Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
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Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : September | Volume : 16 | Issue : 9 | Page : OC10 - OC14 Full Version

Clinico-aetiological Profile of Meningoencephalitis: A Prospective Observational Study in a Tertiary Care Centre, Hubli, Karnataka, India


Published: September 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/53337.16835
Amruth, Sushma Shetty, Geeta Chintamani, G Krupashree

1. Professor and Head, Department of Neurology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India. 2. Senior Resident, Department of General Medicine, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India. 3. Senior Resident, Department of Medicine, Kims Hubli, Karnataka, India. 4. Senior Resident, Department of Medicine, Kodagu Institute of Medical Sciences, Kodagu, India.

Correspondence Address :
krupashree G,
Senior Resident, Department of Medicine, Kodagu Institute of Medical Sciences,
Kodagu, India.
E-mail: 19sushmashetty@gmail.com

Abstract

Introduction: Meningoencephalitis is a syndrome leading to fatality and neurological damages. Worldwide, infection of the central nervous system is the most common cause of meningoencephalitis. In encephalitis, a leptomeningeal involvement along with inflammation of brain parenchyma is invariably present and the clinical symptoms reflect both diffuse and focal cerebral pathology as well as meningitis. Correct immediate diagnosis and introduction of early symptomatic and specific therapy has a dramatic influence upon survival and reduces the extent of permanent brain injury and also has major impact on the outcome.

Aim: To study the clinical profile and aetiological causes of meningoencephalitis and also to analyse the mortality and morbidity due to meningoencephalitis in a tertiary care centre.

Materials and Methods: It was a prospective observational study conducted between December 2018 to December 2020 in a tertiary care centre, Karnataka Institute of Medical Sciences, Hubali, Karnataka, in which 184 patients of meningoencephalitis who fulfilled inclusion criteria were included. Detailed history and clinical examination was done followed by laboratory investigations, complete hemogram, serum electrolytes, liver function tests, Fundoscopy, Electroencephalography (EEG). Cerebrospinal Fluid (CSF) analysis including CSF culture and Cartridge Based Nucleic Acid Amplification Test (CBNAAT), Computed Tomography (CT)/Magnetic Resonance Imaging (MRI) Brain were also done and results analyzed. Microsoft (MS) Excel and MS word was used to obtain various types of graphs such as bar diagram, pie diagram. Percentages, means were calculated using Statistical Package for Social Sciences (SPSS) statistics software version 22.0.

Results: Out of 184 patients majority of patients were in the age group of 31 to 50 years accounting for 85 (46.2%) of cases. Majority of patients were males (n=113) than females (n=71). Tubercular aetiology was found in 51.6%, viral cause in 25%, bacterial cause in 21.2%, fungal cause in 2.17% of patients. Out of 184 patients of meningoencephalitis, 50% patients recovered, 27.17% patients recovered with residual neurological deficit, 11.95% patients died and 10.86% were discharged .

Conclusion: Detailed history and clinical examination along with appropriate investigations are necessary to confirm the diagnosis of meningoencephalitis. The Tubercular (TB) Meningitis was common with high morbidity and mortality.

Keywords

Bacterial, Fungal, Leptomeningeal, Tubercular, Viral

Meningoencephalitis is a medical emergency (1). Meningitis is a serious infection of the meninges that surround the brain and spinal cord (2). Encephalitis is a serious form of neurological disease with inflammation of the brain parenchyma (3). Meningoencephalitis refers to the inflammation of meninges and brain and is considered as a neurological emergency. The infection may be caused by bacteria such as Streptococcus pneumoniae, Hemophillus influenza and Mycobacterium tuberculosis etc; Viruses like Herpes simplex virus, fungi like Cryptococcus neoformans or parasites like plasmodium (4). Bacterial meningitis is an acute purulent infection within subarachnoid space that is followed by a central nervous system inflammatory reaction that causes coma, seizure, raised intracranial pressure and stroke. The meninges, subarachnoid space and the brain parenchyma are all involved in the inflammatory reaction, hence meningoencephalitis is a more accurate descriptive term (5). In encephalitis a degree of leptomeningeal inflammation is invariably present (2). Tubercular meningitis is a very critical disease in terms of fatal outcome and permanent sequelae, requiring rapid diagnosis and treatment. Death may occur as a result of missed diagnosis and delayed treatment.

