Interdisciplinary Neurosurgery 19 (2020) 100609

Contents lists available at ScienceDirect

Interdisciplinary Neurosurgery
journal homepage: www.elsevier.com/locate/inat

Case Reports & Case Series

Characteristics and outcomes of pediatric tuberculous meningitis patients T

with complicated by hydrocephalus with or without tuberculoma at
Regional Public Hospital Teluk Bintuni, West Papua, Indonesia
⁎
Ahmad Farieda, , Satria P.S. Putrab, Eka W. Suradjib, Triantob, Rafiqa R. Akbarb,
Natalia K. Nugrahenib, Muhammad Z. Arifina
a
Department of Neurosurgery, Faculty of Medicine, Universitas Padjadjaran–Dr. Hasan Sadikin Hospital, Bandung, West Java, Indonesia
b
Regional Public Hospital Teluk Bintuni, West Papua, Indonesia

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Our national data on tuberculosis epidemiology shows that children are mostly affected in a highly
Teluk Bintuni prevalent populations. Age plays a major role in the pathophysiology of tuberculous meningitis (TBM), espe-
Tuberculous meningitis cially children in developing countries, such as Indonesia, are exacerbated by poor nutrition, squalor, poverty,
Hydrocephalus and tuberculoma lack of health awareness and poor health infrastructure.
Methods: A retrospective cohort study was performed on pediatric TBM patients that were admitted to Regional
Public Hospital (RSUD) Teluk Bintuni, West Papua, Indonesia (Jan 1st–Dec 31st, 2017).
Results: Out of fourty three pediatric tuberculosis patients, there were 7 children with TBM complicated by
hydrocephalus with or without tuberculoma or tuberculoma only; TBM developing hydrocephalus with tu-
berculoma: 4 cases, hydrocephalus: 1 case, tuberculoma: 1 and within normal limit: 1 case. The cases were
evaluated using modified British Medical Research Council staging: Stage I (1/7), Stage IIa, IIb and III were each
2/7. The outcomes of TBM: 3/7 had clinical improvement, for vegetative state 1/7 and mortality were 3/7.
Conclusions: In conclusion, majority of TBM pediatric patients in RSUD Teluk Bintuni develop hydrocephalus
and tuberculoma. The present of hydrocephalus and tuberculoma in these cases showed the severity of their
conditions in which resulted in poor outcome. The capability for early diagnosis, or even prevention aspect in
Regional Public Hospital Teluk Bintuni pediatric TBM patient is a very important factors that might affect the
outcomes.

1. Introduction is due to untreated primary tuberculosis in children [1]. Hydrocephalus

Tuberculosis (TBC) is an endemic infectious disease with high
mortality rate in children. Almost one to third of world population,
especially in the developing countries, is infected with mycobacterium
TBC. Nine point six million new cases is being found every year, 15% of
which is in the form of extrapulmonary TBC both new and relapse cases
[1]. In 2015, the TBC infected children accounts for 9% from the total
number of tuberculosis TBC cases in Indonesia, varying 1.2–17.3% in
different provinces [2]. Teluk Bintuni located in West Papua, Indonesia
(Fig. 1) with population of 76,000 people that include 20,000 children.
There were 56 pediatric TBC cases in Teluk Bintuni area 2016; went up
to 58 cases in 2017. One of the complications seen in pediatric tu-
berculosis is tuberculous meningitis (TBM). The risk of a primary tu-
berculosis to develop TBM is higher in children than adults, where 0.3%
is one of the most frequent complications found in TBM. A retrospective
study in 2017 shows 204 of 289 cases of pediatric TBM (70.5%) de-
velops hydrocephalus. That is significantly higher than other findings
such as tuberculoma (4.8%) [3]. A similar study in South Africa in 2017
shows an incidence of 80–90% of hydrocephalus in TBM [4].
The prevalence TBM complication data is not available yet in Teluk
Bintuni even West Papua province. Therefore the aim of this study is to
provide prevalence data of pediatric TBM patients complicated by hy-
drocephalus with or without tuberculoma or tuberculoma only. We
provide the descriptive characteristics data such as: age, gender, clinical
symptoms, pediatric tuberculosis score, TBM staging modified by
British Medical Research Council, cerebrospinal fluids (CSF) analysis,
the head computed tomography (CT) scan results and the outcomes of
pediatric TBM patients on Regional Public Hospital (RSUD) Teluk

