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Clinical Medicine

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    Tuberculous meningitis and cryptococcal meningitis co-infection in hospitalised patients in Durban, KwaZulu-natal (KZN), South Africa.
    (2023) Mohamed, Faaizah.; Hoosen, Muhammed Zaid.; Mohammed , Mitha.
    Background: Cryptococcal meningitis (CCM) and Tuberculous meningitis (TBM) co-infection have been previously described, however, the diagnosis is rare. This may be due to the paucibacillary nature of TBM and the difficulty in diagnosing these conditions due to the overlap in symptoms and cerebrospinal fluid (CSF) findings. This study aimed to determine the frequency and outcome of TBM and CCM co-infection in hospitalised patients. Methods: A retrospective review of routine laboratory and clinical records for TBM and CCM co-infection cases at four regional hospitals in a single district (Ethekwini) of South Africa between 01 January 2005 and 31 December 2009. CSF TB data at Inkosi Albert Luthuli Central Hospital TB Culture Laboratory, the only TB culture lab in Kwa Zulu Natal, was the starting point to identify CSF TB culture-positive cases. CSF microbiology laboratory data at each identified hospital study site was then reviewed for this retrospective analysis. All adult patients with positive TB cultures in the cerebrospinal fluid were included. These positive MTB samples were then matched with CSF samples positive for cryptococcosis by CLAT, India ink, or culture. Variables analyzed included age, sex, HIV status, CD4 count, HIV viral load, and CSF chemistry and microbiology. A chart review of dual-infected cases was then conducted.Results: A total of 418 patients were identified based on positive CSF TB culture extracted from laboratory data. A total of 15 patients had dual infection. The prevalence of dual infection was 3.5%. The mean age was 37 years. 12 of 15 patients were diagnosed with TBM posthumously. 6 patients were found to have multidrug-resistant TBM on CSF culture. The in-hospital mortality was 80% (12/15). Despite the age of the data set, the study remains valid and relevant due to the rarity of TBM and CCM co-infection. Conclusion: In this study, we found that dual infection of the meninges with mycobacterium tuberculosis and cryptococcus neoformans in HIV-infected patients is rare, however the diagnosis may often be missed or not considered initially. The underdiagnosis and possible delay in diagnosis of dual infection may result in patients not being treated appropriately and adequately leading to increased morbidity and mortality. This case series highlights the difficulty of diagnosing TBM-CCM co-infection. This study was undertaken prior to the introduction of the Xpert® MTB/RIF Ultra test as well as the lateral flow urine lipoarabinomannan (LF-LAM) assay, and we postulate that with the subsequent introduction of these tests, the diagnosis of TBM may improve earlier detection and yield. Co-infection reflects the advanced immunosuppression characteristic of patients with HIV-associated CCM and the complexities of diagnosis and management in patients at risk of intercurrent opportunistic infections. Our research demonstrates both the need to consider co-infection at baseline diagnosis and the need to remain vigilant for co-infection throughout the follow-up period.