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Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa;
of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
2Department
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relationship with CD41 cell count recovery [16]. However, in this study,
overall mortality risk (and risk stratified
by TB meningitis grade) was similar to
that reported in studies of HIV-associated TB meningitis conducted in the
same setting prior to the availability of
ART [17, 18]. This questions the extent
to which this patient group derived
benefit from ART and, in fact, whether
they benefitted at all.
Although causes of death were not
defined, the overriding risk factor for
death was the TB meningitis severity
grade, which suggests that deaths may
well have been largely attributable to
TB meningitis rather than to other HIVassociated copathologies. It was also
notable that 85 (58.2%) of the 146
deaths occurred within the first month
of observation, which further suggests
that many of the patients had such
advanced disease at study entry that
they simply could not be salvaged. Use
of dexamethasone is an important adjunctive therapy in HIV-uninfected patients with TB meningitis in this setting
and has been shown, in a randomized
controlled trial, to improve survival by
30% [18]. However, no conclusive
benefit was demonstrated among patients with HIV-associated TB meningitis in the same study, which was
conducted in the pre-ART era [18]. No
trials involving corticosteroids have been
performed among patients receiving
ART, because the use of corticosteroids
is now regarded as standard of care [5].
The high proportion of patients with
advanced TB meningitis severity grades
was a key factor in the overall mortality
and may have been related to the
prolonged symptom duration (median
duration of symptoms, 21 days; interquartile range, 1030 days) prior to
study entry. Because the Hospital for
Tropical Diseases in Ho Chi Minh City
is a tertiary referral hospital that serves
a population of 38 million people in
southern Vietnam [17], referral delays
from peripheral hospitals may be
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