Meningoencephalitis is a severe neurological condition that results in significant morbidity and mortality (6). Early diagnosis and treatment can have major impact on the ultimate outcome for a patient with meningoencephalitis (7). Correct early diagnosis and administration of symptomatic and specific treatment will lead to increased influence upon survival and also decreases the extent of neurological consequences (8). Distinguishing the etiologies and identification of specific agent helps in terms of both reducing antibiotic usage, prognosis, hospital bed occupancy and reassuring contacts of cases and health care staff (9).Present study also focuses on mortality and morbidity of admitted patients with meningoencephalitis in a tertiary care center. The objective of the present study was to observe the clinical profile and aetiological causes of meningoencephalitis and to analyze the mortality and morbidity due to meningoencephalitis in a tertiary care center.

Material and Methods

The prospective observational study was conducted in the Department of Medicine at Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India, between December 2018 and December 2020 after obtaining the Institute Ethical Committee clearance (reference number KIMS:ETHICSCOMM:1084:2021).

Inclusion criteria: Patients with age 12 years to 80 years admitted with symptoms and signs suggestive of Meningoencephalitis (fever, headache, vomiting, seizures, altered sensorium, neurological deficits, neck rigidity) (4) were included.

Exclusion criteria: Cases of Metabolic encephalopathy, cerebrova-scular accident and patients or relatives who did not give consent for the study were excluded from the study.

Sample size calculation: Sample size calculation was done by using formula, n=(z)2pq/d2 where, n=sample size, z=static for a level of confidence, p=prevalence, q=1-p, d=precision, confidence intervals (CI)=95%, d=0.05, z=1.96, p=0.08, q=0.92.

prevalence (p)=number of meningoencephalitis cases (1280)/total number of patients admitted in medicine department per year (16000), p=1280/16000, p=0.08

n=(1.96)2×0.08×0.92/(0.05)2

n=113 minimum sample size was 113 but the final sample collected was 184.

Procedure

A total of 184 cases who met Inclusion criteria were included, after taking written informed consent from patients/relatives. Patient’s demographic and medical details were entered in preformed proforma sheet designed for the study. Detailed history was taken and clinical examination was done and mental status was assessed and staged as per modified Medical Research Council (MRC) criteria as stage 1 with Glasgow Coma Scale (GCS) of 15 and without any neurological deficits, stage 2 with GCS of 11-14 or GCS of 15 with neurological deficits and stage 3 with GCS below 10 (10). It was followed by laboratory investigations like complete hemogram (11), random blood sugar, total count, platelet count, urea, creatinine, serum electrolytes (12), Arterial Blood Gas (ABG) analysis (13), Liver function tests (14), Fundoscopy (15), chest X ray (16), CT Brain, EEG (17), CSF analysis (18),(19),(20) included CSF culture, CSF CBNAAT and MRI brain. Diagnosis of CNS infection was made from clinical history examination, CSF analysis, blood investigations, neuro imaging and clinical response to appropriate treatment (antitubercular drugs/antibiotics/antiviral/antifungal).

Statistical Analysis

The information collected regarding all the selected cases were entered in masterchart. Microsoft word and Microsoft excel were used to generate tables and graphs. Data analysis was done with the help of computer using SPSS statistics software version 22.0 (International Business Management (IBM) SPSS Statistics, Somers New York, United States of America). Percentages, means were calculated using this software. MS Excel and MS word was used to obtain various types of graphs such as bar diagram, Pie diagram.

Results

In the present study, patient’s age ranged from 12 years to 80 years. Mean age among male was 42.1±15.65 years and mean age among females was 38.43±14.23 years. Majority of patients were in the age group of 41 to 50 years, accounting to 43 (23.36%) followed by 31 to 40 years accounting to 42 (22.8%) of cases hence the age range had a peak in 31 to 50 age group accounting to 85 (46.18%) and male to female ratio was 1.59:1 (Table/Fig 1).

In the present study, out of 184 patients, all 184 (100%) patients had fever, 173 (94%) patients had headache, 153 (83.2%) patients had neck rigidity, 123 (66.8%) had altered sensorium, 101 (54.8%) had vomiting, 46 (25%) had seizures and 1 (0.5%) had focal deficits (Table/Fig 2).

