INTRODUCTION
Tuberculosis (TB) is a highly transmissible air-borne respiratory disease that continues to challenge Indian healthcare. In 2023, 2.55 million TB cases were reported nationwide, with 20% being extrapulmonary, and it presents distinct diagnostic and therapeutic complexities due to the disease’s propensity to mimic other infections and the limited microbiological diagnostic yield from affected tissues. The National TB Elimination Program (NTEP) has improved accessibility to TB services, achieving a commendable 95% treatment initiation rate and implementing enhanced testing for drug-resistant (DR)-TB compared to previous years. Not withstanding these endeavors, the mortality rates of TB in India remain substantial, as 320,000 fatalities were recorded in 2023.
METHODS
Type of sampling and reasons for selection
This case series retrospectively examined six rare clinical presentations of extrapulmonary TB (EP-TB) treated at Sir Sayajirao Gaekwad Hospital, Vadodara. It affected structures such as the kidneys, pleura, meninges, axial skeleton, and the integumentary system. Some cases presented as community-acquired bacterial infections whereas in several instances, it mimicked the neutrophilic response of acute bacterial infections seen on laboratory analysis. Patients underwent thorough history taking, clinical examination, multimodal diagnostic tests such as radiological imaging (chest X-ray, ultrasonography, computed tomography [CT] scan, magnetic resonance imaging [MRI]), hematological tests, microbiological tests (Ziehl–Neelsen staining for acid-fast bacilli [AFB], AFB culture, gram stain, cytology of sputum, aspirated fluid, pus, and cerebrospinal fluid [CSF]), molecular diagnosis (GeneXpert/Cartridge-based nucleic acid amplification tests [CBNAAT]), and histopathological examination. Drug susceptibility testing (first line [FL]/second line [SL]-line probe assay [LPA]; FL; SL) determined resistance. The antitubercular therapy (ATT) (first-, second-, and third-line agents) was given as per guidelines while adjunctive therapies, such as specialized surgical interventions (neuro/uro/thoracic-surgery) and nutritional supplementation, were instituted in required scenarios. Outcomes were based on clinical improvement, radiological resolution, and microbiological clearance during follow-up.
Ethical considerations
This study is a retrospective observational case series. The Institutional Ethics Committee of the Baroda Medical College and SSG Hospital (IECBHR) determined that formal approval was not required, as the research does not involve direct interaction with animals and poses minimal risk to human subjects. The study ensures the anonymity and confidentiality of all data, and no personal identifying information will be disclosed. All data handling adheres to ethical standards as stipulated by the Declaration of Helsinki.
Patient consent statement
The authors certify that they have obtained written informed consent from all patients for voluntary inclusion and have given his/her/their consent for the utilization of his/her/their clinical images, and clinical information to be reported. The patients understand that no data in any format revealing their identity/biographical information will be published and efforts will be made to safeguard their anonymity.
Inclusion criteria
All patients of extrapulmonary/disseminated TB, with rare clinical features or diagnostic/therapeutic complexities, those with documented drug resistance, and those who had voluntarily consented in writing, were only included in the study.
Exclusion criteria
Cases of isolated pulmonary TB and those patients who did not consent for the study were excluded from the study.
RESULTS
We report six rarest EP-TB presentations among four males and two females with diverse comorbidity and demographic profiles highlighting unusual clinicopathological and microbiological similarities with other common infections that improved only after prompt ATT addition or escalation.
Case 1: Masquerade of disseminated tuberculosis: A case of pulmonary Koch with genitourinary involvement
A 28-year-old immunocompetent male, a tobacco addict, presented with a 15-day history of worsening breathlessness, low-grade fever for 1 month, and atraumatic bilateral flank pain and oliguria without a history of recurrent urinary infections or obstructive or irritative urological symptoms in an emergency room. He was anemic, febrile, hypotensive, and in respiratory distress with decreased breath sounds in left lung zones and hyperresonant tympanic notes on percussion. Chest X-ray and high-resolution CT (HRCT) [Figures 1a and c] revealed left-sided hydropneumothorax. Postintercostal drainage (ICD) tube placement in the trapped lung was peculiar, while higher antibiotics were instituted, as shown in investigations [Table 1 and Figure 1d]. Despite this and hemodialysis, his renal function worsened with persistent microscopic hematuria and sterile pyuria.
