Clinical, cerebrospinal fluid and pathological findings and outcomes in HIV-positive and HIV-negative patients with tuberculous meningitis

Background: The early diagnosis of tuberculous (TB) meningitis remains difficult. In South Africa, the HIV epidemic has shifted the spectrum of meningitis towards chronic infections (mainly tuberculosis [TB] and cryptococcosis). This study aimed to analyze clinical, cerebrospinal fluid (CSF) and pathological findings and outcomes in TB meningitis to evaluate whether HIV infection significantly influences the characteristic findings. Patients and Methods: 40 consecutive patients with TB meningitis presenting at the Pretoria Academic Hospital were evaluated clinically and chest X-rays (CXR), computerized tomography (CT) brain scans, CSF profiles, HIV and routine blood tests were analyzed. Postmortem examinations (PM) were performed in seven patients and outcomes were assessed after treatment. Results: 20 patients were HIV-positive and 17 were negative (three not tested). History and clinical findings were similar in both groups. The mean Glasgow Coma Scale (GCS) value on admission was 13 in both groups, while CXR showed abnormalities consistent with TB in 9/17 with HIV and 7/15 without, with abnormal CT brain scans in 15/19 patients with HIV and 12/16 without. Dilated ventricles and infarcts occurred more commonly in HIV-positive patients. The CSF results showed similar results in both groups. PM in three HIV-positive patients showed weakly formed granulomas and extensive endarteritis and infarcts. Outcomes were similar in the two groups, but a Low GCS value on admission was a better prognostic indicator than the CD4-count in HIV positive patients. Conclusion: HIV infection does not significantly alter clinical and CSF findings in TB meningitis in South Africa, but ventricular dilatation and infarcts are more frequent in HIV-positive patients. The GCS gives a better indicator of prognosis than the CD4-count.