Intracerebral mass lesions in patients affected by AIDS

Summary Toxoplasma gondii cerebral abscess is a common opportunistic infection in patients affected by AIDS. Making a reliable diagnosis of acute cerebral toxoplasmosis is difficult in AIDS patients because of the lack of specificity of serological data and neuroradiological findings. Brain biopsy is the only procedure which enables a reliable diagnosis to be made a trial of specific medical therapy for toxoplasmosis in patients affected by AIDS and intracranial mass lesion can be advisable before performing brain biopsy. The authors report the cases of three patients affected by AIDS and cerebral toxoplasmosis.Tissue diagnosis was made in the first patient from autopsy material while a presumptive diagnosis was made in the other two cases since specific medical therapy resulted in a dramatic improvement of the neurological status.Despite the good possibilities in the treatment of this complication AIDS, however, carries a poor prognosis.     

Stereotactic biopsy of cerebral lesions in patients with AIDS.

Central nervous system involvement with AIDS is not uncommon. The indications and timing of brain biopsy remains controversial. Stereotactic CT-guided biopsy offers a safe and effective means of establishing a diagnosis in any patient with a cerebral mass lesion and has less morbidity and mortality than freehand biopsy or exploratory craniotomy. Eleven patients with AIDS have undergone CT-directed stereotactic biopsy between May 1987 and November 1990 with one death from intracerebral haemorrhage. Histological diagnosis of the biopsy specimens showed multifocal leucoencephalopathy, toxoplasmosis, lymphoma and non-specific changes. Biopsy is recommended for patients with an atypical presentation, negative serology, progressive clinical deterioration and differential response of lesions to empirical therapy.     

The role of stereotactic biopsy in the management of HIV-related focal brain lesions.

The criteria for brain biopsy in patients with acquired immunodeficiency syndrome (AIDS) remain unclear and without universal acceptance. In order to shed more light on this issue, the authors reviewed the records of 25 AIDS patients with focal cerebral lesions who consecutively underwent stereotactic biopsy between November 1988 and October 1990. The most frequently occurring diagnoses were lymphoma (36%), progressive multifocal leukoencephalopathy (24%), and toxoplasmosis (8%). Patients whose central nervous system disease resulted in their initial presentation (approximately 40%) survived a median of 37 weeks, as opposed to 6 weeks for those who had previous AIDS-related infections. The proportion of biopsies of contrast-enhancing lesions that were diagnostic and thereby contributed to the patients' therapeutic management was 87.5%. On the other hand, only 67% of the biopsies of nonenhancing lesions were diagnostic, and none of these lesions were treatable. All of the lymphoma patients had had AIDS for some time and, despite a reasonable preoperative Karnofsky score and postoperative radiation therapy, their median survival was only 6 weeks; however, biopsy was critical to their therapeutic management. Early brain biopsy, rather than empiric antitoxoplasmosis therapy, appears indicated for aggressive therapy of contrast-enhancing lesions in patients who have had previous manifestations of AIDS. The role for biopsy of nonenhancing lesions is less clear, but it may provide prognostic information.     

Electron microscopic diagnosis of cerebral toxoplasmosis. Case report

Rapid and specific diagnosis of infections involving patients with acquired immunodeficiency syndrome (AIDS) is imperative. Toxoplasmosis is one of the most frequent causes of central nervous system disease in these patients. The authors present a case of cerebral toxoplasmosis in an AIDS patient, diagnosed by electron microscopy of brain biopsy tissue using rapid techniques.     

Clinical investigations of lymphadenopathy, including lymph node biopsies, in 24 homosexual men with antibodies to the human T-cell lymphotropic virus type III (HTLV-III)

The findings of 27 lymph node biopsies performed on 24 homosexual patients with lymphadenopathy are presented. Six had acquired immune deficiency syndrome (AIDS) and 18 lymphadenopathy only, of whom one subsequently developed AIDS. All these patients had antibodies to the human T-cell lymphotropic virus type III (HTLV-III) suggesting that HTLV-III is currently the commonest cause of lymphadenopathy in homosexual men. The histopathological findings of six of seven nodes from AIDS patients showed either follicular depletion alone or follicular and paracortical lymphocyte depletion. Nodes from four patients showed Kaposi's sarcoma, three of which also showed follicular hyperplasia. In two of these patients there were no cutaneous manifestations of this condition. One lymph node from a patient with persistent generalized lymphadenopathy (PGL) showed Mycobacterium tuberculosis. Six nodes from six other patients have had features of toxoplasmosis although there was no serological or clinical evidence of recent toxoplasma infection. The remaining 11 lymph nodes from patients with PGL and one node from a patient with transient lymphadenopathy, showed reactive follicular hyperplasia only. We conclude that homosexuals with lymphadenopathy who are HTLV-III antibody positive do not need a routine node biopsy unless an alternative diagnosis is strongly suspected.     

