| Objective: To analyze the clinical features of tuberculous meningitis(TBM)in children,including the evolution of cerebrospinal fluid(CSF).To investgate the presentation,predictors and impact on prognosis of paradoxical reaction(PR)in tuberculous meningitis.To assess the predictive factors of short term and long term prognosis of TBM in children.Methods: The clinical and follow up data of TBM in 88 children who were admitted to the Department of Pediatrics of Affiliated Hospital of Zunyi Medical University between January 2013 to October 2019 were retrospectively analyzed.The clinical characteristics of TBM were summarized,and the evolution of CSF was analyzed by one way anova.The children were divided into PR group and non PR group.predictive factors of PR selected by univariate analysis were entered into multivariate logistic regression model for screening independent risk factors.To evaluate the inpact of PR on long term prognosis of TBM.Impact of PR on cumulative survival rate was analyzed by Kaplan Meier.Patients were divided into the good prognosis group and poor prognosis group.Influencing factors of short term and long term prognosis selected by univariate analysis were entered into multivariate logistic regression model for screening independent risk factors.Results: 1.Clinical characteristics(1)88 children with TBM were included in this study,with the mean age was 8.27±6.15 years,48 boys and 40 girls,and acute and subacute onset accounted for 80.7%(71/88).The common symptoms and signs were fever(73/88,83.0%),headache(50/88,56.8%),disturbance of consciousness(37/88,42.0%),meningeal stimulation(82/88,93.2%),paralysis(29/88,33.0%)and cranial nerve palsy(31/88,35.2%).Staging I and II accounted for 36.4%(32cases)andstaging III for 27.3%(24 cases).(2)There were 60 cases(68.2%)the first CSF examination showed a typical change,and another 23 cases(26.1%)showed a typical change after the second CSF examination within 2 weeks.There were 40 children(45.5%)who completed the CSF examination at admission and 1,2 and 3 weeks after treatment.One way analysis of variance showed that the average white blood cell count began to decrease after 2 weeks of treatment and continued to decrease after 3 weeks,but there was no significant difference between the four time points.The protein level showed slowly decreasing trend,and decreased from admission 1.86g/L to 1.15g/L after 3 weeks(P<0.05).Glucose concentration showed continuously rising trend,and rose to normal after 2 weeks.There was a significant difference between 2 weeks and 3 weeks after admission(all P<0.05).(3)Neuroimaging showed that 86 cases(97.7%)were abnormal,which the common features were hydrocephalus(46/88,52.3%),basal meningeal enhancement(23/88,26.1%),cerebral tuberculoma(22/88,25%),and cerebral infarction(19/88,21.6%).2.The clinical characteristics,risk factors and impact on prognosis of paradoxical reactions(1)The incidence rate of PR was 35.2%(31/88),and it developed in 33(21–180)days of the median time of antit uberculosis treatment,presenting with aggravation or recurrence of previous symptoms(22/31,71.0%),deterioration of CSF(25/31,86.6%)and deterioration of brain imaging(16/31,51.6%).(2)Multivariate analysis showed that limb paralysis(OR=5.13,95%CI: 1.47–17.91),positive SPOT test for T lymphocytes of tuberculosis infection(T SPOT.TB)(OR=4.67,95% CI: 1.07–20.38),and elevated lactic dehydrogenase(LDH)level in CSF >60U/L(OR=10.38,95% CI: 1.74–62.04)were independent risk factors for PR(all P<0.05).(3)Development of PR was not associated with prognosis or cumulative survival rate(all P<0.05).3.Risk factors of short term and long term prognosis for tuberculous meningitis(1)Univariate analysis showed that short term prognosis was associated with younger age,stage II,stage III,convulsion,significantly increased CSF LDH level and hydrocephalus(all P<0.05).Multivariate analysis showed that stage III(OR=47.44,95%CI: 4.54–495.83)and overtly increased CSF LDH levels(OR=1.01,95%CI:1.00–1.02)were independent risk factors of poor short term prognosis(all P<0.05).(2)Univariate analysis showed long term prognosis was associated with stage III,limb paralysis,convulsion,obviously elevated CSF LDH level and hydrocephalus(all P<0.05).Multivariate analysis showed that stage III(OR=22.87,95%CI: 1.22–428.70)and distinctly increased CSF LDH level(OR=1.01,95%CI: 1.00–1.02)were independent risk factors for poor long term prognosis(all P<0.05).Conclusions: 1.The common clinical manifestations of TBM in children were fever,headache,disturbance of consciousness,meningeal irritation,cranial nerve palsy and limb paralysis.The time of CSF improvement was 2 weeks after anti tuberculosis drug treatment,when glucose concentration anti tuberculosis can return to normalize,but white blood cell count and protein level need longer time to return to normalize.The common features of brain imaging were hydrocephalus,basal meninges enhancement,tuberculoma and cerebral infarction.2.The incidence of TBM PR in children was35.2%,and the independent risk factors were limb paralysis,positive T SPOT.TB,and increased CSF LDH level.PR was not related to the prognosis.3.Age was a risk factor for short term prognosis,and the younger the age,the worse short term prognosis.The short term and long term independent risk factors for TBM were stage III and significantly increased CSF LDH. |
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