Computed Tomography of the Head Before Lumbar Puncture in Adults With Suspected Meningitis in High-HIV Prevalence Settings

James Milburn; Christopher G Williams; Kwana Lechiile; Keatlaretse Siamisang; Leah Owen; Ezekiel Gwakuba; Thandi Milton; Tichaona Machiya; Tshepo Leeme; Hannah E Barton; Ponego Ponatshego; Kaelo K Seatla; Gerald Boitshepo; Rachita Suresh; Ikanyeng Rulaganyang; William Hurt; Samuel Ensor; Kebatshabile Ngoni; Ronan Doyle; Daniel Grint; Wallace T Miller Jr; Mark W Tenforde; Madisa Mine; David M Goldfarb; Margaret Mokomane; Joseph N Jarvis

doi:10.1093/ofid/ofae565

Computed Tomography of the Head Before Lumbar Puncture in Adults With Suspected Meningitis in High-HIV Prevalence Settings

Open Forum Infect Dis. 2024 Sep 26;11(10):ofae565. doi: 10.1093/ofid/ofae565. eCollection 2024 Oct.

Authors

James Milburn^{1

2}, Christopher G Williams¹, Kwana Lechiile¹, Keatlaretse Siamisang¹, Leah Owen³, Ezekiel Gwakuba⁴, Thandi Milton³, Tichaona Machiya⁵, Tshepo Leeme¹, Hannah E Barton³, Ponego Ponatshego¹, Kaelo K Seatla¹, Gerald Boitshepo⁶, Rachita Suresh¹, Ikanyeng Rulaganyang³, William Hurt³, Samuel Ensor¹, Kebatshabile Ngoni¹, Ronan Doyle², Daniel Grint⁷, Wallace T Miller Jr⁶, Mark W Tenforde³, Madisa Mine⁸, David M Goldfarb⁹, Margaret Mokomane⁴, Joseph N Jarvis^{1

2}

Affiliations

¹ Botswana Harvard Health Partnership, Gaborone, Botswana.
² Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
³ Botswana-UPenn Partnership, Gaborone, Botswana.
⁴ School of Allied Health Professions, University of Botswana, Gaborone, Botswana.
⁵ Microbiology Department, Princess Marina Hospital, Gaborone, Botswana.
⁶ Department of Radiology, University of Botswana, Gaborone, Botswana.
⁷ Department of Infectious Disease Epidemiology and International Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.
⁸ National Health Laboratory, Gaborone, Botswana.
⁹ Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada.

Abstract

Background: The role of computed tomography (CT) before lumbar puncture (LP) is unclear, with limited evidence for a causal link between LP and cerebral herniation or for the ability of CT to identify individuals at risk of herniation. The risks of LP delay or deferral are potentially greater in high-HIV prevalence, resource-limited settings; we analyzed data from such a setting to determine the impact of CT on time to LP and treatment, as well as mortality.

Methods: Adults with suspected central nervous system (CNS) infection were enrolled prospectively into the Botswana National Meningitis Survey between 2016 and 2019. Inpatient mortality and clinical data including time of treatment initiation and CT were captured from medical records. Associations between preceding CT and outcomes were assessed using logistic regression.

Results: LPs were performed in 711 patients with suspected CNS infection; 27% had a CT before LP, and 73% were HIV positive. Time from admission to LP and time from admission to appropriate treatment were significantly longer in patients who had a CT before LP compared with those who did not (2.8 hours and 13.2 hours, respectively). There was some evidence for treatment delays being associated with increased mortality; however, there was no significant difference in mortality between those who had or did not have CT.

Conclusions: Patients who had a CT had delays to diagnostic LP and initiation of appropriate treatment; although treatment delays were associated with increased mortality, our observational study could not demonstrate a causal association between delays in diagnosis and treatment introduced by CT and mortality.

Keywords: HIV; central nervous system infection; computed tomography; meningitis; neuroimaging.