The Changing Epidemiology of HIV-Associated Adult Meningitis, Uganda 2015-2017
The Changing Epidemiology of HIV-Associated Adult Meningitis, Uganda 2015-2017
复制标题
DOI：
10.1093/ofid/ofz419
复制
发表时间：
2019-10-01
影响因子：
4.2
通讯作者：
Boulware, David R.
中科院分区：
文献类型：
--
作者：
Ellis, Jayne;Bangdiwala, Ananta S.;Boulware, David R.
背景。中枢神经系统 (CNS) 感染仍然是撒哈拉以南非洲地区的一个主要公共卫生问题，导致 15%-25% 的艾滋病相关死亡。随着抗逆转录病毒疗法 (ART) 的广泛应用和诊断方法的改进，传染性脑膜炎的流行病学正在不断发展。我们前瞻性地招募了 2015 年 3 月至 2017 年 9 月在乌干达坎帕拉和姆巴拉拉出现 HIV 相关脑膜炎的成年人。参与者对血液隐球菌抗原 (CrAg)、脑脊液 CrAg、结核性 (TB) 脑膜炎 (TBM) 的 Xpert MTB/RIF、Biofire Multiplex 进行了结构化、逐步的诊断算法。 聚合酶链反应、传统显微镜和培养。结果。我们连续筛查了 842 名疑似脑膜炎的 HIV 感染者：57% 为男性，中位年龄 35 岁，中位 CD4 26 个细胞/mcL，55% 接受 ART。总体而言，60.5% (509/842) 被诊断为首次发作隐球菌性脑膜炎，7.4% (62/842) 被诊断为第二次发作。 6.9% (58/842) 的初步诊断为确诊/疑似结核性脑膜炎； 5.3% (n = 45) 患有微生物学确诊（明确）的结核性脑膜炎。另外 7.8% (66/842) 未达到确定/可能 TBM 的诊断阈值，但接受了经验性 TBM 治疗。细菌性脑膜炎和病毒性脑膜炎的诊断率分别为 1.3% (11/842) 和 0.7% (6/842)。采用具有成本效益的逐步诊断算法，使 79% (661/842) 的人能够以每人 44 美元的平均成本获得确认的微生物学诊断。结论。尽管抗逆转录病毒治疗已广泛应用，但隐球菌仍然是艾滋病毒相关脑膜炎的主要原因。第二常见的病因是结核性脑膜炎，总体治疗率为 14.7%。微生物学确诊的 TBM 病例比例的增加反映了新改进的分子诊断的影响。
Background. Central nervous system (CNS) infections remain a major public health problem in Sub-Saharan Africa, causing 15%-25% of AIDS-related deaths. With widespread availability of antiretroviral therapy (ART) and the introduction of improved diagnostics, the epidemiology of infectious meningitis is evolving.Methods. We prospectively enrolled adults presenting with HIV-associated meningitis in Kampala and Mbarara, Uganda, from March 2015 to September 2017. Participants had a structured, stepwise diagnostic algorithm performed of blood cryptococcal antigen (CrAg), CSF CrAg, Xpert MTB/RIF for tuberculous (TB) meningitis (TBM), Biofire multiplex polymerase chain reaction, and traditional microscopy and cultures.Results. We screened 842 consecutive adults with HIV presenting with suspected meningitis: 57% men, median age 35 years, median CD4 26 cells/mcL, and 55% presented on ART. Overall, 60.5% (509/842) were diagnosed with first-episode cryptococcal meningitis and 7.4% (62/842) with second episode. Definite/probable TB meningitis was the primary diagnosis in 6.9% (58/842); 5.3% (n = 45) had microbiologically confirmed (definite) TB meningitis. An additional 7.8% (66/842) did not meet the diagnostic threshold for definite/probable TBM but received empiric TBM therapy. Bacterial and viral meningitis were diagnosed in 1.3% (11/842) and 0.7% (6/842), respectively. The adoption of a cost-effective stepwise diagnostic algorithm allowed 79% (661/842) to have a confirmed microbiological diagnosis at an average cost of $44 per person.Conclusions. Despite widespread ART availability, Cryptococcus remains the leading cause of HIV-associated meningitis. The second most common etiology was TB meningitis, treated in 14.7% overall. The increased proportion of microbiologically confirmed TBM cases reflects the impact of new improved molecular diagnostics.