Unit of General Epidemiology and Disease Control, Institute of Tropical Medicine of Antwerp, Antwerp, Belgium.
Escuela de Medicina, Universidad Peruana de Ciencias Aplicadas, Lima, Peru.
Trop Med Int Health. 2018 Apr;23(4):367-374. doi: 10.1111/tmi.13041. Epub 2018 Mar 8.
Diagnosis of tuberculous meningitis (TM) is a challenge in countries with a high burden of the disease and constrained resources and clinical prediction rules (CPRs) could be of assistance. We aimed at developing a CPR for diagnosis of TM in a Latin American setting with high tuberculosis incidence and a concentrated HIV epidemic.
We enrolled adult patients with clinical suspicion of TM attending two hospitals in Lima, Peru. We obtained information on potential anamnestic, clinical and laboratory predictive findings that are easy to collect and promptly available. We independently diagnosed TM according to a composite reference standard that included a series of microbiological tests. We performed bivariate analysis and constructed a logistic regression model to select the predictive findings associated with TM. With the selected predictors included in the model, we developed a score-based CPR. We assessed its internal validity and diagnostic performance.
Of 155 analysed patients, 59 (38%) had TM. The CPR we derived includes three predictors: cough for 14 days or more, 10-500 cells in CSF and adenosine deaminase ≥ 6 U/l in CSF. It classifies patients into high-, moderate- or low-score groups and has an overall area under the ROC curve of 0.87. 59% of patients were assigned to either the high- or the low-score group, permitting prompt decision-making. In patients in the high-score group, it attains a positive likelihood ratio for TM of 10.6 and in patients with low scores, a negative likelihood ratio of 0.10. Bootstrap analysis indicated high internal validity.
This CPR could support decision-making in patients with clinical suspicion of TM. External validation and further assessment of its clinical impact are necessary before application in other settings.
在结核病负担沉重且资源有限的国家，诊断结核性脑膜炎（TM）具有挑战性，临床预测规则（CPR）可能会有所帮助。我们旨在为拉丁美洲国家开发一种 CPF，这些国家结核病发病率高，艾滋病毒流行集中。
我们纳入了秘鲁利马的两家医院就诊的有 TM 临床疑似症状的成年患者。我们获得了易于收集和及时获得的潜在病史、临床和实验室预测发现的信息。我们根据包括一系列微生物学测试的综合参考标准独立诊断 TM。我们进行了双变量分析并构建了逻辑回归模型，以选择与 TM 相关的预测发现。在模型中纳入选定的预测因素，我们开发了基于评分的 CPR。我们评估了它的内部有效性和诊断性能。
在分析的 155 名患者中，59 名（38%）患有 TM。我们得出的 CPR 包括三个预测因素：咳嗽 14 天或以上、CSF 中有 10-500 个细胞和 CSF 中的腺苷脱氨酶≥6U/L。它将患者分为高、中或低评分组，ROC 曲线下的总体面积为 0.87。59%的患者被分配到高或低评分组，以便快速决策。在高评分组的患者中，TM 的阳性似然比为 10.6，而在低评分组的患者中，阴性似然比为 0.10。自举分析表明内部有效性高。
该 CPR 可支持对有 TM 临床疑似症状的患者进行决策。在其他环境中应用之前，需要进行外部验证和进一步评估其临床影响。
