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Journal of Critical Care xxx (2015) xxxxxx

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Journal of Critical Care


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Outcome of tuberculous meningitis patients requiring


mechanical ventilation
U.K. Misra, J. Kalita , S. Betai, S.K. Bhoi
Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Science, Raebareily Rd, Lucknow

a r t i c l e

i n f o

Keywords:
Tuberculous meningitis
Mechanical ventilation
Chronic meningitis
Intensive care unit
Mortality
Outcome

a b s t r a c t
Purpose: There is paucity of information about the outcome of tuberculous meningitis (TBM) patients on mechanical ventilation (MV). In this communication, we report the clinical characteristics, predictors of MV, and
outcome of TBM patients requiring MV.
Method: Thirty-eight (18%) of 205 patients with TBM requiring MV were included; and their demographic, clinical, cerebrospinal uid, and magnetic resonance imaging nding at admission and follow-up were noted. The
ventilator-related and systemic complications, hospital death, and 3-month functional outcome were noted.
The predictors of need of MV were derived by multivariate regression analysis.
Results: There were 38 MV and 36 non-MV TBM patients who were matched for age, sex, and stage of meningitis
on admission. The requirement of MV was independently related to leukocytosis, seizure, and cerebrospinal uid
pleocytosis on admission. Patients on MV had higher frequency of septicemia (9 vs 2), bedsores (6 vs 0), and gastric hemorrhage (4 vs 0) compared with non-MV patients. Only 29% of MV patients survived and had poor outcome at 3 months; but in the non-MV group, all the patients survived, and only 11% had poor outcome.
Conclusion: Mechanical ventilation was needed in 18% TBM patients because of TBM-related or systemic complications. Those requiring MV had high mortality and may be categorized separately.
2015 Elsevier Inc. All rights reserved.

1. Introduction

2. Subjects and methods

Tuberculosis is an important public health problem. It is estimated


that more than 2 billion people are infected with Mycobacterium tuberculosis, and 10% of them develop active tuberculosis [1]. Tuberculosis results in 2 million deaths annually, and 90% of these deaths occur in the
developing countries of Asia and Africa. About 50% of new cases are
from Bangladesh, Pakistan, India, China, Indonesia, and the Philippines
[2]. Tuberculous meningitis (TBM) constitutes about 5% of extrapulmonary tuberculosis and is the most severe form of tuberculosis
with high mortality and morbidity. About 10% to 30% of patients with
TBM die, one third of the surviving patients have long-term functional
decit, and 78% have neurological sequelae [37]. In TBM, there may
be vasculitis, exudates, hydrocephalous, and tuberculoma which contribute to increased intracranial pressure, altered sensorium, and brain
herniation with ominous consequences [4,8]. Intensive care management of these patients can be challenging but lifesaving. There is a paucity of information regarding intensive care unit (ICU) management of
TBM patients. In this communication, we report our experience of management of TBM patients in a neurology ICU and evaluate the predictors
of mechanical ventilation (MV) and their outcome.

Patients with TBM admitted to neurology ICU during 2010-2014


were included. These patients were retrospectively analyzed from a
prospectively maintained TBM registry. The diagnosis of TBM was
based on clinical, cerebrospinal uid (CSF), and magnetic resonance imaging (MRI) ndings. The essential diagnostic criteria were symptoms
of meningitis (fever, headache, vomiting) for at least 2 weeks in which
malaria, septic meningitis, and fungal meningitis were excluded. The
supportive criteria included (a) CSF cells greater than 2 10 9/L with
lymphocyte predominance, protein greater than 1 g/L, sterile bacterial
and fungal culture, and negative cryptococcal antigen; (b) computed tomography (CT) or MRI showing exudate, hydrocephalous, tuberculoma,
or infarction; and (c) extra central nervous system (CNS) tuberculosis.
Presence of essential criteria with 2 supportive criteria was considered TBM. Presence of acid-fast bacilli (AFB) in CSF, smear or BACTEC
culture, polymerase chain reaction (PCR), or immunoglobulin M
enzyme-linked immunosorbent assay was considered as denite and
the remaining as probable TBM [5].
2.1. Evaluation

Corresponding author at: Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareily Rd, Lucknow, 226014. Tel.: +91 522 2494177;
fax: +91 522 2668811.
E-mail addresses: jayanteek@yahoo.com, jkalita@sgpgi.ac.in (J. Kalita).

