When human immunodeficiency virus (HIV)-infected patients present with neurologic problems, lumbar puncture and cerebrospinal fluid (CSF) analysis are often performed, usually to rule-out the presence of meningitis. However, ahe test characteristics of CSF analyses in this population are unknown.
Methods
To examine the diagnostic characteristics of CSF analyses for secondary causes of meningitis in HIV-infected adults, we performed a case-control study of 322 HIV-infected adults who received diagnostic lumbar puncture in an urban academic hospital from 1989 to 1992. Using multivariable logistic regression analyses, we determined the independent CSF correlates of cryptococcal and other types of secondary meningitis.
Results
Eighty percent were men who had sex with men, 89% were white, and 85% had AIDS. Thirty-seven case-subjects had a secondary cause of meningitis though none had bacterial or tuberculous meningitis. Excluding the india ink as a candidate variable, logistic regression analysis identified 2 independent CSF correlates of secondary meningitis: the leukocyte count (odds ratio [OR] per 10 cells, 1.2; 95% confidence interval [CI], 1.1 to 1.3), and the CSF-to-serum glucose ratio (OR per 0.10 units, 0.61; CI, 0.43 to 0.88). The areas (± SD) under the receiver operating characteristic curves were 0.76 ± 0.05 and 0.72 ± 0.05, respectively.
Conclusions
In similar clinical settings, these findings may help clinicians assess the probability of secondary meningitis in HIV-infected patients when initial CSF results first become available.
SimpsonDM, TagliatiM.Neurologic manifestations of HIV infection. Ann Intern Med1994;121:769–85.
2.
BacellarH, MuñozA, MillerEN, CohenBA, BesleyD, SelnesOA, BeckerJT, McArthurJC. Temporal trends in the incidence of HIV-1-related neurologic disease: Multicenter AIDS Cohort Study, 1985-1992. Neurology1994;44:1892–900.
3.
KovacsJA, KovacsAA, PolisM, WrightWC, GillVJ, TuazonCV, GelmannEP, LaneHC, LongfieldR, OverturfG, Cryptococcosis in the acquired immunodeficiency syndrome. Ann Intern Med1985;103:533–8.
4.
ZugerA, LouieE, HolzmanRS, SimberkoffMS, RahalJJ. Cryptococcal disease in patients with the acquired immunodeficiency syndrome. Ann Intern Med1986;104:234–40.
5.
ChuckSL, SandeMA. Infections with Cryptococcus neoformans in the acquired immunodeficiency syndrome. N Engl J Med1989;321:794–9.
6.
DismukesWE. Cryptococcal meningitis in patients with AIDS. J Infect Dis1988;157:624–8.
7.
MarshallDW, BreyRL, CahillWT, HoukRW, ZajacRA, BoswellRN. Spectrum of cerebrospinal fluid findings in various stages of human immunodeficiency virus infection. Arch Neurol1988;45:954–8.
8.
MarshallDW, BreyRL, ButzinCA, LuceyDR, AbbadessaSM, BoswellRN. CSF changes in a longitudinal study of 124 neurologically normal HIV-1-infected US Air Force personnel. J Acquir Immune Defic Syndr1991;4:777–81.
9.
HollanderH, StringariS.Human immunodeficiency virus-associated meningitis. Am J Med1987;83(5):813–6.
10.
HollanderH.Cerebrospinal fluid normalities and abnormalities in individuals infected with human immunodeficiency virus. J Infect Dis1988;158:855–8.
11.
HollanderH, McGuireD, BurackJH. Diagnostic lumbar puncture in HIV-infected individuals: analysis of 138 cases. Am J Med1994;96:223–8.
12.
FriedmannPD, SamoreMH, CalkinsDR. Clinical correlates of secondary meningitis in HIV-infected adults. Arch Intern Med1995;155:2231–7.
13.
Centers of Disease Control. 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR Recomm and Reports. 1992;41(RR-17):1–19.
14.
Working Group of the American Academy of Neurology AIDS Task Force. Nomenclature and research case definitions for neurologic manifestations of human immunodeficiency virus-type-1 (HIV-1) infection. Neurology1991;41:778–85.
15.
SAS Institute Inc. SAS/STAT User's Guide: Version 6. 4th ed. Cary, NC: SAS Institute, 1990.
16.
CohenJ, CohenP.Applied multiple regression/correlation analysis for the behavioral sciences. Hillsdale, NJ: Lawrence Erlbaum Associates, 1975;265–90.
17.
