The effect of HIV infection on adult

meningitis in
Indonesia: a prospective cohort study
Journal Reading
Dr. Donna Octaviani
7 April 2011
 Introduction

Indonesia is one of the most rapidly growing HIV

epidemics in Asia.

• The estimated prevalence of HIV among the general population is

0.2%, but among risk groups, especially injecting drug users (IDUs),
rates have been reported up to 50%

Patients with advanced HIV infection often have severe

neurological manifestations, especially meningitis and
with a higher mortality of meningitis
• We conducted a prospective study in a hospital setting in Indonesia
to determine the HIV prevalence, causative agents, clinical and
laboratory features and prognosis of adult patients with meningitis
 Methods

Clinical data were recorded

prospectively from
Patients were admitted to Hasan
all adult patients (>18 years old)
Sadikin Hospital Bandung, Serological testing for HIV
admitted with suspected
Indonesia
meningitis between Nov 2006 –
Nov 2008

Follow-up was
All patients were reevaluated
done until hospital discharge or
monthly until treatment was death
completed
(for at least 6 months)
 Headache, fever and neck stiffness,
Clinical criteria with or without altered
consciousness

Diagnostic criteria meningitis

cell count > 10 cell/ml
protein concentration > 45 mg/dl
CSF criteria or
CSF : blood glucose ratio less < 0.5
alone or combination
Definite tuberculous The neurological
Probable TBM
meningitis (TBM) status patients TBM
• CSF microscopy or • typical CSF findings • Grade I, normal
culture or both  • extra pulmonary consciousness, no
M. tuberculosis TB neurological signs;
• bacteriologically • Grade II, confusion
confirmed TB or neurological
outside the CNS signs (meningeal or
focal)
• Grade III, stupor
or coma
Definite bacterial Probable bacterial Cryptococcal
meningitis meningitis meningitis
• Bacteria in CSF • clinical • India Ink
by microscopy meningitis& examination or
or culture or characteristic cryptococcal
characteristic CSF findings, antigen testing
CSF findings (a without or both of CSF
predominance confirmatory were positive
of PMN bacteriological
cells&CSF : result, but with
blood glucose clinical
ratio <0.4) in improvement
combination with antibiotic
with a positive treatment
blood culture
Result
In our cohort, confirmation of TBM was lower in HIV-positive than in HIV-negative patients.
This is different from other reports from Argentine and Vietnam, which reported a higher
positivity rate among HIVpositive patients .

The use of molecular testing might further increase the number of confirmed cases
Outcome
 Outcome
 Seventy-six patients (41%)
died within the first month
of follow-up, mostly in the
first week. The suspected
cause of death was
available in 68 patients and
was neurologic in 42 (62%)
and systemic in 26 patients
(38%).
 Using Kaplan–Meier
estimates, the death rates
at 6 months were 25.6%
(95% CI 17.3–30.9%) for
HIV-negative and 62.8%
(95% CI 57.9–73.1%) for
HIV-positive patients
Conclusion
 TB is the main cause of adult meningitis
 Adult meningitis patients should be tested
for HIV and that there is a great need for
effective prevention and early HIV testing in
light of the growing HIV epidemic in
Indonesia.
 The high mortality was strongly associated
with HIV
 Most of patient died within the first month
of follow-up, mostly in the first week
TERIMA KASIH