Clinical history including demographic information, symptoms of


meningitis and its duration, alteration in sensorium, seizure, focal weakness, and respiratory symptoms were noted. Consciousness was
assessed by Glasgow Coma Scale (GCS). The patients were considered

http://dx.doi.org/10.1016/j.jcrc.2015.08.017
0883-9441/ 2015 Elsevier Inc. All rights reserved.

Please cite this article as: Misra UK, et al, Outcome of tuberculous meningitis patients requiring mechanical ventilation, J Crit Care (2015), http://
dx.doi.org/10.1016/j.jcrc.2015.08.017

UK. Misra et al. / Journal of Critical Care xxx (2015) xxxxxx

Table 1A
Comparison of demographic and clinical characteristics of tubercular meningitis patients
with and without MV

Sex (female/male)
Age (y)
Stage of TBM, I/II/III
Duration of illness (d)
GCS score
Focal motor decit
Seizures
Status epilepticus
Hypertension
Diabetes mellitus
Coronary artery disease
Renal failure
Liver dysfunction
Diagnosis
Denite/probable
PCR+
AFB+
Culture+

Ventilated (n = 38)

Non ventilated (n = 36)

P value

15/23
35.9 12.6
1/15/22
74.3 65.5
9.8 3.3
24
24
7
9
5
1
5
0

13/23
37.1 16.6
1/18/17
68.5 66.6
11.0 2.7
18
11
3
20
4
2
0
1

.81
.72
.65
.71
.11
.35
.004
.21
.005
1.00
.61
.02
.49
.78

14/24
9/27
3/35
8/30

11/25
7/28
2/34
7/29

+, present.

to have raised intracranial pressure based on extensor posturing, hyperventilation, and pupillary asymmetry. Cranial nerve palsies and
papilloedema were noted. Muscle weakness was recorded as
monoplegia, hemiplegia, paraplegia, or quadriplegia. The severity of
weakness was graded as complete or partial. Muscle tone and tendon
reexes were graded as absent, normal, or increased. Stage of meningitis was categorized as follows [7]:
Stage I: meningitis only
Stage II: meningitis with focal neurological signs or GCS score 11 to 14
Stage III: meningitis with altered sensorium; GCS score less than 11.
2.2. Investigations
Blood counts, hemoglobin, erythrocyte sedimentation rate at rst
hour, blood glucose, serum creatinine, albumin, bilirubin, transaminases, and electrolytes were measured. Chest radiograph, electrocardiogram, and HIV serology were also done. Cranial MRI was done using a
3-T MRI scanner (Signa; GE Medical Systems, Milwaukee, WI). T1, T2,
uid attenuated inversion recovery, diffusion weighted image, and T1
contrast images were obtained in axial, coronal, and sagittal plain. Presence of exudates, hydrocephalus, infarction, and granuloma was noted.
Lumbar CSF was examined for cell, protein, and glucose. Cerebrospinal
uid smear and culture (BD BACTEC TM, BD, Sparks, MD) were done
for AFB. Cryptococcal antigen, immunoglobulin M enzyme-linked immunosorbent assay for M tuberculosis, and PCR were also carried out.
The patients were treated with rifampicin (10 mg/kg, ~450 mg), isoniazid (5 mg/kg, ~ 300 mg), pyrazinamide (20-25 mg/kg, ~ 1500 mg),
and ethambutol (15-20 mg/kg, ~ 800 mg) with prednisolone 0.5
Table 1B
Comparison of baseline laboratory prole of tubercular meningitis patients with and without MV
Parameters

Ventilated
(n = 38)

Non ventilated
(n = 36)

P value

Hemoglobin (g/dL)
Leucocyte count/mm3
Sodium (mEq/L)
Creatinine at admission (mg/dL)
Serum albumin (g/dL)
ALT (mEq/L)
AST (mEq/L)
Serum bilirubin (mg/dL)
CSF total cells/mm3
CSF proteins (mg/dL)

10.7 2.4
13 805.3 6798.3
132.4 8.0
1.1 0.9
3.2 0.8
120.0 119.2
117.7 118.2
0.8 0.4
210.9 251.7
222.0 243.7

11.5 1.8
9713.9 3838.8
133.49 7.3
0.9 0.8
3.5 0.6
101.1 135.2
88.5 91.6
1.0 0.9
78.4 94.4
171.5 174.7

