Central nervous system tuberculosis in Western Sydney: a 10-year retrospective cohort study

Abstract

Background: Central nervous system tuberculosis (CNS-TB) is a rare complication of tuberculosis. There is a lack of data surrounding investigation and management of this in Australia.

Aim: To review CNS-TB cases in Western Sydney, Australia, and understand the epidemiology, investigation, diagnosis, management and outcomes in a low-prevalence setting.

Methods: Retrospective cohort study of all CNS-TB patients managed in Western Sydney from 2013 to 2022. Demographics, risk factors, clinical presentation, investigations and management were reviewed. Clinical outcomes like hospital length-of-stay, adverse drug reactions, paradoxical reactions, functional disability and treatment outcomes, including cure, treatment failure, loss to follow-up and death, were also measured.

Results: Thirty-nine CNS-TB cases were identified, with 16 (41%) confirmed by nucleic acid amplification test or culture of CNS specimens and 23 (59%) diagnosed presumptively without CNS microbiological confirmation. The median age was 32 years. Thirty-seven (95%) were overseas-born; 27 (69%) had no comorbidities. Presenting symptoms included fever (82%), headache (64%) and weight loss (51%). Twenty-five (64%) used fluoroquinolones and nine (23%) used high-dose rifampicin. Steroids were used in all patients. Six (15%) were prescribed aspirin for primary stroke prevention. Twenty-eight (73%) completed treatment, with one requiring re-treatment for presumed treatment failure. Six (15%) were lost to follow-up, and five (13%) died during their treatment course. Twenty-one (54%) experienced an adverse drug reaction.

Conclusion: Tuberculosis is an ongoing public health issue in Australia, with CNS-TB being its most devastating form, and all clinicians to be aware of this rare complication. The efficacy of newer treatment options requires further study.

Keywords: Australia; Western Sydney; central nervous system; tuberculoma; tuberculosis; tuberculous meningitis.

Figure 1

Patient inclusion for the study. AFB, acid fast bacilli; CNS‐TB, central nervous system tuberculosis; CSF, cerebrospinal fluid; NAAT, nucleic acid amplication test; WSLHD, Western Sydney Local Health District.

Figure 2

Different radiological manifestations of central nervous system tuberculosis. (A) A T1‐weighted contrast magnetic resonance imaging (MRI) brain scan depicting severe leptomeningeal enhancement of the basal cisterns. (B) A T1‐weighted contrast MRI with numerous enhancing nodules with mild oedema, suggestive of multiple small tuberculomas. (C) A contrast‐enhanced computed tomography (CT) brain scan depicting a 1.5 × 1.7 × 1 cm ring‐enhancing lesion in the posterior right frontal lobe with vasogenic oedema, concerning for a single tuberculoma. (D) A non‐contrast CT showing moderate–severe hydrocephalus.