In present study, including 184 cases of acute meningoencephalitis, 25.5% (n=47) patients had Diabetes Mellitus but Random Blood Sugar (RBS) was >140 in 115 non diabetic patients which could be due to administration of IV fluids before referring to this hospital or could be transient hyperglycemia due to stress and infection. A total of 34 (18.5%) patients had Hypertension, 12 (6.5%) patients had Human Immunodeficiency Virus (HIV), 4 (2.1%) patients had Hepatitis B surface Antigen (HBsAg) and 2 (1.08%) had both HIV and HBsAg, 63 (34.2%) had history of substance abuse in the form of alcohol intake and smoking, 2 (1.08%) had history of otitis media.

Out of 184 patients, 69 (37.5%) patient’s Body Mass Index (BMI) was below 18.5, 115 (62.5%) patient’s BMI was between 18.5 to 24.9. Out of 184 patients, 26 (14.1%) patients had normal temperature at the time of admission which could be due to administration of antipyretics before referring to our hospital and 158 (85.9%) patients had raised temperature of above 37.7oC. A total of 150 (81.5%) had tachycardia and 34 (18.4%) had normal pulse rate at the time of admission. At the time of admission, all patients (n=184) had normal blood pressure. Out of 184 patients, 28 (15.21%) patients had GCS below 10, 93 (50.54%) patients had GCS between 11 to14 and 63 (34.23%) patients had GCS of 15 on examination at the time of admission.

Out of 184 cases, 71 (38.58%) patients had anaemia, 4 (2.2%) patients had Thrombocytopenia, 5 (2.7%) patients had leucopenia, 36 (19.6%) patients had leukocytosis, 30 (16.3%) patients had abnormal serum electrolytes, 115 (62.5%) patients had Hyperglycemia and 3 (1.6%) patients had abnormal serum Creatinine. EEG was done for 46 (25%) patients who presented with seizures, of them 28 (15.21%) patents had abnormal EEG (Table/Fig 3).

Out of 184 CSF samples from 184 study participants, 145 (78.80%) CSF samples showed Lymphocyte predominance, 39 (21.20%) showed neutrophil predominance. In 6 (3.26%) samples cell count was between 1 to 100, 46 (25%) samples showed between 101 to 500, 91 (49.45%) samples showed between 501 to 1000 and 41 (22.28%) samples showed >1001. In 46 (25%) samples, CSF protein was less than 40 mg/dL, 118 (64.13%) samples CSF protein was between 41 to 300 mg/dL and 20 (10.86%) samples, CSF protein was >301mg/dL. In 45 (24.45%) samples CSF glucose was normal, 47 (25.54%) samples showed increased CSF glucose levels and 92 (50%) showed decreased glucose levels. In 89 (48.36%) samples, CSF Adenosine Deaminase (ADA) was <11 and 95 (51.63%) samples showed CSF ADA>12. Out of six positive samples of CSF culture, Streptococcus pneumoniae was found in 3 (1.63%), Staphyloccus aureus in 2 (1.08%) and Klebsiella pneumonia in 1 (0.5%). Out of 184 patients CSF samples, 95 (51.63%) samples of patients with CSF analysis suggestive of tubercular aetiology were subjected for CSF CBNAAT, of them 18 (9.78%) showed Mycobacterium tuberculosis (MTB) detected and 41.84% showed MTB not detected (Table/Fig 4).

Imaging was done for 184 patients, of them 150 neuroimaging (CT/MRI) showed normal findings, 8 patients had temporal hyperintensity in T2 MRI image, 3 patients showed obstructive hydrocephalus, 12 patients showed tuberculoma, 1 patient had vasculitic infarcts features suggestive of TB meningitis, 1 patient had bilateral thalamic lesions,1 patient had features of diffuse cerebral atrophy on neuroimaging (Table/Fig 5).

The diagnosis for 184 cases in the present study was done by history, clinical examination, investigations and imaging. Of them 39 (21.2%) had Bacterial meningitis, 4 (2.2%) had Cryptococcal meningitis, 1 (0.5%) had Dengue encephalitis, 9 (4.9%) had HSV encephalitis, 1 (0.5%) had Japanese encephalitis, 95 (51.6%) had TB meningitis of which MTB was detected in CSF CBNAAT in 18 (9.78%) patients, 20 (10.9%) had Viral encephalitis, 4 (2.2%) had Viral meningitis, 11 (6%) had Viral meningoencephalitis (Table/Fig 6).

