Managing meningitis in people living with HIV

Dear doctor,

My brother has been living with HIV for many years, but he has never accepted to take treatment. He has been having headaches and fatigue for several weeks, and by the time he was taken to hospital recently, he looked confused. He was started on meningitis treatment, and luckily, he seems to be improving. What kind of meningitis is this that had made him sick for so long? Can it be cured? Is there a way to prevent it in future? Raymond

Dear Raymond,

It is likely that your brother has meningitis caused by a fungal infection known as cryptococcal meningitis. Meningitis refers to inflammation of the meninges, that is; the membranes that surround the brain and the spinal cord. This inflammation can be caused by infections, including bacterial, viral, parasitic and fungal infections.

When the body’s immunity is not working well, (for instance with long-standing untreated HIV infection; use of immune-suppressive treatments; some cancers, among others) then the person is at risk of developing cryptococcal meningitis, caused by cryptococcus fungus. This fungus is normally found in the environment and can enter the body through the respiratory system. The infection usually begins in the lungs and spreads through the blood stream, then to the meninges.

The symptoms of cryptococcal infection usually progress gradually over several weeks and may include fever, cough, difficulty in breathing, weight loss, worsening headache, stiff neck, nausea and vomiting. Severe disease may result in changes in vision, hearing, speech and movement; confusion; seizures; coma and even death. The infection may affect any other organ in the body, causing symptoms that are related to that organ system such as skin changes and liver inflammation.

Meningitis is diagnosed through several tests, and specific anti-fungal treatment is given to treat it. The treatment is done in phases, with different medications and/or different dosages of the medications given in the different phases. The first phase, the induction phase, takes two weeks and should be done in the hospital, together with any other supportive treatments. The second phase, the consolidation phase, lasts for eight weeks. The last phase, the maintenance phase, lasts for at least one year.

The medication given during the maintenance phase should not be stopped until the person’s immunity is seen to have significantly improved, as shown by at least two tests that are six months apart, and the person should have been taking anti-retroviral treatment well and achieved viral suppression. This medication that is given during the maintenance phase also works to prevent future infections. But this has to be accompanied by suppression of the HIV virus, which will give the immune system an opportunity to recover. It is vitally important for your brother to take the medication as prescribed and also to take anti-retroviral medication, as per the healthcare professional’s guidance.

Dear doctor,

Twice now, I have had a very bad smelling stone-like thing coming from the back of my mouth, and I think it has been making my breath smell bad. What could this be?

Hellen

Dear Hellen,

It is likely that you had a tonsil stone or a tonsilolith. This is a lump that forms within the irregular surface of the tonsils, and it is made up of food particles, microorganisms and minerals like calcium, which makes the lumps harden. The tonsil stones may be white or yellow in colour and may range in size from small to large.

Tonsil stones may cause bad breath (halitosis), sore throat, a feeling of something being stuck in the throat; and difficulty with swallowing. Tonsil stones can also lead to ear discomfort and pain. Rarely, the surrounding area may get inflamed, and there may be infection.

It is possible for any person to get tonsil stones, but the risk is higher if you do not take adequate water, if your tonsils are enlarged or if you suffer from tonsilitis many times.

Most of the time, tonsil stones can be easily and safely removed at home by either:

- Gargling with warm salty water

- Gently pushing it out with a cotton swab

- Coughing forcefully

- Waiting for them to fall out on their own

If the tonsil stones are very large, or they occur too frequently, or are causing complications, then surgery to remove the tonsils may be done.

You can reduce the risk of getting another tonsil stone by taking adequate amounts of water, brushing your teeth and tongue, and flossing regularly; gargling with warm salty water after cleaning your teeth and stopping smoking.

Dear doctor,

There are places on my skin where I had a cut or a pimple before, but when it heals, it forms a dark coloured lump that doesn’t go away. I have several on the back of my head that are quite big. What are they? Are they treatable? Juma

Dear Juma,

It seems you may have keloids. These are overgrowths of scar tissue. The skin usually forms scar tissue after skin injury or infection as a way of protecting the underlying tissue and promoting healing. Persons with keloids develop an overgrowth of the scar tissue weeks or months after the skin trauma, forming a reddish, light or dark coloured lump or swelling that is bigger than the initial lesion. They can develop following a skin injury, infection, a rash, a burn or at an injection site. Keloids can affect any part of the body, though they are more common on the upper arms, the chest, the back and the ears.

Keloids may change in colour over time, and there may be itchiness or pain at the site. Keloids are usually not dangerous, but can be treated if there are any concerns.

Keloids cannot be cured, because the tendency to form keloids is genetically determined, and there is a higher risk of having keloids if one of your parents also has them. Treatment of keloids is challenging because of the risk of developing additional keloids at the site that is being treated.

Treatment is done by a skin specialist/dermatologist and usually includes multiple approaches to suite the individual’s needs, and this may include medications that are injected into the site; cryotherapy; radiotherapy; laser treatment; surgical excision or use of silicon gel.

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