.11
.002
.53
.44
.05
.53
.25
.26
.005
.34

Table 1C
Baseline MRI ndings of TBM patients who required MV and those who did not

Infarct
Tuberculoma
Hydrocephalus
Meningeal enhancement
Brainstem lesion
Posterior fossa lesion
Midline shift/herniation

Mechanically ventilated
n = 38

Not ventilated
N = 36

P value

20
13
15
11
4
6
1

15
17
19
14
3
6
1

.51
.46
.46
.55
.68
.74
.74

mg/kg (~40 mg) and aspirin 150 mg daily [9]. Prednisolone was tapered
after 1 month and stopped at the end of the second month. All the antitubercular drugs were given for 6 months followed by rifampicin and
isoniazid for an additional 1 year. Drug-induced hepatitis was diagnosed
on the basis of 3- to 5-fold rise in transaminase level after at least 3 days
of antitubercular treatment (ATT) without any other apparent cause for
liver dysfunction whose baseline liver function was normal. After discontinuation of hepatotoxic ATT, there was more than 50% improvement in liver functions. In these patients, ATT was modied and was
restarted sequentially when the transaminase level was less than 2
times the normal [10]. Patients with obstructive hydrocephalus with deteriorating consciousness were subjected to ventriculoperitoneal shunt.
The TBM patients were intubated and articially ventilated if unable
to maintain oxygen saturation by Ventimask or if there was respiratory
acidosis (pH b7.3), carbon dioxide retention (PaCO2 N 50 mm Hg), or
hypoxia (PaO2 b 60 mm Hg) [11]. Blood pressure, pulse, and oxygen saturation were monitored continuously. Arterial blood gas analysis (ABG)
was done daily or more frequently if indicated. Chest radiograph, blood
counts, and blood culture were done as indicated. The duration of MV,
ventilator-related complications (ventilator-associated pneumonia,
pneumothorax), and other complications (deep vein thrombosis, pressure sores, urinary tract infection, sepsis) were also noted.
From our TBM registry, 36 age- and stage-matched TBM patients on
admission who did not require articial ventilation were included as
controls.
2.3. Outcome
Complications during hospital stay were noted. Death during hospital stay and 3-month functional outcome of the surviving patients were
categorized on the basis of activity of daily living (ADL) as complete (independent for ADL), partial (partially dependent for ADL), and poor
(bed ridden or wheel chair bound) recovery [12].
2.4. Statistical analysis
The baseline clinical, laboratory, and MRI ndings between the TBM
patients with and without MV were compared using 2 for categorical
variables and independent t test or Mann-Whitney U test for continuous
variables. The predictors of MV were derived using logistic regression
analysis including the variables with a P value of b.10. The patients
with MV who died were compared with the surviving group with respect to their clinical, demographic, radiological, and ventilator-related
and systemic complications using 2, Mann-Whitney U test, or Student
t test. The predictors of death of MV patients were analyzed using logistic regression analysis. The variable was considered signicant if the
2-tailed P value was less than .05. The statistical analysis was done
using SPSS (Chicago, IL) 16 version software.
3. Results
During the study period, 205 patients with TBM were admitted and
38 (18.5%) of them needed MV. The median age of the MV patients was
32.5 (range, 17-65) years, and 15 (39.5%) were female. On admission,

Please cite this article as: Misra UK, et al, Outcome of tuberculous meningitis patients requiring mechanical ventilation, J Crit Care (2015), http://
dx.doi.org/10.1016/j.jcrc.2015.08.017

UK. Misra et al. / Journal of Critical Care xxx (2015) xxxxxx

the majority of the patients belonged to stage II (15) and stage III (22)
meningitis; and only 1 patient was admitted in stage I TBM. The diagnosis of TBM was denite in 14 (36.8%) patients and probable in 24
(63.2%). The median duration of illness before hospitalization was 60
(range, 7-241) days, seizures were present in 24 (63.2%), and 7
(18.4%) of them had status epilepticus. The admission GCS score ranged
between 3 and 15 (median, 10) and was less than 8 in 10 (26.3%) patients. Focal weakness was present in 24 (63.2%) patients, hemiplegia
in 16 (42.1%), paraplegia in 3 (7.9%), and quadriplegia in 5 (13.2%). Cranial nerve palsies were involved in 5 (13.15%) patients. The comorbidities included hypertension in 9, diabetes in 5, coronary artery disease in
1, and renal failure in 5 patients. On admission, 20 (52.6%) patients were
anemic, 23 (60.5%) had hypoalbuminemia, 25 (65.8%) had hypocalcemia, and 16 (42.1%) had hyponatremia.

