Intra-axial Posterior Fossa Cryptococcosis: MRI Findings

Two case reports of intra-axial posterior fossa cryptococcosis in immunocompetent patients are presented. Magnet ic resonance findings of solitary abscesses with mildly irregular peripheral enhancement within t he medulla, and irregular peripheral enhancement with a nodular component w ith in the right cerebellum are described.     

A comparision of brain biopsy and CSF-PCR in the diagnosis of CNS lesions in AIDS patients

Twenty patients with AIDS who had intracranial lesions underwent both brain biopsy and cerebro-spinal fluid (CSF) examination to compare histological diagnosis with the polymerase chain reaction (CSF-PCR) for the identification of infectious agents. CSF-PCR was performed for herpes simplex virus, varicella zoster virus, cytomegalovirus (CMV), JC virus (JCV), Epstein-Barr virus (EBV), Toxoplasma gondii and Mycobacterium tuberculosis. A definitive diagnosis was obtained by brain biopsy in 14 patients (2 with astrocytoma, 12 with brain infection). CSF-PCR was positive for EBV DNA in 3 of 3 cases of primary cerebral lymphoma, positive for JCV DNA in 6 of 7 biopsy-proven (and one autopsy-proven) cases of progressive multifocal leukoencephalopathy (PML). CSF-PCR was positive for CMV DNA in one biopsy-proven and one autopsy-proven case of CMV encephalitis (the former also had PML) and positive for M. tuberculosis DNA in one case of tuberculous encephalitis. None of the five toxoplasmic encephalitis cases (one definite, four presumptive) were T. gondii DNA positive. There was close correlation between histology and CSF-PCR for CMV encephalitis, PML and PCL. Antitoxoplasma therapy affected the sensitivity of both histological and CSF-PCR methods. Received: 8 November 1995 Received in revised form: 9 July 1996 Accepted: 19 July 1996     

Vasculitis with predominantly leptomeningeal involvement in an AIDS patient

A case of a 45-year-old female AIDS patient with an unusual type of vasculitis is presented. Clinically, she exhibited hemiparesis, hemianopsia, oculomotor abnormalities, grand mal seizures, and multiple cerebral ischemic lesions. Neuropathologic examination revealed a necrotizing, lymphocytic vasculitis predominantly involving the leptomeningeal spaces in various anatomical locations. The vasculitis was most probably due to the primary effect of HIV-1, as no other possible pathogenetic agent was isolated.     

Central nervous system involvement in patients with acquired immune deficiency syndrome (AIDS)

Central nervous system involvement occurred in 28 of 121 patients with acquired immune deficiency syndrome (AIDS). The major risk factor in this AIDS population was intravenous drug abuse (64%). A neurologic symptom or disability was the principal reason for hospitalization in 16 cases (57%). Three patients had primary lymphoma of the brain and the remainder had opportunistic infections. Patients with focal neurological features usually had toxoplasmosis. Progressive headache and meningeal signs occurred with cryptococcosis. A progressive subacute dementia was probably due to cytomegalovirus. Other infections included atypical mycobacteria, candida, herpes zoster and possible progressive multifocal leukoencephalopathy.     

AIDS and dementia: a quantitative neuropsychological study of unselected Danish patients

Retrospective studies of hospitalized patients with the acquired immune deficiency syndrome (AIDS) have indicated that dementia occur in the majority of cases. In order to study the occurrence of dementia among AIDS patients, we conducted a controlled study of 16 unselected cases with a battery of neuropsychological tests known to be sensitive to brain damage of various etiologies. Except for fatigue, mental complaints and neuropsychiatric signs of dementia were generally sparse. As a group, the AIDS patients' performance in the neuropsychological tests did not differ from that of matched, healthy controls. Based on analyses of individual test results only one patient performed significantly inferior to what should be expected. The diagnosis of dementia should not be ascribed to AIDS victims on account of non-specific psycho-behavioral deviations that may represent a normal psychologic reaction to the disease, extreme fatigue, or both. Further, frequency measures of dementia in AIDS, based on large, unselected groups and with sufficient control, are still lacking. However, our study indicates that dementia is a less frequent complication of AIDS than so far assumed.     

Chorea in patients with AIDS

OBJECTIVE: To describe differing etiologies and possible anatomoclinical correlates of choreic movements in a series of AIDS patients. METHODS: We analyzed the clinical records and neuroimaging data of 5 consecutive AIDS patients who developed choreic movements at our center from January, 1994 to December, 1996. RESULTS: There were 2 cases of focal choreic dyskinesias, 1 of right hemichorea, and 2 of generalized chorea. Onset was acute and febrile in 1 case, and subacute in the other 4. In 1 patient the chorea was the AIDS onset symptom; in another choreic movements were the first neurological symptom following AIDS diagnosis; in 2 patients AIDS had a neurological onset other than chorea; and in the fifth patient buccofacial dyskinesias appeared following the development of bacterial encephalitis. CONCLUSION: Chorea was associated with cerebral toxoplasmosis in 2 patients, progressive multifocal leukoencephalopathy in 1, subacute HIV encephalopathy in another, and was probably iatrogenic in the last. Chorea is not unusual in AIDS, however the causes are variable and careful neuroradiological and clinical evaluation is required to identify them. AIDS-related disease should be considered in young patients presenting with chorea without a family history of movement disorders.     