⁎
Corresponding author.
E-mail address: ahmad.faried@unpad.ac.id (A. Faried).

https://doi.org/10.1016/j.inat.2019.100609
Received 15 February 2019; Received in revised form 20 July 2019; Accepted 13 October 2019
2214-7519/ © 2019 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
A. Faried, et al. Interdisciplinary Neurosurgery 19 (2020) 100609

Fig. 1. Map of Teluk Bintuni area that located in West Papua, eastern part of Indonesia.

Bintuni, West Papua, Indonesia. Table 1

Characteristic of pediatric patient with tuberculous in Teluk Bintuni Region.
2. Material and methods Characteristic of Patients Total Patients (n = 43)

Age (years; median ± SD) 1–14 (5 ± 4.03)

This is a retrospective cohort study documenting pediatric patients
Gender
between 0 and 14 years old at Regional Public Hospital of Teluk Bintuni Boy 21 (48.8%)
(RSUD), West Papua, Indonesia, diagnosed as TBM complicated by Girl 22 (51.2%)
hydrocephalus with or without tuberculoma or tuberculoma only Type of TB Diagnose
(January 1st 2017 to Dec 31st, 2017). The data collected from medical Bacteriological Confirmed 2 (4.7%)
Clinical Confirmed 41 (95.3%)
record of pediatric patients who were diagnosed as having TBM with
CTscan; since RSUD has CT-scan that everyone can access. Head CT-
scan was done prior the lumbar puncture and interpreted by a radi-
ologist. The diagnosis of TBM was made by the pediatrician found
meningitis symptom often with specific nerve involvement, it also could
be found with or without tuberculoma at radiographic imaging [2]. A
history of close contact with infectious TB patient and positive tu-
berculin test became consideration for TBM diagnosis. Our pediatrician
is use pediatric TB score to rule out possibility of pulmonary TB as
primary infection, those with score ≥6 is clinically pulmonary TB
or < 6 low probability pulmonary TB (negative tuberculine test and no
contact with infectious TB patient. TBM staging modified was made by
the by British Medical Research Council, divided into 3 groups; those
with Stage I, IIa, IIb or III. The diagnosis supported by CSF analysis if it
shows pleocytosis lymphocytes, a subtle raise in protein concentration
and low glucose level [5]. Hydrocephalus and tuberculoma are the
complications which appeared radiographically in non contrast head
CT-Scan in our patients.

3. Results

Fourty three children were diagnosed with tuberculosis during Jan

1st to Dec 31st 2017 in Teluk Bintuni, consisted of 21 boys and 22 girls.
The youngest age was 1 year old while the oldest was 14 years old with
median age is 5 ± 4.03 (Table 1). Among them, seven children
(16.3%) are TBM developed complications consisted of 4 boys and 3
girls. The youngest age was 2 years old while the oldest was 14 years
old with median age is 6.4 ± 4.1. The clinical symptoms are mainly
weight loss (6/7) (Fig. 2), then prolonged fever and neck stiffness (5/7)
thus followed by decrease of consciousness (4/7). Most of the TBM
children came from the cost area. All detail data information shown in
Fig. 2. The pediatric TBM patients clinical symptoms are mainly observed
Table 2. weight loss.
All pediatric TBM patients had gone through screening using pe-
diatric tuberculous scoring system, there was only one excluded as it
was a miliary tuberculosis condition (hematogenic spreading). Three
cases had a TB score < 6, other three cases had a TB score ≥ 6; the

2
A. Faried, et al. Interdisciplinary Neurosurgery 19 (2020) 100609

Table 2 patient; positive for gram stain in 1 patient.