Table 2
Comparison of laboratory parameters during hospital stay (worst value) in TBM patients
who required MV and those who did not

Hemoglobin (g/dL)
Leucocyte/mm3
Serum albumin (g/dL)
Serum calcium (ionic) (mg/dL)
Serum sodium (mg/dL)
Serum bilirubin (mg/dL)
ALT (U/L)
AST (U/L)
CSF total cells/mm3
CSF protein (mg/dL)

Mechanically
ventilated

Not ventilated

P value

9.1 2.5
16 902 6329
2.6 0.6
4.0 0.5
128.1 6.6
1.5 2.3
235.1 252.2
191.9 155.6
210.9 251.7
222.0 243.7

10.6 1.9
11 578 5374
3.1 0.5
4.3 0.4
127.3 6.0
1.8 2.7
163.5 163.2
136.5 124.4
78.4 94.4
171.5 174.7

.007
.000
.001
.001
.596
.595
.155
0.099
0.005
0.338

3.1. Ventilation characteristics


The patients were intubated after a median duration of 5 (range, 134) days of admission because of respiratory suppression resulting in
inability to maintain oxygen saturation and carbon dioxide retention.
The immediate reason for MV was raised intracranial pressure in 13,
postventriculoperitoneal shunt in 4, pneumonia in 15, and sepsis
with acute respiratory distress syndrome in 6 patients. The patients
needed MV for a median of 8.5 (range, 1-90) days. Prolonged MV
(N15 days) was needed in 11 (28.9%) patients in whom tracheostomy
was done. During MV, the ventilator-related complications included
ventilator-associated pneumonia in 9, pneumothorax in 1, subcutaneous emphysema in 1, and lung collapse in 2 patients.
3.2. Comparison of MV and non-MV patients
The TBM patients requiring MV were compared with 36 non-MV patients who were matched for age, sex, and stage of TBM on admission.
There was no difference in the duration of illness, GCS score, focal
motor decit, bladder involvement, and liver dysfunction between the
2 groups on admission. The MV group had higher frequency of seizures
(24 vs 11, P = .006), infrequent hypertension (9 vs 20, P = .008), and
higher frequency of preexisting renal failure (5 vs 0, P = .02) compared
with the non-MV group. On admission, the MV patients had lower
serum albumin (P = .05) and higher leukocyte count (P = .002) compared with the non-MV patients. Serum sodium, alanine aminotransferase (ALT), aspartate aminotransferase (AST), and serum bilirubin were
not different between the 2 groups. The CSF cells were higher in the
MV compared with non-MV patients (P = .005), but CSF protein was
not different (P = .34). The details are presented in Tables 1A and 1B.
On admission, MRI was abnormal in all the patients; and the ndings
such as infarction, tuberculoma, hydrocephalus, meningeal enhancement, brainstem lesion, posterior fossa lesion, midline shift, and herniation were not different between the 2 groups (Table 1C). The diagnostic