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Figure 1: (a-d) Illustrates the radiological (a-c) and microbiological (d) findings of the first case. (a) Shows a heavily infected lung with nodular consolidations (green arrow) in upper mid fields and high-resolution computed tomography (CT) thorax reveals cavitations, centrilobular nodules, and a left-sided pneumothorax ([c] yellow arrows) likely due to Kochs. AFB in sputum (d) confirms this. Coronal (b) and axial (c) plates of CT abdomen images show an irregular left kidney with cortical scarring (pink arrows) and few calcifications (red circle), indicating early renal Kochs
Table 1: Investigations in case of renal tuberculosis
Further imaging [Figure 1b and Table 1] showed bilateral hydronephrosis and left kidney calcifications without stones or strictures. Urinary AFB and CB-NAAT confirmed renal TB and modified ATT was started. Cystoscopy revealed a contracted bladder and stenotic ureter. He was referred for decortication surgery for a trapped lung and bladder augmentation procedure with the ICD in situ to a higher center.
Case 2: Tuberculous abscesses: A case beyond the ordinary central nervous system tuberculosis
A 15-year-old cachexic female patient with a history of headache, diplopia, and vomiting diagnosed with intracranial tuberculomas [Figure 2a and b] on standard four-drug weight-based ATT for 8 months (continuation phase) with good compliance presented to our outpatient department with nonresolution of fever, poor constitutional health, and new insidious-onset multiple swellings over the abdomen and back for 1 month [Figure 2d]. Physical examination suggested tuberculous abscesses, confirmed radiologically [Figure 2c]; that were aspirated and sent for microbiological analysis that turned positive for Mycobacterium tuberculosis (Mtb). Relevant radiopathological laboratory investigations are summarized in Table 2. The patient had drug-sensitive (DS)-TB with no response and was put on a higher weight band [maximum weight-based dosing for Isoniazid (H), Rifampicin (R), Pyrazinamide(Z), Ethambutol (E) - HRZE] with the addition of levofloxacin (Lfx) with compliance monitoring. The LPA (first/second generation) was negative for DR-TB (multidrug resistance [MDR]/preextensive drug resistance [pre-XDR]). Since she did not improve clinical-radiologically, ATT was escalated with the Bedaquiline containing oral longer regimen. She responded with symptomatic resolution, although cost constraints prevented therapeutic drug monitoring.
Figure 2: (a-d) The chest radiograph (a) Posterior-anterior view shows a mildly blunted right costophrenic angle, suggestive of pleural effusion due to tuberculosis (TB) pleuritis (nonaspirable on sonography). Past central nervous system TB is confirmed by multiple ring-enhancing tuberculomas (green arrows in b). Multiple well-defined, mobile, cystic, fluctuating, nontender lumps, likely cold abscesses, were noted, including a 6 cm × 6 cm × 3 cm lump in the right iliac fossa. Computed tomography scans show loculated collections (yellow/red arrows in c), with significant resolution after Bedaquiline addition in 1 month (black arrows and arrowheads in d)
Table 2: Investigations in case of cutaneous dissemination of central nervous system tuberculosis
Case 3: A prolonged battle-managing drug-resistant (preextensive drug resistance) tuberculosis in a case of Pott’s spine
A 22-year-old malnourished male came with complaints of prolonged febrile illness with constitutional symptoms (significant weight loss and anorexia) and lower back pain with nocturnal worsening of pain not relieved by symptomatic treatment. Neurological examination revealed point tenderness at the second to fourth lumbar (L2–L3) spinous processes without paraparesis, sensory loss, abnormal reflexes in the lower limbs, or abnormal curvature of the lumbar spine. He had a history of left-sided tuberculous effusion and loculated empyema with rib erosion 3 years prior, for which he was treated with ATT but defaulted after 3 months. MRI [Figure 3a] suggested infective spondylodiscitis without myeloradiculopathy, for which urgent neurosurgical decompression through a transpedicular approach was performed, and pus was aspirated. Pus CB-NAAT confirmed MDR (Mtb), and first-/second-line LPA identified a pre-XDR strain resistant to Lfx. The patient received an 18-month oral regimen of bedaquiline, delamanid, linezolid, clofazimine, and cycloserine. After 2 years of follow-up, he gained 20 kg, experienced neurological recovery, and had no further vertebral destruction on neuroimaging [Figure 3b].
