TUBERCULOUS MENINGITIS IN SOUTH-AFRICAN URBAN ADULTS

We retrospectively reviewed 56 adults with culture-proven tuberculous meningitis (TBM), investigating clinical signs, cerebrospinal fluid (C SF) findings and outcome. There were 50 patients, aged 18-59 years, 39 with and 11 without human immunodeficiency virus (HIV) infection. Six were aged 60 years or older. Neurological signs of TBM in 18-59-year- olds were unaffected by HIV serostatus while, compared to those greate r than or equal to 60 years of age, there were more patients with meni ngism (86.0% vs. 33.30%; p=0.011) and fewer with seizures (12.0% vs. 5 0.0%; p=0.046). The HIV-infected 18-59-year-olds had significantly mor e extrameningeal tuberculosis compared to the non-HIV-infected (76.9% vs. 9.1 %; p = 0.0001) and 23.1% had 'breakthrough' TBM. CSF analysis revealed 12 patients (21.4%) with acellular fluid (more common in thos e greater than or equal to 60 years of age, p 0.016), of whom three ha d completely normal CSF. A neutrophil predominance was found in 22 pat ients (39.3%). Only three patients (5.4%) had a positive CSF smear for acid-fast bacilli. In-hospital mortality occurred in 39 patients (69. 1%), was similar in all study groups, and was not related to neurologi cal stage. The diagnosis of TBM can be masked by lack of meningism in the elderly and by atypical CSF findings.