certainty of TBM was also similar in both groups. On logistic regression


analysis, blood leukocytosis (odds ratio [OR], 1.0; 95% condence interval [CI], 0.9-1.0; P = .009], seizure (OR, 0.14; 95% CI, 0.03-0.56; P =
.006), and CSF cells (OR, 0.99; 95% CI, 0.98-1.0; P = .02) were independently associated with the need of MV (Fig. 1).
3.3. Hospital course and outcome
The median hospital stay of the MV patients was longer compared
with that of non-MV patients (29.1 32.9 vs 20.9 10.1days; P =
.16). The MV patients had greater drop of hemoglobin (1.47 2.2 vs
0.9 1.1 g/dL; P = .17), serum albumin (0.43 0.6 vs 0.3 0.4 g/
dL; P = .46), and serum calcium (0.30 0.41 vs 0.1 0.3 mg/dL; P =
.18) compared with the non-MV patients. The MV patients also developed more frequent hyponatremia (21 [55.3%] vs 24 [66.7%]; P = .31)
and drug-induced hepatitis compared with non-MV patients (21 vs
16; P = .19). Cerebrospinal uid examination was repeated in 29 patients, and those with MV had higher CSF pleocytosis compared with
the non-MV group (P = .005). Hypotension and shock were present
in 18 (47.4%) patients with MV and 1 (2.8%) without MV, and they
were treated with vasopressors (P b .001). The details are summarized
in Table 2. A second cranial imaging was done in 19 MV patients (CT
scan in 16, MRI in 3) and in 15 non-MV patients (CT scan in 7, MRI in
8) because of clinical worsening. The cranial imaging revealed higher
frequency of new infarctions (10 vs 3; P = .04), herniation (6 vs 0; P
= .01), and increase in hydrocephalous (7 vs 2; P = .09) in MV compared with non-MV patients (Table 3).
The general complications were more frequent in the MV patients
compared with non-MV patients which include septicemia (9 vs 2;
P = .03), bedsore (6 vs 0; P = .01), and gastric hemorrhage (4 vs 0;
P = .04). Three patients with septicemia had positive bacterial culture
(3 vs 0; P = .25). Ventriculoperitoneal shunt was done in 10 (26.3%)
MV and 8 (22.2%) non-MV patients (P = .68).

Fig. 1. Variables independently related to need of MV in the patients with TBM.

Please cite this article as: Misra UK, et al, Outcome of tuberculous meningitis patients requiring mechanical ventilation, J Crit Care (2015), http://
dx.doi.org/10.1016/j.jcrc.2015.08.017

UK. Misra et al. / Journal of Critical Care xxx (2015) xxxxxx

Table 3
Comparison of follow-up imaging (CT/MRI) ndings in MV and non-MV TBM patients
Imaging ndings

MV group

Non-MV group

P value

New infarct
New tuberculoma
Increase in tuberculoma size
New onset hydrocephalus
Increase in hydrocephalus
New onset herniation

10 (26.3%)
1 (2.6%)
1 (2.63%)
7 (18.4%)
7 (18.4%)
6(15.8%)

3(8.3%)
4 (11.1%)
1 (2.77%)
3(8.3%)
2(5.6%)
0 (0%)

.04
.15
.969
.21
.09
.01

Twenty-seven patients (71%) died in the MV group and none in the


non-MV group. They died after a median 5 days of ventilation (range, 153 days): 17 patients within 8 days, 20 within 15 days, and 7 thereafter.
The cause of death was sepsis in 6 (22.2%); pneumonia in 9 (33.3%);
brain herniation due to hydrocephalus, tuberculoma, or stroke in 10
(37%); and shunt malfunction in 2 (7.4%) patients. None of the MV patients recovered completely at 3 months, but 14 patients in the nonMV group recovered completely (Fig. 2). Twelve (31.6%) patients were
intubated for TBM-related causes, and they were intubated after a median 9 (range, 1-33) days of hospitalization compared with 26 (68.4%)
who were intubated for systemic complications after a median of 2
(range, 1-20) days (P = .002). The death rate was higher if the need
of MV was due to systemic causes than that for TBM per se (20/26 vs
7/12; P = .24).

4. Discussion
In the present study, 18.5% of patients with TBM needed MV because
of associated sepsis and pneumonia in 55.3% and because of TBMrelated complications such as raised intracranial pressure and
venticuloperitoneal shunt in the remaining 44.7% of patients. Presence
of sepsis, seizures, and CSF pleocytosis on admission predicted MV. Thirty percent patients with MV survived but had major neurological decit
at 3 months.
This study for the rst time reports the outcome of mechanically
ventilated TBM patients. The outcome of TBM has been reported to be
dependent on age, GCS score, stage of meningitis, hydrocephalus, infarction, and paradoxical response to ATT [4,12,13]. The mortality in TBM
may vary in different stages of meningitis, being worse in stage III and
stage II compared with stage I. The mortality of TBM in stage II and III
has ranged between 66% and 86% [13]. In a study from France in 270 patients with TBM, the mortality was 47.9% in patients receiving corticosteroids and 52.1% in those without corticosteroids. The case fatality
rate in stage III meningitis was 61.5% in the group who received corticosteroids and 74.1% in those who did not [14]. This highlights the high

