 1 (100%) 2 (66.7%) |
0.511 |
Epileptic seizures NO YES |
17 8 |
8 (47.1%) 4 (50.0%) |
9 (52.9%) 4 (50%) |
1.000 |
Hydrocephaly NO YES |
18 7 |
12 (66.7%) 0 (0%) |
6 (33.3%) 7 (100%) |
0.005 |
Cerebral Edema NO YES |
24 1 |
12 (50.0%) 0 (0%) |
12(50.0%) 1 (100%) |
1.000 |
Tuberculomas NO SI |
18 7 |
9 (50.0%) 3 (42.9%) |
9 (50.0%) 4 (57.1%) |
1.000 |
Vasculitis NO YES |
19 6 |
11 (57.9%) 5 (16.7%) |
8 (42.1%) 5 (83.3%) |
0.160 |
Ischemia NO YES |
21 4 |
11 (52.4%) 1 (25.0%) |
10 (47.6%) 3 (75.0%) |
0.593 |
*Chi-squared was applied due to more than two items.
TBM represents 5-10% of extrapulmonary tuberculosis cases globally [31], aligning with its rarity but severe prognosis. The study by Garcia-Grimshaw et al. (2019) in Tijuana reported a young demographic, with 63.4% of male cases primarily between 18 and 40 years old [3]. In contrast, our study finds an older mean age, 31 to 47 years, which may reflect regional differences or a variation in risk factors, such as comorbidities.
Our study and other reports found that headache, fever, and altered consciousness were typical symptoms of TBM, reaffirming their central role in TBM presentations [32]. What sets our study apart is the unique finding of a higher prevalence of seizures, which could be an indicator of more advanced or cerebral-complicated cases. This observation aligns with findings suggesting that neurologic sequelae, like seizures, may be prevalent in advanced disease stages. The common comorbidities in our sample, such as alcoholism, type 2 diabetes, and HIV, are also recognized as risk factors that compromise immune response, potentially exacerbating TBM susceptibility [33]. These unique findings provide a deeper understanding of TBM and its clinical implications.
The association of stupor with higher mortality rates found in our research may underscore the role of early mental status changes as a predictive indicator for outcomes in TBM.
Meningeal enhancement and hydrocephalus were radiologically prevalent, consistent with TBM’s classic presentation in imaging [31]. Our finding of cerebral edema as a predictor of mortality aligns with the literature, noting that brain swelling complicates outcomes in TBM due to increased intracranial pressure. Additionally, the high frequency of tuberculomas or microabscesses in our sample suggests a progressive form of TBM that may require aggressive treatment approaches.
Like many others, our study acknowledges the challenges of TBM diagnosis and treatment. GeneXpert, despite its sensitivity challenges, has significantly improved TBM detection rates, particularly in resource-limited settings [31]. Our study's observed mortality rate of 9.1%, notably lower than that of other studies, could reflect differences in early diagnosis, access to care, or treatment protocols [32]. Acknowledging the challenges and the potential for improvement in TBM diagnosis and treatment is crucial for advancing patient care.
Consistent with other studies, cerebrospinal fluid findings in our sample showed pleocytosis, hypoglycorrhachia, and elevated protein levels. Severe hypoglycorrhachia (under 25 mg/dL), associated with hydrocephalus and altered consciousness in our data, highlights the importance of monitoring glucose levels as a marker of disease severity in TBM. Hypoglycorrhachia correlates with poor outcomes, as lower CSF glucose often indicates a more aggressive inflammatory response, which may be linked to increased mortality risks.
Limitations:
Perspectives:
This study collected the most frequent clinical and radiological findings in the Central Hospital "Dr. Ignacio Morones Prieto population," providing a demographic and clinical overview of the epidemiological state in San Luis Potosí, Mexico. The data aim to improve prompt disease identification in our unit and the region. More analytical studies, comprehensive data collection, and larger sample sizes are necessary for better disease characterization.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
