Abstract / Summary
Abstract Background Central nervous system (CNS) infections remain a major cause of morbidity and mortality in low-resource settings, particularly in high burden of HIV. Data on clinical presentation and prognostic factors in Mozambique are limited. Methods We conducted a prospective cohort study at Maputo Central Hospital, Mozambique, including adults (≥ 18 years) hospitalized with CNS infections between September 2024 and August 2025, with follow-up until September 2026. Demographic, clinical, diagnostic, treatment and outcome data were collected. Cox proportional hazards regression identified independent predictors of death. Results Of 281 patients screened, 265 were included. Median age was 39 years (IQR 28–47), 52% were male, and 185 (70%) were living with HIV. Headache (75%) altered mental status (69%), fever (53%) and seizures (39%) were the most frequent presenting features. Half presented approximately one week after symptom onset and 23% after more than one month. Lumbar puncture was performed in 121 (46%). Overall, 84 patients died in hospital (31.7%). Cerebral toxoplasmosis, cryptococcal meningitis and meningoencephalitis were more frequent among the group of deceased, whereas cerebral malaria predominated among survivors (p < 0.001). Male sex (adjusted hazard ratio [aHR] 2.24, 95% CI 1.39–3.62), GCS 9–12 (aHR 2.03, 95% CI 1.03–3.97), GCS 3–8 (aHR 4.95, 95% CI 2.48–9.88), HIV infection (aHR 2.39, 95% CI 1.27–4.50), and smoking (aHR 2.18, 95% CI 1.18–4.03) were independently associated with increased hazard of in-hospital death. Antiviral treatment was associated with lower hazard of death (aHR 0.11, 95% CI 0.02–0.45) Conclusion CNS infections is associated with high in-hospital case-fatality with approximately one out three patients dying. Severe neurological impairment and HIV infection were major predictors. Delayed presentation limited diagnostic capacity and management emerged as key actionable gaps in care. Improving timely diagnosis and improving management, particularly HIV infection, may reduce case-fatality from CNS infections in Mozambique.