Out of 184 patients of meningoencephalitis during the course of hospital stay, 92 (50%) patients recovered, 50 (27.17%) patients recovered with residual neurological deficit in the form of memory and cognitive impairment, 22 (11.95%) patients died and 20 (10.86%) were discharged against medical advice (Table/Fig 7).

Discussion

The present study included 184 study participants admitted in a tertiary care center and results were analyzed and compared with other similar studies. Majority of patients were in the age group of 41 to 50 years accounting to 23.36% (n=43) followed by 31 to 40 years accounting to 22.82% (n=42) of cases. The age range had a peak in 31 to 50 years age group accounting to 46.18% (n=85). In this study, males were the predominant sex in the study group with male to female ratio of 1.59:1. In a study done by Sarvepalli AK and Dharana PK (21) 19.5% patients were in 21 to 40 years age group, 43.9% patients were in 41 to 60 years age group, 36.52% patients were aged >60 years. In a study done by Dey A et al., (22) 6% patients were in the age group of below 20 years and 50% patients were in the age group of 21 to 40 years age group, 30% patients were in 41 to 60 years age group, 14%patients were aged >60 years. In a study done by Pandey D and Mahale RL (23) 28% patients were in the age group of below 20 years and 45% patients were in the age group of 21 to 40 years age group, 23% patients were in 41 to 60 years age group, 3% patient were aged >60 years. In the present study, 13% were in the age group of below 20 years and 37.5% patients were in the age group of 21 to 40 years age group, 36.4% patients were in 41 to 60 years age group, 13.1% patients were aged >60 years. Meningoencephalitis was common in age group of 31-50 years age group in present study which is in concordance with study done by Pandey D and Mahale RL (23) and Dey A et al., (22) and in discordance with study done by Sarvepalli AK and Dharana PK (21). The reason for increased incidence of meningoencephalitis in 31 to 50 years age group could be probably due to selection bias as less than 12 years age group has not been included in present study.

In a study done by Tan K et al., (7) male to female ratio was 1.27:1, Sarvepalli AK and Dharana PK (21) male to female ratio was 1.39:1, Houseein N et al., (6) male to female ratio was 2:1, Xie Y et al., (24) male to female ratio was 1.76:1, Yerramailli A et al., (25) male to female ratio was 1.45:1. In the present study, the male-to-female ratio was 1.59:1 which is in concordance with the other studies.

In present study, fever was present in 184 (100%) patients, headache was present in 173 (94%), vomiting in 101 (54.8%), convulsions in 46 (25%), altered sensorium in 123 (66.8%) of patients. (Table/Fig 8) is showing comparison of symptoms in present study with similar studies (9),(21),(23),(24),(25),(26).

In a study done by Khan FY et al., (27) including 110 study participants, 9 (7.7%) patients had diabetes mellites, 4 (3.4%) patients had history of substance abuse in the form of alcohol intake, IV drug abuse and smoking, 2 (1.7%) patients had immunosuppression (Sexually Transmitted Disease (STD), Malignancy, others) and 5 (4.3%) had history of otitis media. In a study done by Tan K et al., (7) including 116 study participants, 12 (10%) patients had diabetes mellites, 6 (5%) patients had history of substance abuse in the form of alcohol intake and smoking, 32 (34%) patients had immunosuppression (STD, Malignancy, others) and none had history of otitis media. In a study done by Bhagawati G et al., (9) including 316 study participants, 14.24% patients had diabetes mellites, 14.4% patients had history of substance abuse in the form of alcohol intake and smoking, 15.84% patients had immunosuppression (STD, Malignancy, others) and none had history of otitis media. In present study including 184 study participants, 47 (25.5%) patients had diabetes mellites, 63 (34.2%) patients had history of substance abuse in the form of alcohol intake and smoking, 9.7% (n=18) patients had HIV, HBsAg and 2 (1.08%) had history of otitis media which is in concordance with the study done by Bhagawati G et al., (9) and in discordance with the study done by Khan FY et al., (27) and Tan K et al., (7).

