Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, Assistance Publique-Hôpitaux de Paris, 46 rue Henri Huchard, 75018, Paris, France.
Department of Neurology, Saint Antoine University Hospital, Assistance Publique-Hôpitaux de Paris, 184 rue du Faubourg Saint Antoine, 75011, Paris, France.
Crit Care. 2018 Aug 17;22(1):210. doi: 10.1186/s13054-018-2140-8.
Tuberculous meningitis (TBM) is a devastating infection in tuberculosis endemic areas with limited access to intensive care. Functional outcomes of severe adult TBM patients admitted to the ICU in nonendemic areas are not known.
We conducted a retrospective multicenter cohort study (2004-2016) of consecutive TBM patients admitted to 12 ICUs in the Paris area, France. Clinical, biological, and brain magnetic resonance imaging (MRI) findings at admission associated with a poor functional outcome (i.e., a score of 3-6 on the modified Rankin scale (mRS) at 90 days) were identified by logistic regression. Factors associated with 1-year mortality were investigated by Cox proportional hazards modeling.
We studied 90 patients, of whom 61 (68%) had a score on the Glasgow Coma Scale ≤ 10 at presentation and 63 (70%) required invasive mechanical ventilation. Brain MRI revealed infarction and hydrocephalus in 38/75 (51%) and 25/75 (33%) cases, respectively. A poor functional outcome was observed in 55 (61%) patients and was independently associated with older age (adjusted odds ratio (aOR) 1.03, 95% CI 1.0-1.07), cerebrospinal fluid protein level ≥ 2 g/L (aOR 5.31, 95% CI 1.67-16.85), and hydrocephalus on brain MRI (aOR 17.2, 95% CI 2.57-115.14). By contrast, adjunctive steroids were protective (aOR 0.13, 95% CI 0.03-0.56). The multivariable adjusted hazard ratio of adjunctive steroids for 1-year mortality (47%, 95% CI 37%-59%) was 0.23 (95% CI 0.11-0.44). Among survivors at 1 year, functional independence (mRS of 0-2) was observed in 27/37 (73%, 95% CI 59%-87%) cases.
A poor functional outcome in adult TBM patients admitted to the ICU in a nonendemic area is observed in 60% of cases and is independently associated with elevated cerebrospinal fluid protein level and hydrocephalus. Our data also suggest a protective effect of adjunctive steroids, with reduced disability and mortality, irrespective of immune status and severity of disease at presentation. One-year follow-up revealed functional independence in most survivors.
结核性脑膜炎（TBM）是在结核病流行地区，由于无法获得重症监护，而导致的一种破坏性感染。在非流行地区，重症成人 TBM 患者入住 ICU 的功能预后尚不清楚。
我们进行了一项回顾性多中心队列研究（2004-2016 年），纳入了法国巴黎地区 12 个 ICU 连续收治的 TBM 患者。通过逻辑回归确定了入院时与不良功能预后（即 90 天时改良 Rankin 量表（mRS）评分 3-6 分）相关的临床、生物学和脑磁共振成像（MRI）表现。通过 Cox 比例风险建模研究了与 1 年死亡率相关的因素。
我们共研究了 90 例患者，其中 61 例（68%）在就诊时格拉斯哥昏迷量表（GCS）评分≤10 分，63 例（70%）需要有创机械通气。75 例患者中有 38 例（51%）和 25 例（33%）分别在脑 MRI 上显示出梗塞和脑积水。55 例（61%）患者预后不良，与年龄较大（调整优势比（aOR）1.03，95%置信区间 1.0-1.07）、脑脊液蛋白水平≥2 g/L（aOR 5.31，95%置信区间 1.67-16.85）和脑 MRI 上脑积水（aOR 17.2，95%置信区间 2.57-115.14）独立相关。相比之下，辅助性类固醇具有保护作用（aOR 0.13，95%置信区间 0.03-0.56）。辅助性类固醇治疗的 1 年死亡率（47%，95%置信区间 37%-59%）的多变量调整危险比为 0.23（95%置信区间 0.11-0.44）。在 1 年存活的患者中，27/37 例（73%，95%置信区间 59%-87%）达到功能独立性（mRS 0-2）。
在非流行地区 ICU 收治的成人 TBM 患者中，60%的患者预后不良，与脑脊液蛋白水平升高和脑积水独立相关。我们的数据还表明，辅助性类固醇具有保护作用，可降低残疾和死亡率，而与免疫状态和发病时的严重程度无关。1 年随访显示，大多数幸存者都能恢复独立功能。