CNS involvement in Japanese patients with chronic inflammatory demyelinating polyradiculoneuropathy

Thirteen consecutive Japanese patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) were studied by MRI, evoked potentials, and EEG. We found 3 of these patients exhibited symptoms of CNS disorders. Of these 3, 2 with abnormal MRI and visual evoked potentials, and one with abnormal brainstem auditory evoked potentials were detected. Another case without clinical CNS signs showed abnormal EEG findings. The subclinical CNS abnormalities found in the Japanese patients were considered to be less frequent than in cases from Western countries reported previously.     

CSF in 85 patients with AIDS and CNS cryptococcosis.

In an eight years time period (July 1984-June 1992) CSF samples of 40718 patients were studied, and 610 were from patients with AIDS clinically diagnosed and immunologically confirmed through HIV antibodies detection. Among opportunistic infections detected in them 85 were CNS cryptococcosis. For the purpose of this study the CSF of these 85 patients are the AIDS group of CNS cryptococcosis. For comparison, CSF data from 50 patients with CNS cryptococcosis but without AIDS were taken (non-AIDS group); in this group, 22 patients were immunosuppressed after renal transplant. In AIDS group, the more frequent CSF findings were: yeast presence at direct exam (Fuchs-Rosenthal cell counting chamber), growing of the yeast in cultures, and gamma globulins increase. In non-AIDS group were more frequent: hypercytosis, neutrophil cells presence, and total protein increase. Differences between the two groups are discussed taking into account CNS/CSF immune changes induced by HIV infection. It is concluded that in CNS cryptococcosis of patients with AIDS the CSF evidenced more extensive signs of the fungal opportunistic infection than signs of inflammatory response to the infection. The latter were more prominent among patients of the non-AIDS group of CNS cryptococcosis.     

Prevalence of neuropsychological deficit in HIV infection. Incipient signs of AIDS dementia complex in patients with AIDS

The present study attempts to estimate the prevalence of Aids Dementia Complex assessed by neuropsychological testing in Norwegian patients with AIDS using a clinical control group with acute leukemia and an asymptomatic HIV-positive group as reference groups. Newly diagnosed patients with AIDS and not receiving zidovudine or other anti-viral drugs, patients with asymptomatic HIV infection, and newly diagnosed patients with acute leukemia, were studied with a battery of neuropsychological tests. Speeded tests and composite non-verbal measures discriminated significantly between groups. The results indicate higher than 50% prevalence of ADC in newly diagnosed Norwegian patients with AIDS. Our findings indicate that the AIDS population may contain two distinct groups, a subgroup with ADC and a subgroup with persistently normal neuropsychological function. The group with asymptomatic HIV infection showed normal neuropsychological performance.     

Skeletal muscle involvement in HIV-infected patients

Skeletal muscle involvement may occur at all stages of human immunodeficiency virus (HlV)-infecuon, and represents the first manifestation of the disease in some patients. There have been many controversies about the classification of myopathies related to HIV infection. We usually classify muscle involvement in HIV–infected patients in one of the following categories: (1) HIV–associated myopathy, a myopathy that meets the criteria for polymyositis in a majority of patients, and those for acquired nemaline myopathy in some; (2) zidovudine myopathy, a reversible mitochondrial myopathy; (3) the HIV–wasting syndrome and other AIDS–associated cachexias; (4) opportunistic infections and tumoral infiltrations of skeletal muscle; (5) vasculitic processes and iron pigment deposits. Immunohistology for major histocompatibility complex class I antigen and the histochemical reaction for cytochrome C oxidase are helpful in correctly classifying a myopathy as HIV polymyositis or zidovudine myopathy respectively. Studies of circulating levels and tissue expression of cytokines in HIV–infected patients have yielded new insights into the pathogenesis of the various AIDS–associated muscle disorders.     

Lymphoma-induced polyradiculopathy in AIDS: Two cases

Summary Progressive polyradiculopathy is a rare, well-documented complication of the acquired immunodeficiency syndrome in man. It has been commonly attributed to a cytomegalovirus (CMV) infection. We report two HIV-infected patients with clinical and electrophysiological features of a unique, subacute, progressive polyradiculopathy. Post-mortem examination in case 1 disclosed an infiltration of the leptomeninges, the lumbar spinal cord, and the anterior and posterior roots by a B-cell immunoblastic lymphoma. Immunochemistry for HIV1 and CMV was negative in the peripheral and the central nervous system. Case 2 showed bone-marrow involvement by a Burkitt type lymphoma. Specific chemotherapy was followed by both clinical improvement of the polyradiculopathy and complete remission on a second bone-marrow biopsy. These findings may indicate that a lymphoma must also be considered a possible cause of polyradiculopathy in AIDS.     