Characteristic of pediatric patients with TBM in RSUD Teluk Bintuni. The head CT scan results showed 4 cases of pediatric TBM patients
Characteristic of Patients Total Patients (n = 7) developed hydrocephalus with tuberculoma (Fig. 3), 1 case develop
hydrocephalus only, 1 case with tuberculoma only and 1 case without
Age (years; median ± SD) 2–14 (6.4 ± 4.1) either hydrocephalus nor tuberculoma. Three of TBM patients had de-
Gender
creased consciousness and with hydrocephalus and died, one in their
Boy 4
Girl 3
vegetative state, meanwhile three other cases are going through clinical
Clinical Symptoms improvement.
Weight loss 6
Prolonged fever 5
Neck stiffness 5
4. Discussion
Decrease of consciousness 4
Chronic cephalgia (> 1 month) 2 TBM is an infectious disease caused by mycobacterium tuberculosis
Vomiting 2 with hematogenic spreading. This infection will slowly cause the for-
Seizure 1
mation of tuberculoid granules below the layer of piamater and below
Pediatric Tuberculosis Score
≥6 3 the surface of central nervous system ependymal cells. Once these
<6 3 granules break, the bacterias inside it will invade CSF, causing me-
Miliary TB 1 ningitis symptoms [3]. Thick exudates due to the inflammation process
TBM Staging in the subarachnoid space (especially in the interpeduncular- and am-
Stage I 1
Stage IIa 2
bient-cistern) will then block CSF flow causing hydrocephalus. On later
Stage IIb 2 stage, scar tissue will replace exudates in the subarachnoid space. The
Stage III 2 early stage of inflammation in choroid plexus and ependymal cells will
CSF Analysis (n = 5) increase the production of CSF.
Cell Count (cell/µl; median-IQR) 5–1300 (65–989)
TBM has unspecific symptoms, therefore it is difficult to detect on
Protein (mg/dl; median-IQR) 1.2–7.4 (1.35–4.7)
Glucose (mg/dl; median-IQR) 23–73 (39–43) early stage. Our study shows that the gender was equally distributed
PMN Predominance 1 with boy:girl ratio of 1:0.75. The most prominent symptoms is weight
MN Predominance 4 loss (6/7), followed by prolonged fever - stiff neck (5/7) and decrease of
Positive for Acid Fast Bacteria 1 consciousness (4/7). One study in Pakistan 2013 showed that pro-
Positive for Gram Stain 1
longed fever is the most frequent complaint found (98.1%) followed by
Head CT scan
Hydrocephalus + Tubercoluma 4 stiff neck (84.6%) and decrease of consciousness (76.9%) [6]. Another
Hydrocephalus 1 studies in 2018 showed the decrease of consciousness as a dominant
Tubercoluma 1 complaint (94.3–100%) [7,8], followed by prolonged fever (97.5%) and
Normal 1
seizure (72.5%); but in their study all the subjects are TBM in severe
Outcomes
Clinical Improvement 3 stages [8]. That study finding is different with our finding because the
Vegetative State 1 severity of our sample population comes from varying stages while the
Death 3 decrease of consciousness and seizure are more often seen in severe
clinical stages patients.
According to the Technical Guideline for Management of
scoring were performed based on pediatrician’s clinical consideration Tuberculosis in children 2016, the diagnosis of pediatric tuberculosis is
due to unavailability of mantaoux test. Based on TBM modified British made by bacteriological examination and through the scoring system.
Medical Research Council: Stage I (1/7), Stage IIa, IIb and III were each Most of TBM patients in our study come at the late stage with dis-
2 per 7 cases. The outcome of the treatment were 3 children died, 1 in tribution as follows: Stage I (1 case), Stage IIa (2 cases), Stage IIb (2
vegetative state, while 3 children survive. For CSF analysis, the result of cases), Stage III (2 cases). Definitive diagnosis is made on the finding of
five of them: cell count 5–1300 cell/µl with median-IQR 65–989; pro- acid fast bacilli in CSF smear or culture but this method has low sen-
tein 1.2–7.4 mg/dl with median-IQR 1.35–4.7; glucose 23–73 mg/dl sitivity due to the pauci-bacillary characteristic of mycobacterium tu-
with median-IQR 39 ± 43; there was PMN predominance in 1 patient; berculosis [9]. This characteristic rises from the inability of the bacteria
MN predominance in 4 patients; positive for acid fast bacteria in 1 to penetrate the blood-CSF barrier, therefore mycobacterium