Figure 3: The typical findings of Pott’s spine in lumbosacral sagittal cuts of magnetic resonance imaging specifically at the L2–L4 levels, with changes of infective spondylodiscitis while dense necrotic collection of pus encasing the disc and adjacent structures (red arrows in a). Despite focal destruction of the vertebral body with mild disc space narrowing, early surgical decompression and debridement with antitubercular therapy resulted in preservation of vertebral architecture ([b] posttreatment: pink arrows)
Case 4: Bacterial meningitis: “Neutrophilic army against a Mycobacterium”
A 22-year-old male presented with acute-onset high-grade fever and intermittent severe holocranial headache for 7 days. He was hemodynamically stable, and neurological examination revealed signs of meningeal irritation (positive Kernig’s and Brudzinski’s signs) without focal deficits. He had no risk factors for meningitis, travel history, or zoonotic exposure, and his vaccinations were up to date. CSF analysis [Table 3] indicated community-acquired neutrophilic pyogenic meningitis, based on which empirical antibiotics and systemic glucocorticoids were started within a day. Despite appropriate antibiotic escalation within 72 h, his symptoms and fever did not resolve and his neurological status declined (Glasgow Coma Scale 12/15, reduced sensorium, poor verbal response, with no signs of raised intracranial tension). The MRI showed mild ventricular dilation and pachymeningitis and ruled out mass lesions.
Table 3: Cerebrospinal fluid analysis in meningitis
Meanwhile, the CSF BioFire analysis for viral and fungal pathogens returned negative. Despite a low probability of Mtb [Table 3], empirical ATT was initiated and a good clinical outcome was noted. He was discharged with 9 months of therapy that had no adverse events, good compliance, and no residual neurological deficits.
Case 5: “Tuberculous effusion versus parapneumonic effusion”
A 62-year-old female presented with right-sided pleuritic chest pain with a dry cough for 10 days and dyspnea on exertion for a week. Her prior two admissions history concluded partial symptomatic resolution for complaints of fever, dull epigastric pain, and vomiting treated with higher antibiotics, keeping pneumonia with atypical complaints as diagnosis after ruling out another alternative diagnosis. She was stable and afebrile, with findings of reduced breath sounds with a stony dull percussion note in the right inframammary area noted; the chest X-ray [Figure 4a] confirmed right-sided pleural effusion with subsequent aspirate analysis [Table 4], which suggested parapneumonic effusion. Anticipating nosocomial infection, an empirical higher antibiotic therapy was started, which showed poor response. Additional tests [Table 4] for Mtb were negative, and a protracted course required HRCT-thorax imaging that ruled out loculated effusion or abscess [Figure 4b]. Later, a pleural biopsy confirmed granulomas with caseous necrosis [Figure 4c] which showed clinicoradiological resolution upon the institution of ATT in 2 weeks.
