Tuberculous meningitis (TBM) causes significant morbidity and mortality. The primary objective was to re-examine the concept of “TB zone” and “ischaemic zone” in cerebral infarction in patients with tuberculous meningitis. The secondary objective was to evaluate cerebral infarction, vasculitis and vasospasm in tuberculous meningitis infections. Between 2009 and 2014, TBM patients were recruited. Neuroimaging was performed and findings of cerebral infarction, vasculitis and vasospasm were recorded. Infarcts were classified based on arterial supply and Hsieh’s classification. Fifty-one TBM patients were recruited of whom 34 patients (67%) had cerebral infarction. Based on Hsieh’s classification, 20 patients (59%) had infarcts in both “TB zone” and “ischaemic zones”. 12 patients (35%) had infarcts in “ischaemic zone” and two (6%) patients had infarcts in “TB zone”. In terms of vascular supply, almost all patients (35/36) had infarcts involving perforators and cortical branches. 25 patients (73%) and 14 patients (41%) had infarcts supplied by lateral lenticulostriate and medial lenticulostriate arteries respectively. 15 patients (37%) had vasculitis. Vasospasm was present in six patients (15%). 29 patients (85%) with cerebral infarction also had leptomeningeal enhancement (p = 0.002). In summary, infarcts involved mainly perforators and cortical branches, rather than “TB zone” versus “ischaemic zone”.

Objective EMPOwER, a double-blind, randomised, phase 3 study, evaluated the efficacy and safety of erenumab in adults with episodic migraine from Asia, the Middle East, and Latin America. Methods Randomised patients (N = 900) received monthly subcutaneous injections of placebo, erenumab 70 mg, or 140 mg (3:3:2) for 3 months. Primary endpoint was change from baseline in monthly migraine days at Month 3. Other endpoints included achievement of ≥50%, ≥75%, and 100% reduction in monthly migraine days, change in monthly acute migraine-specific medication treatment days, patient-reported outcomes, and safety assessment. Results At baseline, mean (standard deviation) age was 37.5 (9.9) years, 81.9% were women, and monthly migraine days was 8.2 (2.8). At Month 3, change from baseline in monthly migraine days (primary endpoint) was −3.1, −4.2, and −4.8 days for placebo, erenumab 70 mg, and erenumab 140 mg, respectively, with a statistically significant difference for erenumab versus placebo (P = 0.002 [70 mg], P < 0.001 [140 mg]). Both erenumab doses were also significantly superior to placebo on all secondary endpoints, including the proportion of patients achieving ≥50% reduction from baseline in monthly migraine days, change from baseline in monthly acute migraine-specific medication treatment days and change from baseline in the Headache Impact Test-6™ scores. The safety profile of erenumab was comparable with placebo; no new safety signals were observed. Conclusions This study of erenumab in patients with episodic migraine from Asia, the Middle East, and Latin America met all primary and secondary endpoints. A consistent numerical benefit was observed with erenumab 140 mg versus erenumab 70 mg across all efficacy endpoints. These findings extend evidence of erenumab’s efficacy and safety to patients under-represented in previous trials. ClinicalTrials.gov identifier: NCT03333109

BackgroundThere is limited data on the nutritional status of Asian patients with various aetiologies of cirrhosis. This study aimed to determine the prevalence of malnutrition and to compare nutritional differences between various aetiologies.MethodologyA cross-sectional study of adult patients with decompensated cirrhosis was conducted. Nutritional status was assessed using standard anthropometry, serum visceral proteins and subjective global assessment (SGA).ResultsThirty six patients (mean age 59.8 ± 12.8 years; 66.7% males; 41.6% viral hepatitis; Child-Pugh C 55.6%) with decompensated cirrhosis were recruited. Malnutrition was prevalent in 18 (50%) patients and the mean caloric intake was low at 15.2 kcal/kg/day. SGA grade C, as compared to SGA grade B, demonstrated significantly lower anthropometric values in males (BMI 18.1 ± 1.6 vs 26.3 ± 3.5 kg/m2, p < 0.0001; MAMC 19.4 ± 1.5 vs 24.5 ± 3.6 cm, p = 0.002) and females (BMI 19.4 ± 2.7 vs 28.9 ± 4.3, p = 0.001; MAMC 18.0 ± 0.9 vs 28.1 ± 3.6, p < 0.0001), but not with visceral proteins. The SGA demonstrated a trend towards more malnutrition in Child-Pugh C compared to Child-Pugh B liver cirrhosis (40% grade C vs 25% grade C, p = 0.48). Alcoholic cirrhosis had a higher proportion of SGA grade C (41.7%) compared to viral (26.7%) and cryptogenic (28.6%) cirrhosis, but this was not statistically significant.ConclusionSignificant malnutrition in Malaysian patients with advanced cirrhosis is common. Alcoholic cirrhosis may have more malnutrition compared to other aetiologies of cirrhosis.

