: Neurological conditions associated with HIV remain major contributors to morbidity and mortality and are increasingly recognized in the aging population on long-standing combination antiretroviral therapy (cART). Importantly, growing evidence shows that the CNS may serve as a reservoir for viral replication, which has major implications for HIV eradication strategies. Though there has been major progress in the last decade in our understanding of the pathogenesis, burden, and impact of neurological conditions associated with HIV infection, significant scientific gaps remain. In many resource-limited settings, ARVs considered second or third line in the United States, which carry substantial neurotoxicity, remain mainstays of treatment, and patients continue to present with severe immunosuppression and central nervous system (CNS) opportunistic infections. Despite this, increased global access to cART has coincided with an aging HIV+ population with cognitive sequelae, cerebrovascular disease, and peripheral neuropathy. Further neurological research in low-income and middle-income countries (LMICs) is needed to address the burden of neurological complications in HIV+ patients, particularly regarding CNS viral reservoirs and their effects on eradication.

Central nervous system (CNS) involvement of tuberculosis (TB) is the most severe manifestation of TB and accounts for approximately 5 to 10% of all extrapulmonary TB (EPTB) cases and approximately 1% of all TB cases. TB meningitis (TBM) is the most common form of CNS TB, though other forms occur, often in conjunction with TBM, including intracranial tuberculomas, tuberculous brain abscesses, and spinal tubercular arachnoiditis. CNS TB often presents with nonspecific clinical features that mimic symptoms of other neurological conditions, often making diagnosis difficult. Defining neuroimaging characteristics of TBM include thick basal meningeal enhancement, hydrocephalus, and parenchymal infarctions most commonly involving the basal ganglia and internal capsule. Traditional cerebrospinal fluid sample analysis frequently requires lengthy times-to-result and have low sensitivity. Given the pitfalls of conventional CNS TB diagnostic methods, various molecular-based methods, including immunoassays and polymerase chain reaction (PCR)-based assays have emerged as alternative diagnostic tools due to their rapidity, sensitivity, and specificity. Expert panels on TBM have recently emphasized the need for standard research procedures with updated case definitions and standardized study methods, which will hopefully pave the way for more robust multicenter international studies. In this article, we review the epidemiology, diagnosis, molecular factors associated with disease presentation and outcome, and treatment of CNS TB.

Community-acquired bacterial meningitis (CABM) morbidity and mortality remains high in those infected. Rapid diagnosis and treatment is paramount to reducing mortality and improving outcome. This retrospective cohort study aims to assess the time from presentation to diagnosis and treatment of vaccine preventable CABM as well as identify possible factors associated with delays in diagnosis and antibiotic administration. A retrospective chart review was conducted of individuals who presented to Columbia University Irving Medical Center (CUIMC), Children’s Hospital of New York (CHONY), Mount Sinai Medical Center, and Weill Cornell Medical Center with BM due to Haemophilus influenzae type B, Streptococcus pneumoniae, and Neisseria meningitidis between January 1, 2012 and December 31, 2017. Diagnosis was delayed by more than 8 hours in 13 patients (36.1%) and 5 individuals (13.9%) had a delay of 4 hours or more from presentation to the administration of antibiotics with appropriate CNS coverage. All of these patients were also initially misdiagnosed at an outpatient clinic, outside hospital, or emergency department. This retrospective study identified febrile and/or viral infections not otherwise specified and otitis media as the most common misdiagnoses underlying delays from presentation to diagnosis and to antibiotic treatment in those with BM.

Background Outcomes in community-acquired bacterial meningitis (CABM) are significantly impacted by delays in diagnosis and treatment. This retrospective case series aims to describe the sociodemographic, epidemiological, and clinical variables including time to diagnosis and treatment of vaccine preventable CABM in three tertiary care settings in New York City (NYC). Methods A retrospective chart review was conducted of patients at Columbia University Irving Medical Center (CUIMC), Children’s Hospital of New York (CHONY), Mount Sinai Health System, and Weill Cornell Medical Center with CABM due to Haemophilus influenzae type B, Streptococcus pneumoniae, and Neisseria meningitidis between January 1, 2012 and December 31, 2017. A descriptive statistical analysis was performed. Results Our case series consisted of 36 patients, 24 (66.7%) females, and 12 (33.33%) males with a median age of 42 years (IQR 55 years). Median time from presentation to lumbar puncture (LP) was eight hours (IQR 7). The median time from hospital presentation to diagnosis was 12 hours (IQR 9), and the median time from LP to diagnosis was three hours (IQR 5). Delay in diagnosis which is defined by more than 8 hours from hospital presentation, occurred in 13 patients (36.1%) due to initial misdiagnosis, most commonly systemic febrile and/or viral infections and otitis media. Conclusions Despite evidence of the importance of early diagnosis and treatment for CABM, this case series shows the ongoing challenges with early clinical diagnosis. Misdiagnoses were an underlying reason for delays from presentation to LP and to antibiotic treatment in the majority of our patients. This study in NYC identifies ongoing major delays in diagnosis and antimicrobial treatment in CABM, and future studies are needed to identify mechanisms to improve time to antibiotic treatment and LP in CABM.