Central Nervous System involvement in tuberculosis: An MRI study considering differences between patients with and without Human Immunodeficiency Virus 1 infection - 26/09/19

Doi : 10.1016/j.neurad.2019.07.008

Alberto Di Napoli ^a, Massimo Cristofaro ^b, Andrea Romano ^a, Elisa Pianura ^b, Gioia Papale ^a, Federica Di Stefano ^b, Edoardo Ronconi ^a, Ada Petrone ^b, Maria Camilla Rossi Espagnet ^a, Vincenzo Schininà ^b,⁎ , Alessandro Bozzao ^a
^a NESMOS Department University of Rome Sapienza. Azienda Ospedaliero-Universitaria Sant’Andrea, Roma, Italy
^b Department of Diagnostic Imaging, National Institute of Infectious Diseases Lazzaro Spallanzani IRCCS, Roma, Italy

^⁎Corresponding author.

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Thursday 26 September 2019
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Graphical abstract

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Highlights

•	This is the first adult cohort study comparing MRI in two adult groups (HIV+ and HIV−) with CNS tuberculosis.
•	Stroke in the basal is the only early MRI feature that differentiates between the two groups.
•	Stroke was not correlated with meningeal enhancement suggesting that even a subtle exudate can cause obstruction of small terminal vessels.
•	Meningeal enhancement can develop in later stages of disease.
•	We suggest that a new onset of basal ganglia stroke in an HIV+ patient should raise the suspicion of tuberculosis, leading to a test to rule out this diagnosis.

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Abstract

Background

Magnetic resonance imaging (MRI) is largely used in the diagnosis of central nervous system involvement of tuberculosis (CNSTB), yet there is no MRI comparison study between HIV+ and HIV− patients with CNSTB. The aim of the present study was to identify MRI differences in CNSTB between HIV+ and HIV− patients and possibly find early characteristics that could raise the suspect of this disease.

Methods

We included all patients admitted in our institution between 2011 and 2018 with confirmed diagnosis of CNSTB, and MRI performed in the first week. Patients with preexisting brain pathology or immunodeficiency not HIV related were excluded. We compared CNSTB MRI features between the two groups.

Results

Sixty-nine patients were included (19 HIV+; 50 HIV−). Findings in HIV+ group: 6 lung TB, 5 hydrocephalus, 4 meningeal enhancement, 6 stroke, 2 hemorrhages, and 10 tuberculomas. HIV− group: 22 lung tuberculosis, 15 hydrocephalus, 21 meningeal enhancement, 5 stroke, 4 hemorrhages, 20 tuberculomas. The only statistically significant difference between the two groups was in the stroke occurrence, more frequent in the HIV+ group (P=.028), all involving the basal ganglia.

Conclusions

Stroke involving the basal ganglia best differentiates CNSTB patients who are HIV+ from those HIV−. This finding was not correlated with meningeal enhancement suggesting that small arteries involvement might precede it. Therefore, we think that HIV+ patients with a new onset of stroke should be evaluated for CNSTB. Follow-up MRI should also be planned since meningeal enhancement might appear in later stages of the disease.

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Keywords : MRI, Tuberculosis, HIV, Stroke