Tuberculous Meningitis-Mimicking Varicella-Zoster Meningitis

Abstract

BackgroundVaricella-zoster virus (VZV) is one of the most common etiologies of aseptic meningitis. The severest manifestation of VZV meningitis is occasionally confused with tuberculous meningitis (TBM). Thus, we investigated the clinical manifestations of VZV meningitis as compared with those of TBM.Materials and MethodsAll adult patients who were diagnosed with VZV meningitis or TBM were enrolled at a tertiary hospital in Seoul, South Korea, during an 8-year period. The clinical characteristics and cerebrospinal fluid (CSF) profile of patients were analyzed.ResultsSeventy-nine patients with VZV meningitis and 24 patients with TBM were enrolled in this study. Of the 79 patients with VZV meningitis, 63 (80%) did not received empirical anti-tuberculous therapy (Group 1) and the remaining 16 (20%) received empirical anti-tuberculous therapy (Group 2), compared with 24 patients with TBM (Group 3). Altered mental status, intensive care unit (ICU) admission, neurologic sequelae, CSF protein levels, and CSF adenosine deaminase levels revealed a trend of being higher in Group 3 than Group 2, which was higher than Group 1. However, the CSF/serum glucose ratio was significantly lower in Group 3 than in Group 1 or Group 2.ConclusionAbout one fifth of VZV meningitis cases presented as severe manifestations, mimicking TBM. The CSF/serum glucose ratio might be useful to differentiate VZV meningitis from TBM until definite diagnostic tests are available. Physicians should keep in mind that a differential diagnosis between severe VZV meningitis and TBM is needed.

10-Year Retrospective Review of the Etiologies for Meningitis With Elevated Adenosine Deaminase in Cerebrospinal Fluid: Etiologies Other Than TB

“…Also, this evinces the possibility of the existence of a significant difference between the actual diagnosis and the clinician’s diagnosis based on the empirical belief that meningitis with lymphocyte-dominant pleocytosis and elevated CSF-ADA level is TBM. These results are consistent with a series of prior studies that have reported elevated ADA levels in patients with VM ( Cho et al., 2013 ; Ekermans et al., 2017 ; Hong et al., 2017 ). Hong et al.…”

“…reported a study that compared CSF-ADA levels of VZV meningitis, VZV meningitis previously misdiagnosed as true TBM. In that study, the ADA level of the misdiagnosed groups (range, 8.0–15.0 IU/L) overlapped with that of the true TBM group (range, 11.7–31.6 IU/L), while the proportion of lymphocytosis (median, 83% versus 60% in the misdiagnosis versus the true TBM group, respectively; p < 0.001) was the significant difference between the misdiagnosed and true TBM groups ( Hong et al., 2017 ). Clinicians should be aware that misdiagnosis and inappropriate treatment of meningitis can occur if they depend heavily on the ADA findings when patients are without etiology-specific symptoms or signs.…”

“…The secondary aim of this study was to compare the clinical and laboratory characteristics of the three most common diagnoses: considering that the clinical diagnosis could be biased, only the definitive diagnoses with microbiological evidence were compared. Moreover, the CSF characteristics of definite TBM, clinical TBM, and definite VM were compared, since each of these diseases can present with lymphocyte-dominant pleocytosis in the CSF and can mimic the clinical manifestations of the others ( Hong et al., 2017 ).…”

“…Nevertheless, CSF-ADA levels are frequently elevated in various meningitis forms caused by other infectious or non-infectious etiologies including malignancies ( López-Cortés et al., 1995 , Ekermans et al., 2017 ; Hong et al., 2017 ). Consequently, it is challenging for clinicians to decide to start anti-TB treatment in undetermined meningitis with elevated CSF-ADA, especially when meningitis patients in the areas with a high prevalence of TB show elevated CSF-ADA levels without any disease-specific symptoms or laboratory results.…”

Machine-Learning-Based Approach to Differential Diagnosis in Tuberculous and Viral Meningitis

“…Since the number of cases was not large enough, only a limited number of features known as useful characteristics for differentiating between TBM and VM were searched and included in the analysis because of the overfitting concern. Based on the previous studies, data on age [ 6 ], duration of illness from the appearance of symptoms and onset of signs to hospital visit [ 7 ], vomiting [ 7 ], neurologic symptoms and signs [ 6 ], serum sodium [ 6 ], CSF glucose [ 8 ], CSF protein[ 8 ], and CSF adenosine deaminase (ADA) [ 9 ] were collected as discriminative features for machine-learning. Neurologic symptoms and signs were defined according to one of the following symptoms or signs: lethargy, confusion, cranial nerve palsy, hemiparesis, delirium, stupor, coma, seizures, hemiplegia, or paraparesis [ 6 ].…”