Tuberculous meningitis in HIV-infected individuals

HIV-infected individuals are at increased risk for all forms of extrapulmonary tuberculosis, including tuberculous meningitis. This risk is increased at more advanced levels of immunosuppression. The time interval between onset of symptoms and presentation to medical care may vary widely, and consequently individuals may present with acute or chronic meningitis. The clinical presentation of tuberculous meningitis in HIV-infected individuals is more likely to include an altered level of consciousness, cranial imaging is more likely to show cerebral infarctions, and the yield of culture of cerebrospinal fluid may also be greater. Given that delayed initiation of therapy is a strong predictor of mortality in cases of tuberculous meningitis, clinicians must consider tuberculosis in the differential diagnosis of the HIV-infected individual with acute or chronic lymphocytic meningitis. Additional treatment considerations for HIV-infected individuals include the timing of initiation of antiretroviral therapy, the potential for drug-drug interactions, and the role of adjunctive corticosteroid therapy.