Fig. 3. Head CT scan results shown a representative imaging of pediatric TBM patient developed hydrocephalus (enlarge ventricles) with tuberculoma (red circle).
(For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

3
A. Faried, et al.
tuberculosis enters CSF when the granules of its focus of infection
break. This explains why we only found one case of TBM with positive
acid fast bacilli in the CSF. Our result is similar with another study
showing only 3.8% of 50 patients with TBM is positive with acid fast
bacilli in their CSF [6]. In spite of CSF smear or CSF culture, the more
simple examination such as measurement of plasma lactate level as
routine examination in determining cellular damage in pediatric TBM
patients need to be consider, which been proofed as predictor for poorer
outcome [10]. Head CT scan on our patients showed the characteristics
such as basal enhancement, tuberculomas and infarcts. We were unable
to perform a contrast CT scan due to the unavailability of the contrast
and its injector. Five TBM patients with TBM develop hydrocephalus, 4
accompanied with tuberculoma; both complications commonly found
in the late stage of TBM. Similar findings are stated by another study in
Pakistan where there is 80% of hydrocephalus within TBM cases [8].
One study in South Africa showed 80–90% incidence of hydrocephalus
within TBM [4]. A study in India affirms the event of hydrocephalus in
pediatric TBM is as high as 71%, much higher than those found in adult
with TBM (12%) [5], where 87% of hydrocephalus in children are
classified as severe diseases [11].
TBM patients with early clinical sign of hydrocephalus are advised
to undergo operative procedure as soon as possible for better prognosis
[12]. Hydrocephalus can be managed using diuretics, osmotic agents,
frequent lumbar puncture, external ventricular drainage or using ven-
triculoperitoneal shunt. On medium to severe hydrocephalus, the pla-
cing of shunt within two days of the diagnosis being made has better
prognosis than those undergoing shunt instalment three weeks later
[5]. Where in RSUD Teluk Bintuni, we have difficulties to perform
operative procedure due to our resource limitation. Patients and fa-
milies also prefer to seek traditional alternative medication as they
believe that a head surgery will worsen the patient’s condition. This
complicates the informed consent process and education. Proper sur-
veillance of treatment for anti tuberculosis drugs is also difficult to do
as the community often moves around (nomads), making them even
harder to be located and contacted, even if we were using cellular
phone. Some patients then decide to stop the treatment as they will go
back to using their traditional medication.
The limitation in this study is in the small sample size and further
studies regarding the clinical characteristics of TBM with complications
involving other centers in Papua are needed. In spite of the limitation,
our results can be used as a reference of pediatric tuberculosis and TBM
with complications in eastern part of Indonesia.
5. Conclusions
Majority of pediatric TBM patients in Regional Public Hospital
Teluk Bintuni develop hydrocephalus and tuberculoma. The present of
hydrocephalus and tuberculoma in these cases showed the severity of
their condition which resulted in poor outcome. The capability for early
diagnosis, or even prevention aspect in Regional Public Hospital Teluk
Bintuni pediatric TBM patient is a very important factors that might
affect the outcomes.
6. Declarations
6.1. Ethics Approval and Consent to Participate