MetzCE, HermanB, WangPL, ShenJH, KronmanHB. LABROCI program for the IBM-PC. Chicago: Department of Radiology and the Franklin McLean Memorial Research Institute, University of Chicago; 1993.
18.
MetzCE, ShenJ-H, HermanBA. New methods for estimating a binormal ROC curve from continuously-distributed test results. Invited presentation. Joint Statistical Meetings of the American Statistical Association and the Biometric Society; 1990 Aug; Anaheim, CA.
19.
SimelDL, SamsaGP, MatcharDB. Likelihood ratios with confidence: sample size estimation for diagnostic test studies. J Clin Epidemiol1991;44 (8):763–70.
20.
JaeschkeR, GuyattGH, SackettDL, for the Evidence-Based Medicine Working Group. Users' guides to the medical literature. III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients. JAMA1994;271:703–7.
21.
ConcatoJ, FeinsteinAR, HolfordTR. The risk of determining risk with multivariable models. Ann Intern Med1993;118:201–10.
22.
MacArthurJC. Neurologic manifestations of AIDS. Medicine1987;66(6):407–37.
23.
SackettDL, HaynesRB, GuyattGH, TugwellP.Clinical Epidemiology. A basic Science for clinical medicine, 2nd ed. Boston: Little, Brown and Company; 1991:119–140.
24.
DujardinB, Van den EndeJ, Van GompelA, UngerJP, Van der StuyfP.Likelihood ratios: a real improvement for clinical decision making?Europ J Epidemiol1994;10:29–36.
25.
TuckerT, DixRD, KatzenC, DavisRL, SchmidleyJW. Cytomegalovirus and herpes simplex virus ascending myelitis in a patient with acquired immune deficiency syndrome. Ann Neurol1985;18:74–9.
26.
de GansJ, TiessensG, ProtegiesP, TutuarimaJA, TroostD.Predominance of polymorphonuclear leukocytes in cerebrospinal fluid of AIDS patients with cytomegalovirus polyradiculomyelitis. J Acquir Immune Defic Syndr1990;3:1155–8.
27.
GrayF, BélecL, LescsMC, ChrétienF, CiardiA, HassineD, Flament-SaillourM, de TruchisP, ClairB, ScaravilliF.Varicella-zoster virus infection of the central nervous system in the acquired immune deficiency syndrome. Brain1994;117:987–99.
28.
MeierPA, StephanKT, BlattSP. Cytomegalovirus polyradiculopathy in HIV-infected patients. J Gen Intern Med1996; 11:47–9.
29.
BerenguerJ, MorenoS, LagunaF, VicenteT, AdradosM, OrtegaA, Gonzalez-LattozJ, BouzaE.Tuberculous meningitis in patients infected with the human immunodeficiency virus. N Engl J Med1992;326:668–72.
30.
DubeMP, HoltomPD, LarsenRA. Tuberculous meningitis in patients with and without human immunodeficiency virus infection. Am J Med1992;93:520–4.
31.
LaneHC, MasurH, EdgarLC, WhalenG, RookAH, FauciAS. Abnormalities of B-cell activation and immunoregulation in patients with the acquired immunodeficiency syndrome. N Engl J Med1983;309:453–8.
32.
SimberkoffMS, El-SadrW, SchiffmanG, RahalJJJr. Streptococcus pneumoniae infections and bacteremia in patients with acquired immune deficiency syndrome, with a report of a pneumococcal vaccine failure. Am Rev Respir Dis1984;103:1174–6.
33.
WittDJ, CravenDE, McCabeWR. Bacterial infections in adult patients with the acquired immune deficiency syndrome (AIDS) and AIDS-related complex. Am J Med1987;82(5):900–6.
34.
MascolaL, LiebL, ChiuJ, FanninSL, LinnanMJ. Listeriosis: an uncommon opportunistic infection in patients with acquired immunodeficiency syndrome A report of five cases and a review of the literature. Am J Med1988; 84:162–4.
35.
DeckerCF, SimonGL, DiGrioiaRA, TuazonCU. Listeria monocytogenes infections in patients with AIDS: report of five cases and review. Rev Infect Dis1991;13:413–7.
36.
HavlirDV, WittMD, SandeM.A 32-year old man with the acquired immunodeficiency syndrome and pneumococcal meningitis. West J Med1987;146:618–9.
37.
ReddSC, RutherfordGW, SandeMA, LifsonAR, HadleyWK, FacklamRR, SpikaJS. The role of human immunodeficiency virus infection in pneumococcal bacteremia in San Francisco residents. J Infect Dis1990;162:1012–7.
