Effect of general, extratherapeutie Factor in Prognosis of Tuberculous Meningitis Treated with Tuberculostatic Aids

Abstract

Though the therapeutic intervention by tuberculostatic means — streptomycin, paraaminosalycilic acids, hydracid isonicotine — is generally accepted as the chief factor in prognosis of tuberculous meningitis, yet a number of other additional factors are also involved, which are responsible for the most variable results of this therapy. It is only in this way that the heavy lethality rate can be accounted for, which — in cases of tubercoulous meningitis treated tuberculostatically — ranges from 20% to 80% according to various groups of patient, on the assumption that the course of treatment was faultless in all the groups concerned.

The general, extra-therapeutic, factors are: (1) Age of chilđ, (2) Time of therapeutic intervention, (3) Condition of patient, particularly that of his sen­sorium, (4) Simultaneity of meningitis with miliary tuberculosis, (5) Intial changes in cerebrospinal liquor, (6) Massiveness of tuberculous infection, (7) Condition of allergy to tuberculin, (8) Antecedence of anergising infectious diseases.

The significance of the above mentioned extratherapeutic prognostic factors being variously interpreted by various authors, we have felt it necessary to study these factors on the basis of our material relative to tuberculous meningitis, taking into consideration the first examinations only, i.e. those before the start of actual treatment with tuberculostatic aids.

(1) Age of child. Estimation of prognosis in individual cases of tuberculous meningitis depends on whether we are concemed with children in the first year of the life, young children, or those of school age. This fact is clearly bome out by our material, the lethality rate being 85,7% in patients of the first year, 68, 5°/o of the second and third years, and only 47,2% in those between the fourth and fourteenth years of age;

(2) Time of therapeutic intervention. How great is the progncstic importance of this factor is best to be seen from the following data: in patients admitted for treatment in the course of the first week of illness, the mortality rate was 33,3%, in those admitted in the second week of illness 65,3%, in the third 88,8%, and in those of the fourth week 100%. Delay in therapeutic intervention may have disastrous consequences particularly in cases of children in the first year of the life. Thus in this age where the treatment had begun in the first week of illness, the lethality rate was 50%, in the second week 83,3%, and in the third week 100%.

(3) Condition of the patients’ sensorium. Our experience shows that patients who, at the time of their first examinaticn, exhibit sign of somnolence, torpor, stupor, or are in coma, have far fewer chances of recovering than those with normal consciousness. Thus the lethality rate in our patients was 87,7% in cases of those who on admittance had been found to suffer from disorđers of the sensorium (somnolence, torpor, stupor, coma), while the percentage was smaller by half (43,8%) in those with normal consciousness.

(4) Simultaneity of meningitis with miliary tubercu­losis. This factor exerts a most damaging influence upon the evolution of tuberculous meningitis. Our data show a lethality rate of 73,9% in patients with an established tuberculous meningitis contemporaneous with miliary tuberculosis, whereas the rate is 53,9% in patients where the tuberculous meningitis was developing without clinical signs of miliary tuberculosis.

(5) Initial changes in cerebrospinal liquor. Our experience has shown that the lethality rate is much higher (77,1%) in patients with whom, at the time of the first examination of liquor, the quantity of albumen found exceeded 50 mg%, whereas the latter is considerably lower (41,1%) in patients with albuminose of liquor below 50 mg %. The differences in mortality rate, though existing, are smaller in patients with initial hypoglycorachia (below 45 mg %) and those with normal glycorachia; in the former the mortality rate was 62,6%, and in the latter 50%.

As to chlore, cur results were not convincing enough for warrantable inferences to be made. Investigations with the object of deciding whether changes in cytologic formula of liquor — established at the time of the first lumbar puncture — could serve for prognostic purposes, resulted in showing that the lethality rate was lower (40%) in patients vvith the percentage of polynuclear elements below 10%, vvhile being considerably higher (61,4%) in those with polynuclear percentage over 10%.

(6) Massiveness of tuberculous infection. The nature of infection itself has proved to be an adđitional factor that can be used for prognostic purposes. Our data conceming tuberculous meningitis show a lethality rate of 68,9% in cases of children infected intra-familiarly (where the infection is quotidian and massive due to continuous contact), while in those infected extra-familiarly (the infection usually being temporary and less massive) the rate was 31,1%.

(7) Condition of allergy to tuberculin. Insufficiency of allergic reactions to tuberculin can also be used for prognostic purposes. In our patients with extinct allergy to tuberculin, the lethality rate was 73%, whereas in those with positive reactions to tuberculin the rate was 56,8%.

(8) Antecedance of anergising infectious diseases. According to our experierrces there is a certain difference in the lethality of the patients in whose anemnosis (at the latest six month before the occurence of t.m.) we find morbilli (58,6%) and those with whom pertussis was the proceeding disease (64,6%). These numbers are not specially in favour of the prognostic meaning of antecedancne of a anergising infectious diseases, as the lethality in the control group of the patients was approximately the same (59,5%).

It would be incorect to conclude that the quoted factors, taken each separately, can serve as a definite measure for a prognosis of tuberculous meningitis. These factors can be estimated only as complex of factors mutually joined so that they proceed one from another or that they simultaneously combine one with the other.

Knowing the general, extratherapeutic, prognostic factors has a special meaning because of the following reasons:

1. That from the beginning the right place for treatment can be decided upon, as it is not the same if the most important period of treatment, the initial one — will take place in a higly qualified institution or in a not sufficiently fomished hospital department.

2. That it can be decided, as soon as possible, which way the tuberculostatics will be given, as it is not irrelevant if they will be introduced only lumbally or lumbally and suboccipitally or eventually lumbally, suboccipitally and ventriculary.

3. That from the beginning the ađequate combination of individual antibiotics and their corresponding dose can be prescribed.

4. Finally, it is important that the parents should be acquainted with, as far as possible, ali likely perspectives of the disease. as this is of great psychologic significance.