Diagnostic value of stereotactic biopsy of cerebral lesions in patients with AIDS

Summary A neurological complication occurs in 40–60% of HIV infected patients during the course of the disease. In 10–20% the neurological complication is the first manifestation of the HIV infection. A reliable neuropathological diagnosis is a prerequisite for a specifically selected treatment. While modern computer-assisted imaging techniques, such as computed tomography or magnetic resonance imaging, do possess a high sensitivity, they do not as a rule permit an unambiguous diagnosis.Between October 1989 and July 1994 we biopsied 38 HIV infected patients stereotactically. The indication for the biopsy was determined by having radiologically detectable lesions with no regression tendency in patients under antitoxoplasmosis therapy. In 89% an unambiguous diagnosis wa made based on the biopsy; 11 % of the biopsies were not diagnostic. For the most part, toxoplasmosis (31%) and progressive multifocal leucoencephalopathy (29%) were involved. 18% of the patients suffered from a non-Hodgkin lymphoma. The foci were primarily frontal (47%), parietal (21%) or localised in the basal ganglia area (11%). The result of the biopsy led to a change in treatment for 52% of the patients. Morbidity and mortality of the operation were 0%.The results or our research series are similar to other groups. It was shown that stereotactic brain biopsy is a safe and effective method for establishing a sound basis for treating the frequently life-threatening cerebral complications of AIDS.     

Strategy for diagnosis of Toxoplasma gondii in stereotactic brain biopsies.

The colloidal gold method using polyclonal antitoxoplasma antibodies was used to detect Toxoplasma organisms in stereotactic brain biopsies of patients with AIDS. For comparison, conventional histologic staining and additional other immunohistochemical methods were also studied in the same cases. Compared to the other stains, a reliable diagnosis of Toxoplasma gondii could be established with the colloidal gold method in all patients investigated. This method was highly specific and sensitive and stained both the encysted and the tachyzoite forms of the organism. Stronger contrast of the single parasite and better identification is possible if it is applied together with silver enhancement. Conventional staining and immunohistochemical peroxidase techniques are not advantageous, because they allow a diagnosis only by observation of the rare pseudocysts and not by free parasites in tissue, so the colloidal gold method appears to be the preferred method for a rapid diagnosis of cerebral toxoplasmosis, especially in cases where only small amounts of tissue can be obtained.     

Brain biopsy in AIDS. Diagnostic value and consequence

Summary Nineteen male patients with AIDS were investigated by biopsy of brain lesions. Six patients had progressive multiple leucoencephalopathy and no specific treatment was given. Toxoplasmosis (two patients), bacterial abscesses (two cases), viral encephalitis (two patients) and only gliosis (two cases) accounted for almost half of the cases. A fungal infection, a lymphoma and a sarcoma-like tumour were found in three patients. In two patients the biopsy was not diagnostic: one had only necrosis and one had normal findings. The biopsy findings gave reason for modifying the treatment in only three cases.The mean survival rate was relatively short, only 76 days with a range from 1 to 1041 days. Two patients were in a very bad clinical condition at the time of biopsy and one died of a haemorrhagic complication due to the biopsy. In ten cases an autopsy was carried out. In five cases there was agreement between the biopsy and autopsy findings. In the other five cases the autopsy findings differed widely.In our experience we can recommend cerebral biopsy in patients with AIDS only after treatment for toxoplasmosa and mainly to estimate the prognosis.     

Comparison of biopsy-proven Pneumocystis carinii pneumonia in acquired immune deficiency syndrome patients and renal allograft recipients

Pneumonia unresponsive to antibacterial agents in patients with acquired immune deficiency syndrome (AIDS) has become a new indication for lung biopsy. In 14 patients, transbronchial or open-lung biopsy demonstrated Pneumocystis carinii. An additional 12 patients, who were immunosuppressed after renal transplantation, were seen with P. carinii pneumonia. The diagnosis was established by transbronchial biopsy in the majority of patients. All patients were treated initially with trimethoprim plus sulfamethoxazole. Pentamidine was added after diagnosis if improvement did not occur. Both groups demonstrated reversal in the T cell helper: suppressor ratio. We compared these two groups of immunocompromised patients with respect to clinical presentation, lung pathology, response to therapy, and survival. Patients with AIDS were seen with a two- to three-week prodrome of fever, lymphadenopathy, weight loss, and malaise followed by hypoxia and leukopenia within 12 hours. Transplant patients became acutely ill with fever and hypoxia within 24 to 36 hours. In both groups, chest roentgenogram showed bilateral diffuse infiltrates; sputum cultures were generally negative; and lung biopsy demonstrated Gomori-Jones periodic acid-methenamine-silver-positive P. carinii. Mortality was substantially higher in patients with AIDS (50% versus 8%). This difference may be explained by the fact that the T cell defect in AIDS has an infectious cause, while the defect in the renal allograft recipient is pharmacologically mediated.     

