TB encephalitis

Today we discussed a very interesting case of an HIV+ man with a CD4 count of 20, found to have CMV encephalitis and TB meningitis. Clinical pearls include: - sometimes, there ARE 2 diagnoses and Hocm's razor does not apply - TB meningitis can sometimes present with neutrophilic predominance in the CSF cell count, so do not be fooled. High PMNs with a negative CSF C&S should alert you to the possibility of TB meningitis.

Here's a review article on CNS TB. This is a broad topic that warrants lots more than 5 pages, but its a good start while you're busy on team.

Lastly, we didn't discuss too much about the role of steroids in TB meningitis. A cochrane review of 7 trials showed a small but significant mortality benefit in HIV-NEGATIVE patients (Prasad K, Singh MB. Corticosteroids for managing tuberculous meningitis. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD002244. DOI: 10.1002/14651858.CD002244.pub3); there is insufficient data to support use in HIV+ patients. A study in NEJM showed a mortality benefit in all-comers (no difference in longterm disability in survivors), but subgroup analysis in HIV+ patients showed nonsignificance. As expected, in this trial the case fatality was much higher in HIV+ patients at 65.3 percent, vs. 28.4 percent overall. (N Engl J Med 2004;351:1741-51)