title: Differential diagnosis of stroke in a setting of high HIV prevalence in Blantyre, Malawi.
abstract: OBJECTIVE
  The differential diagnosis of stroke in Africa in areas with high HIV prevalence includes brain infections. We studied causes of stroke in Blantyre, Malawi, where HIV prevalence among medical in-patients is 70%.
  
  
  METHODS
  In a descriptive study of 8 month duration, all patients presenting at Queen Elizabeth Central Hospital, Blantyre with central neurological deficit of acute onset (< 24 hours) had baseline investigations, including full blood count, blood glucose; serology for toxoplasmosis, syphilis and HIV; ECG, echocardiogram, ultrasound of the carotid arteries and computerized tomography scan of the brain. A lumbar puncture was performed unless contraindicated.
  
  
  RESULTS
  Ninety-eight consecutive patients (49 males) were studied. In those who were HIV positive (48%) the mean age was 37.5 years; ischemic stroke was the commonest diagnosis (n = 25, 58%) followed by infection (n=11, 23%; including tuberculous [n=4] and cryptococcal [n=2] meningitis; toxoplasmic encephalitis [n=1]; neurocysticercosis [n=1]; brain abscess [n=1]; and progressive multifocal leucoencephalopathy [n=2]). No clinical or laboratory parameters could be identified as predictors for infection, but 3 of 5 patients with fever on admission had tuberculous meningitis. In HIV negative patients (mean age 58.6 years) 55% had ischemic stroke and 31% had intracerebral hemorrhage; no brain infection was diagnosed. Presence of vascular disease correlated with age but not with HIV status.
  
  
  CONCLUSIONS
  Ischemic stroke was found in half of patients irrespective of HIV status. In those who are HIV positive, brain infection should be considered for which the presence of fever and examination of CSF seem most useful in diagnosis.
authors.affiliation: Department of Medicine, College of Medicine, Blantyre, Malawi.
authors.forename: J J
authors.initials: JJ
authors.lastname: Kumwenda
authors.affiliation: Department of Medicine, College of Medicine, Blantyre, Malawi.
authors.forename: G
authors.initials: G
authors.lastname: Mateyu
authors.affiliation: Department of Radiology, Queen Elizabeth Central Hospital, Blantyre, Malawi.
authors.forename: S
authors.initials: S
authors.lastname: Kampondeni
authors.affiliation: Department of Medical Microbiology Leiden University Medical Centre, Leiden, the Netherlands.
authors.forename: A P
authors.initials: AP
authors.lastname: van Dam
authors.affiliation: Department of Parasitology, Leiden University Medical Centre, Leiden, the Netherlands.
authors.forename: L
authors.initials: L
authors.lastname: van Lieshout
authors.affiliation: Department of Medicine, College of Medicine, Blantyre, Malawi.
authors.forename: E E
authors.initials: EE
authors.lastname: Zijlstra
keywords: HIV; stroke