Figure 4: (a) Shows an initial chest radiograph with mild right-sided CP angle blunting (pleural effusion) and consolidated lung (yellow arrows), suggesting parapneumonic effusion. Axial HRCT ([b], orange arrows) shows loculated pleural effusion with pleural and mild pericardial thickening. (c) displays pleural biopsy with lymphocytic infiltration (blue circle) and granulomas (blue arrows and arrowheads) with scanty caseous necrosis, showing a typical TB “necklace” pattern of epithelioid cells
Table 4: Pleural fluid analysis in parapneumonic effusion
Case 6: Cachexia and pleuropulmonary tuberculosis leading to superior mesenteric artery syndrome
A 14-year-old male presented with severe cachexia, high-grade fever for 5 days, toxic facies, severe left-sided pleuritic chest pain, wall tenderness, and a dry cough persisting for a week. He had a month-long history of low-grade fever, weight loss, postprandial abdominal pain, occasional vomiting, and anorexia. Examination revealed reduced breath sounds on the left side and a scaphoid abdomen. Chest X-rays [Figure 5a] indicated left-sided hydropneumothorax with possible empyema, leading to urgent ICD insertion. After draining 800 mL of foul-smelling pus, some symptomatic improvement was noted, and the results of fluid analysis [Table 5] warranted broad-spectrum antimicrobials with anaerobic coverage. Standard ATT was initiated as drain fluid was tested for Mtb (CBNAAT-positive) as prior therapy failed to show clinical improvement. It resulted in the resolution of systemic symptoms and increased appetite. Despite this, persistent postprandial epigastric pain and nonbillions vomiting required a CT abdomen to rule out peptic ulcer disease, gastric outlet obstruction, or small bowel obstruction. It revealed a depleted mesenteric fat pad and hyperacute aortomesenteric angle (5°), suggesting superior mesenteric artery (SMA) syndrome [Figure 5b and c]. The patient was treated with 9 months ATT, a high-calorie, protein-rich diet, which improved symptoms and improved weight gain. He was referred for future decortication surgery for a trapped lung [Figure 5a].
Figure 5: An air-fluid level in the left lung, indicating hydropneumothorax (red arrows) with a mediastinal shift. Postintercostal drainage (tip of intercostal drainage tube: yellow arrow in a) reveals poor lung expansion and collapse (small red arrows in a). (c) Shows a sagittal computed tomography (CT) of the abdomen with a narrowed aortomesenteric angle (5°), indicating superior mesenteric artery Syndrome. (b) An axial CT view shows a depleted mesenteric fat pad without signs of peptic ulcer disease or obstruction (blue arrows)
Table 5: Drain fluid analysis in superior mesenteric artery syndrome patient
DISCUSSION
EP-TB poses diagnostic and therapeutic challenges that require thorough clinical assessment, pathoradiological techniques, and microbiological/molecular analysis to detect Mtb in specimens from affected sites, which can be invasive at times that often deter patients. EP-TB is more common in immunocompromised individuals (40%–50%) but also affects immunocompetent people (15%–20%), especially in India.[1] Diagnosing EP-TB is more challenging when it occurs without pulmonary Kochs and carries higher mortality rate in immunocompromised despite treatment.[2,3] Among the drug defaulter population, there is the emergence of MDR/pre-XDR/XDR EP-TB, that is, prone to poor survival outcomes owing to prolonged therapy, poor compliance, and higher costs which put higher economic burden on India. This series highlights six rare cases of EP-TB that mimicked community-acquired infections and presented with neurosurgical emergency, while a few cases presented with symptomatic anatomical alterations as seen in SMA syndrome.
Renal TB is the third most common site of EP-TB in developing countries, yet it is frequently missed due to its resemblance to pyogenic pyelonephritis, as evident in case 1.[4] Initially, the patient was treated as tuberculous hydropneumothorax with secondary bacterial pyelonephritis (MDR strains) that caused septic acute kidney injury. With persistent obstructive symptoms, failure of resolution of sterile pyuria despite appropriate antibiotic escalation led to early suspicion of renal TB that prompted further investigations [Table 1]. Failure to diagnose early, results in irreversible progression to chronic kidney disease (CKD), with typical radiological findings often appearing late. Common presentations of renal TB such as flank/abdominal mass, renal abscess, hydronephrosis, strictures in the upper and lower collecting system, fistula, and calcified shrunken kidneys (putty kidneys) were absent in the present case and are late features. Early identification requires a high degree of clinical suspicion and initiation of ATT is crucial to prevent CKD progression and associated morbidity attributed to hemodialysis and cardiovascular side effects.