CSF culture was positive in six samples and organisms isolated were Streptococcus pneumoniae in 1.63% (n=3), Staphylococcus aureus in 1.08% (n=2) and Klebsiella pneumonia in 0.5% (n=1). Hence most common organism isolated in CSF Culture was Streptococcus pneumonia in the present study which is in concordance with study done by Fouad R et al., (28).

Liver function test, renal function tests, serum sodium tests were done in order to rule out common causes of encephalopathy like hepatic encephalopathy, uremic encephalopathy and hyponatremic encephalopathy.

Distribution of aetiology of meningoencephalitis in different studies

In a study by Tan k et al., (7), in which 116 patients were recruited, tubercular aetiology was found in 3.4%, bacterial cause in 31.0%, viral cause in 53.4%, fungal cause in 12.06% and other causes in 5.1%. In a study by Modi S and Anand AK (29), in which 120 patients were recruited, tubercular aetiology was found in 4.2%, bacterial cause in 36.7.0%, viral cause in 28.3%, fungal cause in 0% and other causes in 30.8%. In a study by Pandey D and Mahale RL (23), in which 100 patients were recruited, tubercular aetiology was found in 54%, bacterial cause in 38.0%, viral cause in 8%, fungal cause in 0% and other causes in 0%.

In a study by Yerramilli et al., (25), in which 147 patients were recruited, tubercular aetiology was found in 28%, bacterial cause in 28.1%, viral cause in 39%, fungal cause in 3% and other causes in 2.1%. In the present study, in which 184 patients were recruited, tubercular aetiology was found in 51.6% (n=95), bacterial cause in 21.19% (n=39), viral cause in 25% (n=46), fungal cause in 2.17% (n=4). In the present study, Tuberculosis was the major cause of meningoencephalitis which is in concordance with study done by Pandey D and Mahale RL (23) and is in discordance with study done by Tan K et al., (7), Modi S and Anand AK (29) and this discordance could be due to variation in geographical distribution, social factors, methodology of the study. Distribution of aetiology of Acute meningoencephalitis in different studies is shown in (Table/Fig 9) (7),(23),(25),(29).

In a study done by Pandey D and Mahale RL (23) imaging (CT/MRI Brain) findings suggestive of tuberculoma was seen in 26% cases, vasculitic infarcts seen in 10% cases, hydrocephalus in 8%, features suggestive of meningitis in 89% cases. In the present study out of 184 cases neuroimaging findings suggestive of tuberculoma was seen in 6.5% cases, vasculitic infarcts seen in 0.5% cases, hydrocephalus in 1.6%, features suggestive of meningitis in 4.3%, Temporal hyperintensity in T2 MRI in 4.3% cases, bilateral (b/l) thalamic lesion in 0.5%, diffuse cerebral atrophy in 0.5% cases. These findings are in discordance with study done by Pandey D and Mahale RL (23).

Limitation(s)

In many patients of meningoencephalitis definite diagnosis/causative organism could not be made due to non availability of specific investigations in the institute. Majority of Bacterial meningitis cases, CSF culture did not yield any growth. This could be due to the use of antibiotics before lumbar puncture in primary care centers before referring the cases to our institute and administration of IV antibiotics in Emergency ward when patient arrived at the institute in odd hours.

Conclusion

Meningoencephalitis is a disease with high morbidity and mortality and considered as medical emergency. In the present study, most of the patients were reported with fever and headache. Lymphocytes were the predominant cells found in CSF analysis. A total of 6.52% patients reported tuberculoma in CT/MRI. TB Meningitis was the most common aetiology with high morbidity and mortality. Early recognition and if treated appropriately increases the survival rate and also neurological sequelae secondary to meningoencephalitis can be minimized to some extent which adds on to the quality of patients life. In tertiary care centers where referred and critical cases are more, detailed history and clinical examination along with appropriate investigations are necessary to confirm the diagnosis of meningoencephalitis. Sensitive, rapid and affordable investigations are required for the accurate and early diagnosis.

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DOI and Others

DOI: 10.7860/JCDR/2022/53337.16835

Date of Submission: Nov 18, 2021
Date of Peer Review: Jan 06, 2022
Date of Acceptance: Jul 06, 2022
Date of Publishing: Sep 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Nov 19, 2021
• Manual Googling: Jun 30, 2022
• iThenticate Software: Aug 08, 2022 (9%)

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