mortality of TBM in stage III meningitis which is similar to our patients


who were mechanically ventilated and all our patients received corticosteroid and aspirin. None of our patients in stage III died who did not require MV is fallacious. Because the TBM patients who developed TBM
related or systemic complications having altered blood gas analysis received MV; therefore, none died in the non-MV group. The baseline demographics and stage of meningitis though were comparable between
the MV and non-MV groups, but the outcome was signicantly different
with respect to mortality and disability. Tuberculous meningitis is a
polymorphic disease with variable manifestations such as meningoencephalitis, granuloma, infarction, and hydrocephalous in various permutations and combinations [4,15]. The response to ATT is also
variable. After initiating ATT, the granuloma may increase in size or
new ones may appear. There may be appearance of infarction and hydrocephalus, which may lead to worsening after starting ATT [5,16]. In
our earlier study on 34 patients with denite TBM, 64.7% had paradoxical tuberculoma mostly within 3 months of starting ATT; but only half
of them had clinical worsening [5]. In the present study, however, paradoxical tuberculoma was not signicantly different in the MV and
non-MV group; but there were more frequent infarctions which may
have contributed to herniation and death in the MV group.
In our study, baseline infarctions were present in 52.6% of patients in
the MV group and in 41.7% in the non-MV group. Ten patients in MV
group developed additional infarction during treatment which might
have been responsible for prolonged MV in 3 (7.9%) patients. Stroke in
TBM has been reported in 45% to 50% of patients in MRI-based studies
[17]. In a study on 122 patients, 45% of patients had infarction on MRI.
Stroke was associated with poor outcome, and 42% of patients with
stroke died or had poor outcome at 3 months [15].
In our study, presence of seizures on admission was signicantly associated with need of MV. Sixty-three percent of TBM patients with seizures needed MV; and 25% of them had status epilepticus, which was
double than those in non-MV patients. Seizures and particularly status
epilepticus may result in raised intracranial pressure and may critically
tilt the balance adversely especially in those who already have raised intracranial pressure. In the developing countries, the CNS infections are
the leading cause of status epilepticus and have been reported in 36%
to 53.8% of patients. The status epilepticus due to CNS infection is generally refractory to treatment and has high mortality [1820].
The patients with raised intracranial pressure had increased sympathetic drive which makes the patients vulnerable to infections [21]. In
acute stroke patients, there is high incidence of pneumonia and infection in the patients with raised intracranial pressure [21]. In the present
study, sepsis and pneumonia were responsible for MV in half the patients. During MV, 24% of patients had ventilator-associated pneumonia
and 24% septicemia, which also contributed to the mortality and morbidity of TBM. In our patients, the death was related to pneumonia in
33% and to sepsis in 22%; and it was considered to be due to TBM per
se in 44% of patients. In our experience, the complications in TBM patients needing MV were higher compared with Guillain-Barre syndrome and myasthenia gravis. Out 64 patients with myasthenia
gravis, 14 developed crisis and needed MV. Two of whom died because
of associated comorbidities including thalamic hemorrhage in one and
coronary artery disease in the other [22]. In our study on GuillainBarre syndrome, of 362 patients, 44 were mechanically ventilated, 5
(11.4) of whom died because of pneumonia in 2 and severe
dysautonomia in 3 (unpublished data).

4.1. Limitations

Fig. 2. The outcome of TBM patients who were mechanically ventilated (MV) and those
who were not (non-MV).

The present study is limited by its retrospective nature, and conservative protocol of intubation and monitoring. We have not done
intraarterial blood pressure and intracranial pressure monitoring; the
use of these types of monitoring however has not been established to
be benecial in ICU patients in a meta-analysis [23].

Please cite this article as: Misra UK, et al, Outcome of tuberculous meningitis patients requiring mechanical ventilation, J Crit Care (2015), http://
dx.doi.org/10.1016/j.jcrc.2015.08.017

UK. Misra et al. / Journal of Critical Care xxx (2015) xxxxxx

In view of the high mortality in ventilated TBM patients, it seems


that these patients are a group in itself and may be categorized separately and not clubbed with MRC grade III.
Acknowledgement
We thank Mr Rakesh kumar Nigam and Mr Deepak Kumar Anand for
secretarial help.
Funding support: none.
Conict of interest: There is no conict of interest to declare.
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Please cite this article as: Misra UK, et al, Outcome of tuberculous meningitis patients requiring mechanical ventilation, J Crit Care (2015), http://
dx.doi.org/10.1016/j.jcrc.2015.08.017

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