The second case is notable as the patient did not respond to receiving a standard ATT (fixed dose combination of H, R, Z, E as per NTEP) for 12 months, despite weight-based dosage escalation and addition of Lfx and injectable amikacin when prior failed. The patient had good compliance and no DR was documented (1st and 2nd LPA, CB-NAAT). Ideally, therapeutic drug levels should be the next best step before escalation but this was limited by the cost constraints of our setup. It is highly unusual where a documented DS EP-TB strain in an immunocompetent individual failed to respond to first- and second-line ATT and required an oral longer bedaquiline regimen. It is typically reserved for treating MDR/pre-XDR/XDR TB where it reduces the duration of therapy and enhanced mycobacterial clearance. The decision was based on clinical acumen due to the paucity of similar cases in existing literature.
The rise of MDR, pre-XDR, and XDR TB strains is multifactorial, with drug defaulters being significant contributors, as evident in the fourth case. A single centre studies across India have estimated the incidence of DR spinal TB to as high as 28.6% of which pre-XDR strain was a major contributor.[5] On contrary the number of MDR TB cases in India was 119,000, while MDR TB was documented in 7% of FL-LPA, while 29.8% and 1.6% of fluoroquinolones-resistance and second-line injectables resistance were documented on SL-LPA.[6] Musculoskeletal Kochs forms 8% of all EP-TB spectrum with vertebral column affected in 50% cases, presenting as back pain, mimicking other mechanical causes, metastatic diseases requiring extensive diagnostic tests with a low yield that causes delay.[7] Early clinicoradiological diagnosis and decompressive surgery halted a significant risk of lifelong comorbidities associated with paraplegia at a young age.[8] The treatment outcomes for XDR TB are notably poor, i.e., the success rate of 40%, significantly lower than the WHO target of 75% whereas pre-XDR TB had higher success rate of 63.3%. This is attributed to lower drug-related adverse events, higher compliance, and better prognosis compared to XDR strains.[9]
Tuberculous meningitis (TBM) (5%–10% of EP-TB) is a severe complication with a high mortality rate of 20%–54% despite treatment predominately influenced by immune status.[10,11] TBM can present in acute, subacute, or chronic forms, where prompt diagnosis with an institution of ATT within a week is essential to prevent severe neurological deficits such as cranial nerve palsies, obstructive hydrocephalus, and stroke (vasculitic infarct). This patient’s clinical features suggested pyogenic bacterial meningitis that responded poorly to higher antibiotics and systemic glucocorticoids despite timely escalation. Acute TBM can mimic neutrophilic meningitis in the first 2 weeks (10% cases) which requires the addition of ATT within 72 h.[12] The significant overlap makes differentiation of TBM from bacterial, viral, fungal, and amoebic meningoencephalitis difficult which coupled with the low diagnostic yield of CSF in the absence of typical lymphocytosis is challenging. The WHO reported a higher 79.5% pooled sensitivity of CSF CB-NAAT,[13] whereas Indian studies showed low sensitivity of 26%–46.15%.[14] Hence, sole reliance on CSF findings can be detrimental, and neuroimaging should be incorporated in every case.
