Pastick Katelyn A, Kagimu Enock, Dobbin Joanna, Ssebambulidde Kenneth, Gakuru Jane, Milln Jack, Nakabuye Betty, Meya David B, Boulware David R, Cresswell Fiona V, Bahr Nathan C
Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA.
Open Forum Infect Dis. 2022 Oct 6;9(10):ofac513. doi: 10.1093/ofid/ofac513. eCollection 2022 Oct.
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.
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.
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.
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.
结核病是育龄妇女的主要死因之一。然而，尽管孕期是免疫调节的特殊时期，可能使女性易患活动性疾病，但肺外结核病最严重的形式——结核性脑膜炎，在孕期却很少被讨论。
我们识别并描述了2018年至2022年在乌干达脑膜炎临床试验中接受筛查的孕妇或产后妇女中的结核性脑膜炎病例。我们通过PubMed/Medline和Embase对1970年至2022年7月10日的所有英文出版物进行了系统的文献综述，以识别更多病例。
我们在乌干达感染人类免疫缺陷病毒（HIV）的女性中识别出8例与妊娠相关的结核性脑膜炎病例，并通过系统文献综述又识别出40例（均非HIV阳性）。在所有合并病例中，50%（24/48）在产后被诊断；50%（24/48）在孕期首次发病，其中38%（9/24）在妊娠终止后症状加重或疾病复发。33%（16/48）的病例诊断被漏诊或延误。对于已知结局的病例，孕产妇死亡率为23%（11/48），胎儿/新生儿死亡率为30%（13/44）。在存活的孕产妇中，30%（11/37）有残留神经功能缺损。
孕期或产后结核性脑膜炎的真实发病率尚不清楚，但可能未得到充分认识。迄今为止，几乎所有已发表的病例都发生在HIV阴性或其他免疫功能正常的女性中。鉴于孕期有充分描述的生理性免疫抑制以及产后随后的免疫重建，医生必须意识到结核性脑膜炎和妊娠相关免疫重建炎症综合征，尤其是在结核病负担高的国家以及感染HIV的女性中。