Fine-needle aspiration of diffuse cervical lymphadenopathy in patients with acquired immunodeficiency syndrome

Although diffuse cervical lymphadenopathy is one of the earliest and most common findings in patients with AIDS, the appropriate diagnostic approach in these patients has yet to be determined. Fine-needle aspiration (FNA) was performed on 26 patients with AIDS in order to evaluate the role of FNA in patients with diffuse cervical adenopathy. Specimens were sent for cytology, bacterial culture, fungal culture, and acid-fast smear and culture. Ten patients had positive findings, including toxoplasmosis, histoplasmosis, tuberculosis, atypical mycobacterium, and methicillin-resistant staphylococcal infection. All patients with either unilateral adenopathy or lymph nodes 3 cm or larger had positive aspirates. A statistically significant difference between patients with lymph nodes smaller than 2 cm and those with nodes larger than 2 cm was found. Fine-needle aspiration of a representative node in patients with AIDS may allow prompt diagnosis of diffuse lymphadenopathy. Rapid initiation of appropriate treatment can lead to symptomatic improvement. The need for excisional biopsy of involved lymph nodes may be obviated. Fine-needle aspiration is recommended as a diagnostic tool in selected patients with diffuse cervical lymphadenopathy and AIDS.     

Cerebral toxoplasmosis

Opinion statement The choice of drugs for treating cerebral toxoplasmosis is limited. There are only three drugs available, and, of these, pyrimethamine and sulfonamide are invariably used in combination. Clindamycin is an alternative choice. Another drug, spiramycin, has poor central nervous system penetration, but achieves high concentrations in the placenta, and it is useful for treatment of toxoplasmosis during pregnancy. Because long-term maintenance therapy is often necessary, particularly in patients with AIDS, a wider choice of antibiotics is urgently necessary, because of potential problems with drug resistance and side effects. Treatment may be started empirically in any patient with HIV infection and multiple brain lesions. The drugs of choice are a combination of sulfadiazine and pyrimethamine. Folinic acid should be added to prevent pyrimethamine-induced bone marrow suppression. Repeated neuroimaging, 2 weeks after initiating therapy, is needed to assess efficacy of treatment. If CD4 cell counts remain below 100 cells per mm3, lifelong therapy is needed. Tissue diagnosis should be established in patients who do not respond to treatment, who have solitary lesions, or in patients without AIDS. Recent breakthroughs in the understanding of the biology of Toxoplasma will result in the development of a range of new therapies in the near future.     

Use of CT and MR imaging to distinguish intracranial lesions and to define the need for biopsy in AIDS patients

To explore the potential usefulness of imaging studies in the diagnosis of focal central nervous system (CNS) lesions associated with acquired immunodeficiency syndrome (AIDS), the authors retrospectively examined the radiographic studies of 149 AIDS patients who presented with signs and symptoms of the three most common focal CNS lesions. Of these patients, 74 (50%) had Toxoplasma abscesses, 45 (30%) had primary CNS lymphoma, and 30 patients (20%) had progressive multifocal leukoencephalopathy (PML). Magnetic resonance (MR) imaging was more sensitive than computerized tomography (CT) in detecting lesions, especially in cases of PML. Whereas CT was unable to distinguish mass lesions caused by toxoplasmosis from those caused by lymphoma, 71% of the solitary lesions seen on MR images were lymphomas. These results indicate that empirical treatment for toxoplasmosis, the most common initial treatment for AIDS patients with neurological symptoms stemming from mass lesions, is not likely to be successful for patients with solitary lesions on MR images. Rather, early biopsy is advisable. If the presence of lymphoma is confirmed, the rapid initiation of treatment can allow prolonged high-quality survival.     

Toxoplasmosis of the conus medullaris in a patient with hemophilia A-associated AIDS. Case report

Toxoplasma gondii has been reported to be the most common cause of focal brain lesions in patients with acquired immunodeficiency syndrome (AIDS). A case of intramedullary toxoplasmosis of the conus medullaris is reported in a patient with hemophilia A-associated AIDS. The diagnosis is discussed, with particular emphasis on the magnetic resonance imaging appearance.     

