Factors Influencing the Prognosis in Tuberculous Meningitis Treated With Streptomycin

Naismith, James T (1958) Factors Influencing the Prognosis in Tuberculous Meningitis Treated With Streptomycin. PhD thesis, University of Glasgow.

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Abstract

From a study of 102 cases of tuberculous meningitis admitted to Ayrshire Central Hospital, Irvine, and Belvidere Hospital, Glasgow, between June, 1948, and December, 1951, endeavour has been made to analyse the factors that may have had a bearing on the ultimate outcome, expressed in terms of both quantity and quality of survivors. The patients were all treated with streptomycin, with or without adjuvants, in the pre-isoniazid era. Diagnosis was confirmed bacteriologically in 82% of the cases and was not in doubt in any of the others. 66 (64.7%) the patients survived for a minimum of 5 years. In order to determine the inter-relation of all the factors that have been taken into consideration and ascertain the individual effects of each on the ultimate outcome and on the incidence of complications and sequelae, it is clear that a much vaster experience would be required than can be gained by one person - for example, an investigation of the dimensions of the trials conducted by the Medical Research Council using many centres. In a comparatively small series such as this, in which the figures tabulated were obtained in the experience of one person, the results may admittedly be vitiated by the interplay of different factors. An attempt has, however, been made to assess the major factors, and the following are the main conclusions reached. The study was divided into six sections. A. Factors prior to the institution of treatment. Prognosis was significantly better in patients (a) between the ages of 3 and 30 years, (b) with less advanced disease, (c) fully conscious, (d) well nourished, (e) without radiological evidence of miliary or adult pulmonary tuberculosis, (f) with high initial CSF cell count and chloride content. B. Treatment Regime: 7 different regimes of treatment were employed. All patients were given intramuscular and intrathecal streptomycin (or dihydro streptomycin), and in all hut 6 the duration of the initial course of treatment was not less than 6 months. Allowing for the limited numbers in each treatment group, it seemed justifiable to make the following deductions from the results; (a) less than 6 months' treatment was inadequate; (b) prolonged intrathecal therapy did not have any special advantage over shorter courses; (c) the use of dihydrostreptomycin was not associated with a significantly higher mortality rate compared with streptomycin; (d) neither streptokinase nor PPD enhanced the results; the latter, indeed, seemed to be detrimental. C. Type of response to treatment: A good initial response was not necessarily an indication of a favourable outcome. Nor could an accurate prognosis be made on the basis of early disappearance or long persistence of any or all of the main symptoms or signs. The CSF sugar level was not found to have the same prognostic significance as other observers have attached to it. The CSF protein level seemed of greater value in the assessment of prognosis than that of any other CSF constituent; no patient died whose CSF protein became normal - but 7 such patients relapsed. D. Incidence and influence of spinal block; A significantly higher mortality was noted in the 22 (21.6%) patients who developed obstruction to the flow of CSF It seemed likely that patients with initial CSF protein over 200 mg. per 100 ml. may have had incipient block as a significantly high proportion of such patients developed it. Neither streptokinase nor PPD proved to be of any value in relieving the obstruction; indeed it appeared that both, especially the latter, may have been responsible for its development in some cases. E. Incidence and influence of relapse; 20 relapses occurred in 16 patients who had completed a previous course of treatment; 1 of these patients succumbed after 3 relapses. The incidence of relapse did not appear to be related to the initial treatment regime provided this was of 6 months' duration, but a very high proportion of patients relapsed after an initial course lasting 3 1/2 months. All relapses occurred within 1 year, and most within 3 months, of the completion of the previous course of treatment. Most were detected by the recurrence of symptoms and signs and confirmed by CSF findings. A full course of treatment was instituted as soon as relapse was diagnosed, and the prognosis proved to be as good as for the initial illness.

Item Type: Thesis (PhD)
Qualification Level: Doctoral
Keywords: Medicine, Epidemiology
Date of Award: 1958
Depositing User: Enlighten Team
Unique ID: glathesis:1958-79262
Copyright: Copyright of this thesis is held by the author.
Date Deposited: 05 Mar 2020 11:12
Last Modified: 05 Mar 2020 11:12
URI: http://theses.gla.ac.uk/id/eprint/79262

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