Meningitis in a community with a high prevalence of tuberculosis and HIV infection

Objectives: To evaluate the spectrum of aetiologies, and distinguishing cli nical and laboratory features, of meningeal infection in a community with a high prevalence of tuberculosis (TB) and HIV infection, Setting: A hospita l serving mineworkers, originating from rural areas of Southern Africa. Des ign: Prospective cohort of 60 consecutive lumbar punctures (LPs), performed for suspected meningitis. Measurements: Clinical history and examination: concurrent cerebrospinal fluid (CSF) and blood samples: mortality status si x months after entry to study. Results: 38 of 57 patients (66.7%) were HIV- 1 positive, 59.5% of whom had a CD4 count <200 cells/mm(3). Nine patients h ad tuberculous meningitis (TBM) and two had tuberculomas; four developed di sease while on TB therapy. There was one case of multidrug, and two of ison iazid-resistant TBM. There were nine episodes of cryptococcal meningitis (s even patients), nine of aseptic meningitis, two of neurosyphilis and 20 nor mal LPs, including four with AIDS dementia complex (ADC). Ten patients with meningococcal infection, part of a larger outbreak, were significantly you nger (p=0.004). All patients with tuberculous, cryptococcal (most immune-su ppressed p<0.001) and aseptic meningitis were HN-I positive. Within six mon ths, 19 patients had died, Death was associated with HIV positivity (p=0.00 4), low CD4 count (p<0.001) and a diagnosis of cryptococcal meningitis, CNS TB or ADC. Conclusion: HIV has a major impact on the burden of disease and mortality, with a predominance of opportunistic chronic meningitides, desp ite a meningococcal outbreak, in this community. Of concern is the developm ent of TBM despite therapy, and the emergence of drug-resistant strains. (C ) 1999 Elsevier Science B.V. All rights reserved.