Clinical and Microbiological Features of HIV-Associated Tuberculous Meningitis in Vietnamese Adults

Abstract

MethodsThe aim of this prospective, observational cohort study was to determine the clinical and microbiological features, outcome, and baseline variables predictive of death, in Vietnamese adults with HIV-associated tuberculous meningitis (TBM). 58 patients were admitted to the Hospital for Tropical Diseases in Ho Chi Minh City and underwent routine clinical and laboratory assessments. Treatment was with standard antituberculous therapy and adjunctive dexamethasone; antiretroviral therapy was not routinely available. Patients were followed up until the end of TB treatment or death.ResultsThe median symptom duration was 11 days (range 2–90 days), 21.8% had a past history of TB, and 41.4% had severe (grade 3) TBM. The median CD4 count was 32 cells/mm3. CSF findings were as follows: median leucocyte count 438×109cells/l (63% neutrophils), 69% smear positive and 87.9% culture positive. TB drug resistance rates were high (13% mono-resistance 32.6% poly-resistance 8.7% multidrug resistance). 17% patients developed further AIDS-defining illnesses. 67.2% died (median time to death 20 days). Three baseline variables were predictive of death by multivariate analysis: increased TBM grade [adjusted hazard ratio (AHR) 1.73, 95% CI 1.08–2.76, p = 0.02], lower serum sodium (AHR 0.93, 95% CI 0.89 to 0.98, p = 0.002) and decreased CSF lymphocyte percentage (AHR 0.98, 95% CI 0.97 to 0.99, p = 0.003).ConclusionsHIV-associated TBM is devastating disease with a dismal prognosis. CSF findings included CSF neutrophil predominance, high rates of smear and culture positivity, and high rates of antituberculous drug resistance. Three baseline variables were independently associated with death: increased TBM grade; low serum sodium and decreased CSF lymphocyte percentage.

Tuberculous Meningitis in Adults: A Review of a Decade of Developments Focusing on Prognostic Factors for Outcome

“…The mortality for HIV-infected patients with TBM is alarmingly high [5,96,97]. Most patients presenting with TBM are either not receiving antiretrovirals (ARVs) or are not being effectively treated with them.…”

“…Most patients presenting with TBM are either not receiving antiretrovirals (ARVs) or are not being effectively treated with them. CD4 counts of patients with TBM are typically very low (<50) [97]. For these patients, the question of timing of ART is critical.…”

Influence of Antituberculosis Drug Resistance and Mycobacterium tuberculosis Lineage on Outcome in HIV-Associated Tuberculous Meningitis

“…The primary analysis of the observational cohort study and the randomized controlled trial have been previously reported (22,23). We included all patients from these studies who had M. tuberculosis isolated from the CSF and available for analysis of drug resistance: 46/58 (79%) from the cohort study and 141/253 (56%) from the RCT.…”

“…The first study was an observational cohort study of 58 HIV-associated TBM patients admitted to the Hospital for Tropical Diseases, Ho Chi Minh City (HCMC), between November 2004 and September 2005 (22).…”

“…Outcomes are extremely poor, with mortality in HIV-uninfected patients of approximately 30% and severe neurological sequelae in up to half of those surviving (21,25). HIV-infected individuals are more susceptible to developing the severe disseminated forms of tuberculosis (TB), and mortality in these patients can exceed 60% (11,22). The best current predictor of clinical outcome is the British Medical Research Council (MRC) disease stage at which a patient is diagnosed and when the patient starts appropriate chemotherapy (6).…”