Tuberculous meningitis in HIV-infected individuals

Abstract

HIV-infected individuals are at increased risk for all forms of extrapulmonary tuberculosis, including tuberculous meningitis. This risk is increased at more advanced levels of immunosuppression. The time interval between onset of symptoms and presentation to medical care may vary widely, and consequently individuals may present with acute or chronic meningitis. The clinical presentation of tuberculous meningitis in HIV-infected individuals is more likely to include an altered level of consciousness, cranial imaging is more likely to show cerebral infarctions, and the yield of culture of cerebrospinal fluid may also be greater. Given that delayed initiation of therapy is a strong predictor of mortality in cases of tuberculous meningitis, clinicians must consider tuberculosis in the differential diagnosis of the HIV-infected individual with acute or chronic lymphocytic meningitis. Additional treatment considerations for HIV-infected individuals include the timing of initiation of antiretroviral therapy, the potential for drug–drug interactions, and the role of adjunctive corticosteroid therapy.

Cerebrospinal T-Cell Responses Aid in the Diagnosis of Tuberculous Meningitis in a Human Immunodeficiency Virus– and Tuberculosis-Endemic Population

“…This is the first large prospective study using consecutively recruited unselected patients to evaluate the utility of a standardized quantitative T cell ELISPOT assay. The excellent performance outcomes of this assay likely represent a major advance in the rapid diagnosis of TBM, where diagnostic uncertainty often delays treatment, thus increasing mortality (8)(9)(10)(11). Preliminary reports suggest that that the ELISPOT assay may be a useful diagnostic tool (26)(27)(28)(29).…”

“…Delaying therapy in patients with TBM, which frequently occurs because the diagnosis is often difficult to confirm, increases mortality (z30% despite treatment) (8)(9)(10)(11). Smear microscopy under high-burden programmatic conditions has a dismal yield (0-20%) (8,9,12,13).…”

HIV and Tuberculosis: a Deadly Human Syndemic

“…Although pulmonary TB is the most common presentation regardless of the stage of HIV infection, persons with advanced immune suppression are more likely to have extrapulmonary TB than are HIV-infected persons with relatively intact immunity or persons without HIV (15,33,83,136). Unlike persons without HIV, in whom extrapulmonary TB is usually found in the absence of pulmonary TB, HIVinfected persons with extrapulmonary TB are more likely to have concomitant pulmonary TB (15,212,229,255). Symptoms of extrapulmonary TB (with or without concomitant pulmonary TB) in a cohort of 199 HIV-infected patients included fever (95%), respiratory symptoms (66%), lymphadenopathy (62%), gastrointestinal symptoms (37%) with diarrhea and abdominal pain, and neurological symptoms (29%), including confusion and headache (229).…”

“…Symptoms of extrapulmonary TB (with or without concomitant pulmonary TB) in a cohort of 199 HIV-infected patients included fever (95%), respiratory symptoms (66%), lymphadenopathy (62%), gastrointestinal symptoms (37%) with diarrhea and abdominal pain, and neurological symptoms (29%), including confusion and headache (229). Common sites of infection in extrapulmonary TB with HIV coinfection include the following (in decreasing order of frequency): disseminated TB involving bone marrow, blood, or liver; genitourinary TB; peripheral lymphadenitis; pleural TB; mediastinal TB with mediastinal lymphadenopathy and/or pericarditis; central nervous system (CNS) TB with meningitis or parenchymal infection with tuberculous abscesses and tuberculomas; mediastinal and pericardial TB (229); intra-abdominal lymphadenitis or peritonitis; musculoskeletal abscesses or osteomyelitis; or infection at other sites, including the adrenal glands and the gastrointestinal tract (15,33,229,255).…”

Tuberculosis of Central Nervous System

“…These findings suggest reduced T1 response in HIV-infected patients, which contribute to their susceptibility to TB. 79,80 Clinical studies have shown the detrimental effects of TB on the course of HIV infection. M. tuberculosis probably increases HIV replication by inducing macrophages to produce tumor necrosis factor-, interleukin-1 and interleukin-6.…”