Date Published: December 15, 2011
Publisher: Hindawi Publishing Corporation
Author(s): Smita Bhagwan, Kogieleum Naidoo.
We conducted a retrospective review of confirmed HIV-TB coinfected patients previously enrolled as part of the SAPiT study in Durban, South Africa. Patients with suspected meningitis were included in this case series. From 642 individuals, 14 episodes of meningitis in 10 patients were identified. For 8 patients, this episode of meningitis was the AIDS defining illness, with cryptococcus (9/14 episodes) and tuberculosis (3/14 episodes) as the commonest aetiological agents. The combination of headache and neck stiffness (78.6%) was the most frequent clinical presentation. Relapsing cryptococcal meningitis occurred in 3/7 patients. Mortality was 70% (7/10), with 4 deaths directly due to meningitis. In an HIV TB endemic region we identified cryptococcus followed by tuberculosis as the leading causes of meningitis. We highlight the occurrence of tuberculous meningitis in patients already receiving antituberculous therapy. The development of meningitis heralded poor outcomes, high mortality, and relapsing meningitis despite ART.
Tuberculosis (TB) is the most common opportunistic infection in patients with Human Immunodeficiency Virus (HIV). The estimated relative risk of HIV-infected individuals developing TB is 20.6 compared to HIV uninfected, in populations with a generalized HIV epidemic .
We retrospectively reviewed HIV-TB coinfected patients with suspected meningitis. Patients 18 years and older, with confirmed pulmonary TB and HIV, enrolled into the SAPiT study, presenting with suspected meningitis were included in this study. The SAPiT study was a prospective randomized control trial conducted in Durban, South Africa (June 2005–July 2008), investigating the optimal timing of antiretroviral therapy (ART) initiation in patients on antituberculous therapy. All patients in the SAPiT study were sputum smear positive for mycobacteria on enrollment. They were randomly assigned to three groups, each group initiating ART at a different stage in tuberculosis therapy: within 4 weeks after the start of tuberculosis therapy (early arm), within 4 weeks after the completion of the intensive phase of tuberculosis therapy (post intensive arm), or within 4 weeks of completion of tuberculosis therapy (postcontinuation arm) .
From 642 TB-HIV coinfected patients enrolled, 20 (3.1%) patients presented with clinical features suggestive of meningitis, with 10 (50%) classified as not having meningitis (two cerebral tuberculomas, one cerebral toxoplasmosis, three with normal CSF, and four with insufficient data to support our case definitions). Fourteen episodes of meningitis that met our case definitions occurred in 10 patients, summarized in Table 1.
In this first case series evaluating meningitis in confirmed HIV-TB coinfected patients, we demonstrate that the leading cause of meningitis is cryptococcus followed by tuberculosis, which is in keeping with population-based reports from sub-Saharan Africa investigating meningitis in patients with HIV alone . In this sample of coinfected patients, development of meningitis was associated with poor outcomes including relapsing meningitis (30%) and high mortality (40%), even in patients already initiated on ART (57%). Patients in this study were severely immunocompromised with low CD4+ cell counts (median 13 cells/mm3), which could account for the reduced frequency of fever as a presenting complaint and the high mortality and relapse rates.