Tandon, Prakash N (2020) Expert Commentary on “The Brain and Meninges in Tuberculosis Meningitis - Gross Pathology in 100 Cases and Pathogenesis” by Darab K Dastur, VS Lalitha, PM Udani, and Usha Parekh. Neurol India, 68 (6). pp. 1281-1284.

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Abstract

I deem it a privilege to have been asked by Prof. P. Sarat Chandra, Editor, to write a Commentary on the paper mentioned above by Prof. Dastur et al., published half a century ago. Prof. Dastur was not only a personal friend, but we also had a common interest in this subject. We ended up jointly co-editing a monograph “Tuberculosis of the Nervous System” in 1973.[1] Before I comment on this paper, let me say a few words about the author, who was one of the pioneers of neuropathology in the country who set standards for high-quality research, notwithstanding limited facilities. He was a meticulous, deeply committed, untiring scientist with an obsession for details and clinicopathological correlation. Besides neuro-tuberculosis and neuro-oncology, he contributed to diverse neuropathologic conditions, which included experimental studies on poliomyelitis, pathology of leprosy, Japanese encephalitis, Kyasanur Forest Disease, nutritional neuropathology, and lathyrism, among others.[2] Coming to the subject of the paper under consideration, having extensively reviewed the subject personally and followed it throughout my professional life, I can state without fear of being contradicted that Prof. Dastur et al.'s description of the “Gross Pathology” of brain and meninges in tuberculous meningitis is undoubtedly the most detailed account on the subject reflecting his characteristic, scientific traits mentioned above.[3] Beginning with a brief historical introduction on the subject, particularly the earliest Indian contributions of Morehead[4] (1849) from Bombay (now Mumbai), he has meticulously described the gross pathology of 100 brains of the patients (78 children and 22 adults) who died of tuberculosis meningitis. While describing the pathological findings, attention has been paid to clinical correlations [Table 2]. The nature and extent of the meningeal exudate are provided in meticulous details, supported by ten figures of autopsy specimens. “It is highly recommended for the readers interested in the history of tuberculous meningitis to refer to the following articles by the authors such as Pandya[5] and Tandon.[6],[7],[8] The co-existing parenchymal pathology consisting of border-zone encephalitis, diffuse edema, ventriculitis, infarction, and tuberculomas has been precisely recorded. These lesions have been correlated with duration of the disease [Figure 12], among those who were treated or untreated [Figure 11]. A detailed account has been provided of the involvement of the arteries of the circle of Wills and consequent infarction of the brain and occasional hemorrhagic lesions.[3] This has been further elaborated in other publications in the same year (Dastur and Lalitha, 1973).[9],[10] It is interesting to note that the unique entity, “Tuberculosis encephalopathy with and without meningitis” a subject of several papers by Dastur and Udani, published before this paper, does not find any reference to it in this detailed study of 100 brains.[11],[12],[13] In this paper, there is only a passing reference to it, “Another interesting but prognostically serious mechanism of brain damage accompanying even mild tuberculous meningitis and leading to rapid death, is diffuse cerebral edema.” In these papers, not only is the entity called “Tuberculous Encephalopathy,” but also a detailed account of its macro and microscopic features is provided. They attribute it as some type of allergic response.[11],[12],[13] In the same issue of Neurology India, in our paper on “Experimental Tuberculosis of the Nervous System,” we had described similar pathology observed in monkeys, a model of the tuberculosis of the central nervous system. It stated, “hypersensitized animals showed a tendency to exaltate the reaction resulting in a much degree of edema and necrosis,” as illustrated in [Figure 8] of this paper.[14],[15] When brought to his notice, Dastur agreed to the similarity and pathogenetic basis of the two lesions. This was further elaborated by Dastur et al.[9],[15],[16] The possible role of proteins liberated by dead tubercle bacilli in the pathogenesis of such lesions was referred by Ridley[17] and Chandramukhi and Shankar.[18] Before discussing this paper further, let me mention some of the other papers by him on the subject of neuro-tuberculosis. Dastur and Wadia described the clinical and pathological features of spinal meningitis and radiculopathy.[19],[20] Dastur and Lalitha (1970) published a detailed account of “Many facts of neuropathology of neuro-tuberculosis: an epitome in neuropathology” in progress in neuropathology edited by Zimmerman.