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Meningite tuberculosa : caracterização de uma coorte de doentes e revisão de terapêuticas futuras
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Resumo(s)
A meningite tuberculosa é a forma mais severa de tuberculose, correspondendo a 1-5% dos casos e apresentando uma mortalidade até 30%. O diagnóstico de meningite tuberculosa é frequentemente atrasado pela reduzida performance ou disponibilidade limitada das técnicas laboratoriais. O tratamento é baseado na terapêutica da tuberculose pulmonar, o que resulta em níveis farmacológicos subótimos no LCR, com impacto clínico ainda pouco claro. O papel de novos regimes está a ser explorado em ensaios clínicos. O objetivo primário do estudo foi realizar uma caracterização demográfica e clínica dos doentes com meningite tuberculosa internados no Hospital Fernando da Fonseca, bem como uma descrição das técnicas diagnósticas e terapêuticas aplicadas. O objetivo secundário foi avaliar o prognóstico destes doentes. Este trabalho consistiu num estudo observacional analítico longitudinal retrospetivo e não interventivo, realizado através da revisão dos processos clínicos de adultos diagnosticados com meningite tuberculosa entre 1 de janeiro de 2012 a 31 de dezembro de 2022. Foram incluídos doentes com confirmação laboratorial por PCR ou cultura do LCR positiva para Mycobacterium tuberculosis. Foram diagnosticados 22 doentes com meningite tuberculosa. Destes, 64% eram homens e 50% eram de nacionalidade portuguesa. A mediana de idades foi 53,5 anos. Apenas 14% dos doentes apresentava infeção VIH e 23% imunossupressão. O tempo até ao diagnóstico foi, em média, 6,4 dias. Em 64% dos doentes foi realizado o diagnóstico de tuberculose disseminada. A taxa de sequelas ligeiras foi de 14%, não tendo havido nenhum doente a permanecer com incapacidade nas atividades de vida diária. A taxa de mortalidade foi cerca de 46%, tendo a hidrocefalia sido a causa de morte mais frequente. A presença de fatores como idade mais avançada, diabetes mellitus, hidrocefalia, PCR e/ou cultura positiva e resistência antibiótica inicial associaram-se a pior prognóstico.
Tuberculous meningitis is the most severe form of tuberculosis, accounting for 1- 5% of cases and presenting a mortality rate of up to 30%. The diagnosis of tuberculous meningitis is often delayed by poor performance or limited availability of laboratory techniques. Treatment is based on pulmonary tuberculosis therapy, resulting in suboptimal pharmacological levels in the CSF, with a still unclear clinical impact. The role of new regimens is being explored in clinical trials. The primary objective of the study was to perform a demographic and clinical characterization of patients with tuberculous meningitis admitted to Hospital Fernando da Fonseca, as well as a description of the diagnostic and therapeutic techniques applied. The secondary objective was to assess the prognosis of these patients. This work consists of a retrospective, non-interventional, longitudinal analytical observational study, carried out through the review of clinical files of adults diagnosed with tuberculous meningitis between 1st January 2012 and 31st December 2022. Patients with laboratory confirmation by PCR or CSF culture positive for Mycobacterium tuberculosis were included. Twenty-two patients were diagnosed with tuberculous meningitis; of these, 64% were male and 50% were of Portuguese nationality. Median age was 53.5 years. Only 14% of the patients had HIV infection and 23% were immunosuppressed. The average time to diagnosis was 6.4 days. A diagnosis of disseminated tuberculosis was made in 64% of the patients. The rate of mild sequelae was 14%, and no patient remained with disability in the activities of daily living. The mortality rate was around 46%, hydrocephalus being the most frequent cause of death. The presence of factors such as older age, diabetes mellitus, hydrocephalus, positive PCR and/or culture and initial antibiotic resistance were associated with worse prognosis.
Tuberculous meningitis is the most severe form of tuberculosis, accounting for 1- 5% of cases and presenting a mortality rate of up to 30%. The diagnosis of tuberculous meningitis is often delayed by poor performance or limited availability of laboratory techniques. Treatment is based on pulmonary tuberculosis therapy, resulting in suboptimal pharmacological levels in the CSF, with a still unclear clinical impact. The role of new regimens is being explored in clinical trials. The primary objective of the study was to perform a demographic and clinical characterization of patients with tuberculous meningitis admitted to Hospital Fernando da Fonseca, as well as a description of the diagnostic and therapeutic techniques applied. The secondary objective was to assess the prognosis of these patients. This work consists of a retrospective, non-interventional, longitudinal analytical observational study, carried out through the review of clinical files of adults diagnosed with tuberculous meningitis between 1st January 2012 and 31st December 2022. Patients with laboratory confirmation by PCR or CSF culture positive for Mycobacterium tuberculosis were included. Twenty-two patients were diagnosed with tuberculous meningitis; of these, 64% were male and 50% were of Portuguese nationality. Median age was 53.5 years. Only 14% of the patients had HIV infection and 23% were immunosuppressed. The average time to diagnosis was 6.4 days. A diagnosis of disseminated tuberculosis was made in 64% of the patients. The rate of mild sequelae was 14%, and no patient remained with disability in the activities of daily living. The mortality rate was around 46%, hydrocephalus being the most frequent cause of death. The presence of factors such as older age, diabetes mellitus, hydrocephalus, positive PCR and/or culture and initial antibiotic resistance were associated with worse prognosis.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2023
Palavras-chave
Meningite Tuberculose Terapêutica Prognóstico Complicações Doenças transmissíveis