This study was approved by RSUD Teluk Bintuni Ethics Committee
Review Board (0082A/RSUD/II/2018) participants gave informed
consent, patients consent was written.
6.2. Consent
Informed consent was obtained from the patient for publication of
Interdisciplinary Neurosurgery 19 (2020) 100609
this case report and any accompanying images. His family was present
at the time.
6.3. Consent to publish
All authors declare that written informed consent was obtained
from the patient details for publication of this study and accompanying
images to be published.
6.4. Availability of data and materials section
Authors declare that the data will not be shared, since its patient
confidentiality.
6.5. Competing interests
Authors have declared that no competing interests exist.
Funding
A.F. supported by the Grants-in-Aid from the Ministry of Research,
Technology and Higher Education of the Republic of Indonesia 06/E/
KPT/2019.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.inat.2019.100609.
References
[1] Global tuberculosis report 2017. Geneva: World Health Organization; 2017 https://
creativecommons.org/licenses/by-nc-sa/3.0/igo.
[2] R.I. Kementrian Kesehatan, Petunjuk Teknis Manajemen dan Tatalaksana TB Anak,
Kementrian Kesehatan RI, Jakarta, 2016.
[3] R.K. Garg, H.S. Malhotra, A. Jain, Neuroimaging in tuberculous meningitis, Neurol.
India 64 (2016) 219–227.
[4] U.K. Rohlwink, T. Kilborn, N. Wieselthaler, E. Banderker, E. Zwane, A.A. Figaji,
Imaging features of the brain, cerebral vessels and spine in pediatric tuberculous
meningitis with associated hydrocephalus, Pediatr. Infect. Dis. J. 35 (2016)
e301–e310.
[5] J.M. Murthy, Tuberculous meningitis: the challenges, Neurol. India 58 (2010)
716–722.
[6] S. Salekeen, K. Mahmood, I.H. Naqvi, M.Y. Baig, S.T. Akhter, A. Abbasi, Clinical
course, complications and predictors of mortality in patients with tuberculous
meningitis–an experience of fifty two cases at Civil Hospital Karachi, Pakistan, J.
Pak. Med. Assoc. 63 (5) (2013) 563–567.
[7] A. Faried, A. Ramdan, H.M. Nataprawira, Characteristics and surgical outcomes of
tuberculous meningitis and of tuberculous spondylitis in pediatric patients at Dr.
Hasan Sadikin Hospital, Bandung: a single center experience, Interdiscip.
Neurosurg.: Adv. Tech. Case Manage. 11 (2018) 37–40.
[8] N. Anjum, N. Noureen, I. Iqbal, Clinical presentations and outcomes of the children
with tuberculous meningitis: an experience at a tertiary care hospital, J. Pak. Med.
Assoc. 68 (1) (2018) 10–15.
[9] S. Vita, C. Ajassa, M. Caraffa, M. Lichtner, C. Mascia, F. Mengoni, M.G. Paglia,
C. Mancarella, D. Colistra, C. Di Biasi, R.M. Ciardi, C.M. Mastroianni, V. Vullo,
Immunological diagnosis as an adjunctive tool for an early diagnosis of tuberculous
meningitis of an immune competent child in a low tuberculosis endemic country: a
case report, BMC Res. Notes 10 (2017) 123.
[10] A. Faried, G. Arief, M.Z. Arifin, H.M. Nataprawira, Correlation of lactate con-
centration in peripheral plasma and cerebrospinal fluid with Glasgow outcome scale
for acute hydrocephalus tuberculous meningitis that undergone fluid diversions,
World Neurosurg. 111 (2018 Mar) e178–e182, https://doi.org/10.1016/j.wneu.
2017.12.007.
[11] V. Rajshekhar, Management of hydrocephalus in patients with tuberculous me-
ningitis, Neurol. India 57 (4) (2009) 368–374.
[12] A.L. Novalia, A. Berbudi, A. Faried, H.M. Nataprawira, Characteristics and com-
plications in tuberculous meningitis hydrocephalus patient undergone fluid diver-
sion in department of neurosurgery, Dr. Hasan Sadikin General Hospital, Bandung,
J. Integr. Health Sci. 6 (1) (2018) 6–10.