[9] Udani et al. (1971) elaborated their extensive experience on “Neurological and related syndromes of CNS tuberculosis: Clinical features and pathogenesis.”[21] Dastur and Dave (1977) described “Ultrastructural basis of vasculopathy in and around brain tuberculoma – The possible significance of altered basement membrane.”[22] Dastur and Dave provided “Further observations on the fine structure of blood vessels in neuro-tuberculosis” in Advances in Neurology edited by Cervos Navarro.[23] In addition, Dastur et al. published a series of papers on the other aspects of CNS tuberculosis, which dealt mostly with brain tuberculomas.[24],[25],[26],[27],[28] Reviewing this paper also brings nostalgic memories of our work and those of other colleagues on the subject of neuro-tuberculosis, some of which elaborated Dastur's observations while others provided new knowledge. I take the liberty to refer to these for the sake of our younger colleagues and in the interest of our history. The subject of neuro-tuberculosis aroused widespread interest in the country in the 1960s and 1970s, first owing to the frequency of the disease and second because the interest in the subject abroad had waned. In the interval between the publication by Moorhead (1849) and the initiation of the first Neurosurgical Service in India by Dr. Chandy, I could find two interesting papers on the subject of neuro-tuberculosis. The first one was by De, a renowned microbiologist, who in 1949 published a paper in the British Medical Journal “Streptomycin in development of hydrocephalus in tuberculous meningitis.”[29] This was soon after the availability of streptomycin in the country. In 1951, Reddy, a pathologist, published the first report on autopsy proved four tuberculomas among 38 cases of intracranial tumors.[30] Soon after Chandy and Isaiah (1952) reported on 8 cases of tuberculomas of the brain,[31] while Ramammurthi (1956) reported 35 cases.[32] These were followed by a number of reports on intracranial tuberculomas from different centers. Bagchi from Calcutta,[33] Ramamurthi and Varadarajan,[34] Ramamurthi and Natrajan,[35] Ramamurthi Madras.[36] Dastur and Anil Desai,[37],[38] Dastur and Shah,[24] Sinh et al.[26] from Bombay, Mathai,[39] and Mathai and Chandy[40] from Vellore provided a detailed account of these lesions. However, there were a large number of publications on the different facets of neuro-tuberculosis in the 1960s and 1970s. The following account is mostly restricted to this period. More recent papers on the subject are not included. Thus, Khatua,[41] Ginde,[42] Ghosh,[43] Mathai and Chandy,[40] Deshpande et al.,[44] Bharucha et al.,[45] Tandon and Pathak,[46] and Tandon and Tandon[47] dealt with in detail various aspects of tuberculous meningitis. Ginde and Banker,[48] Singh et al.,[49] Bawa and Wahi,[50] Rao and Subrahmanyam,[51] Tandon and Mishra,[52] and Kak et al.[53] described primary and secondary spinal meningitis/arachnoiditis. Raised intracranial pressure and postmeningitic hydrocephalus were the subjects of a number of publications dealing with its pathogenesis, diagnosis, and therapy. Dastur et al.,[54] Bhagwati and Singhal,[55],[56] Singhal et al.,[57] Tandon et al. (1975),[58],[59] Bhargava et al.,[60] and Mitra et al.[61] Arteritis, an important feature of tuberculosis meningitis, described in details by Dastur et al. was further investigated by Wadia and Singhal,[62] Mathew et al.,[63] Misra PK et al., (1973),[64] Dalal et al.,[65] and Dastur and Dave.[22],[23] Over the years, besides the references included here, we published a chapter in national and international textbooks comprehensively dealing with the subject, Tandon and Pande.[66] This has been summarized in a monograph “My Tryst with Biomedical Research” and a recent review in National Medical Journal.[67],[68] Obviously, there have been many more contributions by other colleagues in India in recent years than listed here. Comments here are primarily directed to the features highlighted in the paper under review. It is worth mentioning that Indian contributors in the field were widely recognized. In a book on “Infections of the Nervous System,” Kennedy and Jhonson published by Butterworth in 1987 Kocen writing on the Tuberculosis of the Nervous System stated that “In more recent years, the major contributions on both pathology and the varied clinical manifestations of the brain and spinal cord have come from workers in India, in particular Dastur, Tandon, and Wadia.

Item Type:	Article
Subjects:	Neurodegenerative Disorders Neuro-Oncological Disorders Neurocognitive Processes Neuronal Development and Regeneration Informatics and Imaging Genetics and Molecular Biology
Depositing User:	Dr. D.D. Lal
Date Deposited:	03 Aug 2021 05:04
Last Modified:	16 Dec 2021 07:44
URI:	http://nbrc.sciencecentral.in/id/eprint/721

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