Indications for and Diagnostic Efficacy of Open-Lung Biopsy in the Patient with Acquired Immunodeficiency Syndrome (AIDS)

Pulmonary infiltrates in the patient with acquired immunodeficiency syndrome (AIDS) may be associated with a spectrum of unusual neoplastic and infectious process. Transbronchial biopsy frequently reveals the cause of these infiltrates; however, when transbronchial biopsy is nondiagnostic or contraindicated, or if the patient fails to improve after a diagnostic transbronchial biopsy, further investigation is warranted to direct appropriate therapy. Efficacy of 23 open-lung biopsies in 19 AIDS patients with pulmonary infiltrates was evaluated to define the indications for and the diagnostic yield of open-lung biopsy. Pulmonary infiltrates were recognized for a mean duration (± standard error) of 16 ± 2 days before open-lung biopsy and were associated with fever and cough. These patients did not have prior transbronchial biopsy, and open-lung biopsy was diagnostic in all of these. Prior transbronchial biopsy performed in the remaining 16 patients was nondiagnostic in 10. Open-lung biopsy was diagnostic in 70% of these patients (Pneumocystis carinii pneumonia, 2 patients; Kaposi's sarcoma, 3 patients; Kaposi's sarcoma and Legionella pneumophila, 1 patient; cytomegalovirus, 1 patient). The other 6 patients having a previous diagnostic transbronchial biopsy failed to improve with therapy, and open-lung biopsy resulted in a therapeutic change in 67% of these patients. Two deaths were attributable to open-lung biopsy in patients with postoperative thrombocytopenic hemorrhage. Open-lung biopsy should be performed in AIDS patients when transbronchial biopsy is nondiagnostic or contraindicated, or in patients who fail to improve with appropriate therapy after diagnostic trans-bronchial biopsy, especially in patients with Kaposi's sarcoma. The diagnostic yield will be high, and major therapeutic changes will be instituted.     

Diagnostic accuracy of AIDS-related CNS lesions

Because of the high incidence of neurological complications seen in patients with acquired immunodeficiency syndrome (AIDS), an increasing number of these cases are being referred to neurosurgeons for consideration of intracranial biopsy. To better determine the need for biopsy in these patients we evaluated the accuracy of nontissue-based neurological diagnoses in AIDS patients who subsequently had a final diagnosis on the basis of biopsy or postmortem brain examinations. The records of 56 AIDS patients who had undergone either autopsy or brain biopsy were retrospectively reviewed. Of the ten patients who underwent biopsy, three were found to have a lesion that was different from the suspected diagnosis and that resulted in a change in treatment. Thirty patients with neurological symptoms had postmortem brain examinations. In the cases of the 12 patients who had carried specific diagnoses and received treatments based on those diagnoses, only six diagnoses (50%) were proven correct at autopsy. Of the 18 cases that did not record a specific antemortem diagnosis, in only 5 were normal brains reported, while the others reported a variety of nonspecific or infectious findings. Twelve patients without neurological symptoms had postmortem brain examinations and only six of these (50%) had normal or slightly atrophic brains. Case reports of the others noted nonspecific findings most of which were suggestive of subacute HIV encephalitis. The poor rate of diagnostic accuracy in this series suggests that biopsy should be considered for atypical lesions or those that do not respond to empiric therapy. The use and relative sensitivities of various diagnostic studies are also discussed.     

Pulmonary Kaposi's sarcoma. Premortem histologic diagnosis

Nine open lung biopsies and nine transbronchial biopsies from 10 patients with pulmonary Kaposi's sarcoma were reviewed to define the pattern of involvement in the lung by Kaposi's sarcoma and to determine the usefulness of transbronchial biopsy in making the diagnosis. There were nine patients with acquired immune deficiency syndrome (AIDS) and one patient with sporadic pulmonary Kaposi's sarcoma. A lymphatic distribution was seen in all cases. A spectrum ranging from distinctive polymorphous cellular infiltrates ultimately interpreted as Kaposi's sarcoma to "classic" Kaposi's sarcoma was found. Recognition of the former enabled retrospective recognition of Kaposi's sarcoma in four of eight transbronchial bronchial biopsies. The diagnosis of pulmonary Kaposi's sarcoma in one other patient was made solely on the basis of transbronchial biopsy. Eight patients died from pulmonary Kaposi's sarcoma; two patients are alive with extensive pulmonary Kaposi's at last follow-up. We believe that transbronchial biopsy may be useful in establishing a diagnosis of pulmonary Kaposi's sarcoma in many more patients than is generally appreciated.     

EAU guidelines for the management of genitourinary tuberculosis

Nearly one third of the world's population is estimated to be infected with Mycobacterium tuberculosis. Moreover, tuberculosis is the most common opportunistic infection in AIDS patients. Genitourinary tuberculosis is not very common but it is considered as a severe form of extra-pulmonary tuberculosis The diagnosis of genitourinary tuberculosis is made based on culture studies by isolation of the causative organism; however, biopsy material on conventional solid media may occasionally be required. Drug treatment is the first line therapy in genitourinary tuberculosis. Treatment regimens of 6 months are effective in most of the patients. Although chemotherapy is the mainstay of treatment, surgery in the form of ablation or reconstruction may be unavoidable. Both radical and reconstructive surgery should be carried out in the first 2 months of intensive chemotherapy.