Pregnancy-Related Tuberculous Meningitis and Immune Reconstitution Inflammatory Syndrome: A Case Series and Systematic Review

Katelyn Pastick, Enock Kagimu, Joanna Dobbin, Kenneth Ssebambulidde, Jane Gakuru, Jack Milln, Betty Nakabuye, David B Meya, David R. Boulware, Fiona V. Cresswell, Nathan C Bahr

Research output: Contribution to journalArticlepeer-review

Abstract

Background: Tuberculosis is a leading cause of death among women of reproductive age. However, tuberculous meningitis, the most severe form of extrapulmonary tuberculosis, is rarely discussed in pregnancy despite this being a unique period of immune modulation that may predispose women to active disease. Methods: We identified and described cases of tuberculous meningitis among pregnant or postpartum women screened during meningitis clinical trials in Uganda from 2018 to 2022. We conducted a systematic literature review via PubMed/Medline and Embase for all English-language publications from 1970 to 10 July 2022, to identify additional cases. Results: We identified 8 cases of pregnancy-related tuberculous meningitis in Ugandan women living with human immunodeficiency virus (HIV) and 40 additional cases via systematic literature review (none HIV-positive). Of all combined cases, 50% (24/48) were diagnosed postpartum; 50% (24/48) had initial onset during pregnancy, of which 38% (9/24) had worsening of symptoms or disease relapse following pregnancy cessation. Diagnosis was missed or delayed in 33% (16/48) of cases. For those with known outcomes, maternal mortality was 23% (11/48) and fetal/neonatal mortality was 30% (13/44). Of maternal survivors, 30% (11/37) had residual neurologic deficits. Conclusions: The true incidence of tuberculous meningitis in pregnancy or the postpartum period is unclear but likely underappreciated. To date, nearly all published cases have occurred in HIV-negative or otherwise immunocompetent women. Given the well-described physiological immunosuppression during pregnancy and subsequent reconstitution postpartum, physicians must be aware of tuberculous meningitis and pregnancy-related immune reconstitution inflammatory syndrome, especially in countries with a high burden of tuberculosis and in women living with HIV.

Original languageEnglish (US)
Article numberofac513
JournalOpen Forum Infectious Diseases
Volume9
Issue number10
DOIs
StatePublished - Oct 1 2022

Bibliographical note

Funding Information:
This research is supported by the National Institute of Neurological Disorders and Stroke (award number K23NS110470

Publisher Copyright:
© 2022 The Author(s). Published by Oxford University Press on behalf of Infectious Diseases Society of America.

Keywords

  • HIV/AIDS
  • immune reconstitution
  • meningitis
  • postpartum
  • pregnancy
  • tuberculosis

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