Original ArticleCorrelation of Lactate Concentration in Peripheral Plasma and Cerebrospinal Fluid with Glasgow Outcome Scale for Patients with Tuberculous Meningitis Complicated by Acute Hydrocephalus Treated with Fluid Diversions
Introduction
Tuberculous meningitis (TBM) is a bacterial infection of Mycobacterium tuberculosis that affects the meningeal layers. TBM was first identified by Whytt at Edinburgh University in 1768 after analyzing 10 cases of hydrocephalus caused by M. tuberculosis infection.1 The incidence of tuberculosis (TB) cases in Indonesia has declined with improved health care, but it still ranks very high, tied with China as the second-most TB-infected population, after India. Approximately 528,000 new cases of M. tuberculosis infection were diagnosed in the 232 million people in Indonesia in 2007, which equals 244 new cases per 100,000 people. The number of fatalities in 2007 was 91,400, or 39 cases per 100,000 people.2, 3
Three processes of M. tuberculosis infection create neurologic deficits: formation of adhesions, vasculitis, and encephalitis or myelitis. Adhesions are formed from exudates in the basal portion of the meninges, which become solidified. Exudates are formed after inoculation by a bacilli-rich focus that erupts into the subarachnoid space. The formation of adhesions inhibits cerebrospinal fluid (CSF) flow and absorption, which causes hydrocephalus. M. tuberculosis attaches to the blood-brain barrier, which incites microvascular inflammation, and vasculitis results when M. tuberculosis attacks the endothelial lining of brain vasculature. This reaction causes ischemia, infarcts, and stroke syndromes, creating irreversible neurologic deficits.4
A marker of clinical severity in these patients is needed. This marker should be widespread and easily measured. Lactate levels in CSF were investigated for this role because an increase in lactate level is a more significant predictor than other conventional markers, such as CSF glucose, ratio between CSF and plasma glucose, CSF protein, and leukocyte count.5 Examination of lactate levels when performing CSF diversion is important to determine the severity of brain parenchyma damage caused by vasculitis, edema, and global ischemia resulting from the primary disease and hydrocephalus, which is a complication that causes anaerobic metabolism in glial cells. Comparison of plasma and CSF lactate levels is important to analyze their correlation to the clinical Glasgow Outcome Scale (GOS) score to determine success of treatment of acute hydrocephalus in patients with TBM.
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Materials and Methods
This study was a prospective cohort study of patients with TBM with acute hydrocephalus who underwent fluid diversions. We performed analytic correlations of levels of preoperative plasma lactate, CSF lactate, and GOS score after surgery to determine the effect of acute hydrocephalus in TBM on brain cell metabolism. Nova StatStrip Hospital Glucose Monitoring System (Nova Biomedical, Waltham, Massachusetts, USA) were used to measure lactate concentrations. The target population was patients with
Results
The largest group of patients in our sample were adults >18 years old (64.7%), followed by preschool children 3–5 years old (20.6%). There was a male predilection in the incidence of acute hydrocephalus in patients with TBM (58.8%) with a male-to-female ratio of 1:0.7. Other measured variables included time to CSF diversion, which was mostly 12 to <24 hours (38.2%) and 24 to <48 hours (26.5%). Another variable was Glasgow Coma Scale (GCS) score on presentation: 47.06% of patients arrived
Discussion
The age of our patients closely matched national data on TB epidemiology, with children (3–5 years old; 20.6%) mostly affected in a highly prevalent population and adults (>18 years old; 64.7%) mostly affected in populations with low TB prevalence. Age plays a major role in the pathophysiology of TBM.1, 4 TBM cases in children in developing countries, such as Indonesia, are exacerbated by poor nutrition, squalor, poverty, lack of health awareness, and poor health care infrastructure. Adult
Conclusions
Intraoperative CSF lactate when performing CSF diversion was higher than preoperative plasma lactate levels in patients with TBM and acute hydrocephalus, and these levels reached 1.5 times plasma lactate levels. An increase in preoperative plasma lactate levels in patients with TBM correlated with poorer outcome, as assessed using the GOS; this correlation also applied for increased CSF lactate levels.
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Cited by (6)
Characteristics and outcomes of pediatric tuberculous meningitis patients with complicated by hydrocephalus with or without tuberculoma at Regional Public Hospital Teluk Bintuni, West Papua, Indonesia
2020, Interdisciplinary Neurosurgery: Advanced Techniques and Case ManagementCitation Excerpt :Our result is similar with another study showing only 3.8% of 50 patients with TBM is positive with acid fast bacilli in their CSF [6]. In spite of CSF smear or CSF culture, the more simple examination such as measurement of plasma lactate level as routine examination in determining cellular damage in pediatric TBM patients need to be consider, which been proofed as predictor for poorer outcome [10]. Head CT scan on our patients showed the characteristics such as basal enhancement, tuberculomas and infarcts.
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Conflict of interest statement: This study was supported by Grants-in-Aid from the Ministry of Research, Technology and Higher Education of the Republic of Indonesia No. 30/E/KPT/2017 (PUPT) to A.F. and from the Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia (ALG 1-1-6) to H.M.N.