Sphingomonas paucimobilis is an aerobic gram-negative bacillus. The bacteria can cause infections, which can be devastating and, therefore, the patients need adequate and early antibiotic cover. We are presenting an interesting case of meningitis secondary to an unusual S. paucimobilis infection. This is the second case to our knowledge in the literature on meningitis due to S. paucimobilis. The 31-year-old previously healthy man presented with 2 months' history of weight loss and loss of appetite. He had fever and headache for 3 weeks. He was also speaking irrelevantly for 3 weeks. He had change of behaviour for 1 day. The patient was a farmer and worked in the soil. On examination, he was not responding to questions and was not obeying commands. Computed tomography (CT) brain with contrast revealed meningeal enhancement and cerebral oedema. Lumbar puncture was performed. Cerebrospinal fluid (CSF) opening pressure was more than 50 cm H2O. CSF analysis showed meningitis picture with raised white cell count of 210/μL (predominantly neutrophils), glucose 3.1 mmol/L, and raised protein 2.47 g/L. He was given intravenous ceftriaxone. The following day, his condition deteriorated. CSF culture grew S. paucimobilis sensitive to ceftriaxone. S. paucimobilis causes severe meningitis. This can lead to hydrocephalus, which results in a need for extraventricular drainage. A good occupational history is important with regard to finding the aetiology of serious meningitis (including rare bacteria) even before the culture result is known. Appropriate treatment can be given early and adequately to prevent mortality.

BackgroundVascular complications are important causes of cerebral infarction in tuberculous meningitis (TBM).Transcranial Doppler ultrasonography (TCD) is a non-invasive tool that can provide real-time information about cerebral hemodynamics. However, the literature on the role of TCD in the diagnosis or monitoring of vasculopathy associated with TBM is scarce. We explored the role of TCD in the diagnosis and monitoring of TBM-related vasculopathy of the major intracranial arteries.MethodsConsecutive patients with TBM admitted to our tertiary center between 2011 and 2015 were included. All patients underwent TCD evaluation within 2 weeks of hospitalisation and it was repeated 2 weeks later. Mean flow velocity (Vmean) and pulsatility index (PI) were recorded. Flow velocities obtained from the submandibular internal carotid artery were also measured to calculate the Lindegaard ratio. A correlation was made between the patients who demonstrated vasculopathy on TCD, and patients with confirmed focal narrowing on computed tomography angiography (CTA) or magnetic resonance angiography (MRA). The modified Rankin scale (mRS) was used to assess the clinical outcome at three and six months.ResultsA total of 36 patients were recruited. Focally elevated flow velocities in the middle cerebral artery (MCA) were observed in 11 (30.6%) patients, bilaterally in 6 of them. The Lindegaard ratio was elevated (>3) in 10 (90.9%) of them, which occurred as early as the fourth day of hospitalization and persisted as long as four months. Eighty percent of patients with TBM vasculopathy by TCD criteria, also had narrowing on CTA or MRA. Ten patients (27.8%) achieved good outcome (mRS 0–2) at 3 months, which increased to 13 (36.1%) at 6 months.ConclusionA considerable proportion of patients with TBM develops intracranial vasculopathy, which can be reliably diagnosed and monitored using TCD.