In cases of tuberculous pleural effusion, the causative agent is ascertained through leukocytosis patterns (neutrophilic vs. lymphocytic), adenosine deaminase (ADA) levels, CBNAAT, and laboratory cultures.[15] In this case of parapneumonic effusion, despite higher antibiotics with nosocomial coverage in prior hospital admissions showed a sterile, neutrophilic exudative effusion with negative ADA that warranted a pleural biopsy for definite diagnosis. Challenges arise when ADA activity can be low in elderly patients, those critically ill, and tobacco addicts.[16,17] Empirical ATT was initiated while awaiting biopsy results which returned positive and confirmed the diagnosis and required 6-month therapy as no DR was identified.
Cachexia in TB is a very common, often overlooked entity that indirectly resulted in SMA syndrome due to loss of abdominal fat pad around major vessels and the gastrointestinal tract. SMA syndrome occurs in 0.013%–0.3% of the general population which is even rarer in conjunction with EP-TB.[18] Cachexia not only causes SMA but also predisposes him to other secondary infections, TB relapse, and drug resistance, which worsens the prognosis and increases case fatality. Measures such as adequate calorie supplementation (30–35 kcal/kg/day, protein: 1–1.5 g/kg/day), managing micronutrient deficiencies (supplementation of fat- and water-soluble vitamins), and appetite stimulants (megestrol acetate, cyproheptadine) play a key role in morbidly anorexic patients. Small, frequent liquid meals are essential for SMA syndrome patients, and severely anorexic, bedridden individuals may require nasojejunal/nasogastric feeding or total parenteral nutrition. The food choices should be tailored according to the patient’s cultural and demographic variability and ease of availability. A gradual feeding approach to avoid refeeding syndrome is a cornerstone in management.
CONCLUSIONS
Effective management of DS/DR-EP-TB requires multifaceted diagnostics, guideline-based treatments, and prompt adjustments. In every case, efforts for mycobacterial isolation from hard-to-reach sites and DR testing should be made before/concomitant institution of therapy. Emphasis on drug compliance, nutrition, and interdisciplinary teams is crucial for favorable outcomes, optimizes recovery, and prevents recurrence.
Outcomes of the study
Our study highlights the dilemmas of everyday clinics when there is a significant clinical and investigational disparity in diagnosis and treatment. The demographic and comorbidity profile in this series indicates that predisposition of TB is more common in malnourished, substance addict individuals despite not harboring retroviral infection regardless of their age and gender. Almost all cases highlighted clinical and laboratory findings mimicking those of bacterial infections that failed to respond to antibiotic therapy. Early clinical suspicion and tailored ATT therapy prevented irreversible complications and improved clinical outcomes while case numbers 1, 3, and 6 required interdisciplinary approach for desired outcome. Cases 1, 3, 5, and 6 emphasize the need for invasive procedures to establish the diagnosis while case number 3 highlights the issue of drug defaultation and its hazardous effect on DR. Lack of therapeutic response in DS-TB needs further research to identify and substantiate such scenarios in guideline-based management. The last case depicts the profound impact of TB-cachexia in the causation of SMA syndrome and role of nutritional supplementation which is ignored.
Rationale of the study
The paucity of data on EP-TB in context with rare presentations, drug resistances, the role of multidisciplinary techniques, and integrated approach, especially in cases with questionable characterization (bacterial vs. mycobacterial) in diagnostic evaluation is highlighted here. The notion to empirically treat EP-TB rather than investigate extensively which is prevalent in underdeveloped areas of India has been challenged in this report. The peculiar pattern of resistance, lack of therapeutic response in DS-TB, complication of abrupt defaultation of ATT, and the impact of cachexia have been highlighted here.
Limitations of the study
A larger sample size, better observational study methodology with well-defined controls, and dedicated follow-up period with the incorporation of advanced investigations such as therapeutic drug monitoring will be needed to overcome limitations such as small sample size, selection bias, poorly defined outcomes, and follow-up periods of the present study.
Ethical clearance
As this study is a retrospective observational case series the Institutional Ethics Committee of the Baroda Medical College & SSG Hospital (IEC BHR) exempted it from formal approval, as the research does not involve direct interaction with animals and poses minimal risk to human subjects.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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