Cerebral ventricular enlargement relates to neuropsychological measures in unselected AIDS patients

In a cross-sectional study of unselected Danish AIDS patients various linear measures of cerebral ventricular size obtained by computed tomography were compared with results of neuropsychological test performances. Third ventricular width as well as right and left septum-caudate distances were enlarged in the patients (P less than 0.01). Of 20 patients 15 had at least one abnormal ventricular measurement. Although only one patient was demented, ventricular size correlated inversely with neuropsychological function (r = -0.61, P less than 0.02). The correlation between ventricular size and variation of the reaction time was even closer (r = 0.74, P less than 0.01). It is concluded that neuroradiological signs of central atrophy often occur in AIDS patients.     

Human immunodeficiency virus (HIV) envelope and core proteins in CNS tissues of patients with the acquired immune deficiency syndrome (AIDS)

Summary Frequency, cellular tropism and relation to pathology of productive infection with human immunodeficiency virus (HIV) in human central nervous system (CNS) were studied. Serial sections of formolfixed and paraffin-embedded CNS tissues from 70 patients (69 with acquired immune deficiency syndrome, AIDS) were immunolabeled with monoclonal antibodies against HIV antigens (Ags) p17, p24, and gp41. Additional and double (immuno)stains were used to identify cell types and opportunistic infectious agents. HIV Ags were detected in 52 cases; they were restricted to cells with characteristics of microglia or macrophages. Anti-gp41, anti-p24, and anti-p17 labeled 50, 33, and 15 cases, respectively. Immunoreactivity for core proteins predominated in mature macrophages and microglia of fully developed lesions; additional immunoreactivity for gp41 was seen in microglia adjacent to, or unassociated with, histopathological lesions. Multifocal and/or diffuse lesions previously suggested as HIV induced because of characteristic histopathology, consistently contained large numbers of cells with HIV Ags (33 cases), confirming their HIV specificity. Isolated labeled microglia without associated pathology, found in seven brains, presumably represent the earliest stage of productive CNS infection by HIV. Lesions of opportunistic infections contained no (34 cases), few (16 cases), or many (4 cases) cells with HIV Ags. These data do not suggest transactivation of local HIV production by opportunistic agents as a frequent event in vivo. Development of specific HIV histopathology appears correlated with the number of productively infected cells.Supported by the Austrian Fund for the Advancement of Scientific Research (P 7154-MED). Major parts of this study were presented at the Vth International Conference on AIDS, June 4–9, 1989, in Montreal, Canada (Th. B. P. 248)     

Dendritic changes in the hippocampal formation of AIDS patients: a quantitative Golgi study

We have previously shown that in the hippocampal formation of patients with acquired immunodeficiency syndrome (AIDS) there is neuronal atrophy, without cell loss. Because reductions in neuronal size are suggestive of associated neuritic alterations, we decided to study the dendritic trees of the main neuronal populations in the hippocampal formation. Material was obtained in five male AIDS patients and five male controls. After Golgi impregnation, the dendritic arborizations of dentate granule and hilar basket cells, and of CA3 and CA1 pyramidal cells, were hand traced, and their segments classified, counted and measured. We found an impoverishment of the dendritic trees in all neuronal populations in the AIDS group, which was more striking in the hilus and CA3 field. Specifically, hilar neurons had fewer dendritic segments, and reduced branching density and dendritic extent; in CA3 pyramids there was a decrease in the number of terminal segments in the basal trees, and a reduction in the total number of segments, number of medium order terminals, dendritic branching density and dendritic extent in the apical trees. In CA1 pyramids, the terminals were shorter in the apical trees and the dendritic spine density decreased in the basal trees, whereas in granule cells only the dendritic spine density was reduced in AIDS patients. Subtle signs suggestive of dendritic reorganization were observed. These results point to a regional vulnerability of the hippocampal formation to HIV infection, and might contribute to explaining the occurrence of dementia, as a consequence of overall reduction in the hippocampal neuronal receptive surface.     

Locally synthesized antibodies in cerebrospinal fluid of patients with AIDS

Summary Twelve patients with AIDS were examined by enzyme-linked immunosorbent assay for antibody activity of IgG in serum and CSF. Two patients were only anti-HTLV III antibody carriers (stage I), two had lymphadenopathy syndrome (stage II) and eight had manifest AIDS (stage III). Eight of the 12 patients had 2- to 8-fold higher antibody titres in CSF than in serum, indicating that anti-HTLV III antibodies were produced in the nervous system. One of these patients with obviously locally synthesized anti-HTLV III antibodies in CSF belonged to stage I, two to stage II and five to stage III. Only four of these eight patients also showed locally synthesized IgG in CSF as measured by laser-nephelometry. In contrast, 61 controls with normal CSF (12), impaired blood-CSF barrier (12) multiple sclerosis (12) and various infections of the CNS other than HTLV III (25), the last two groups with locally synthesized IgG in CSF, all revealed negative results. It appears possible that locally synthesized anti-HTLV III antibodies in CSF are a sensitive and early indicator of an HTLV III infection of the nervous system.     

艾滋病痴呆综合征临床分析

目的研究中国人群艾滋病(AIDS)痴呆综合征(ADC)的特征。方法对上海交通大学附属第一人民医院和上海市传染病医院收治的诊断为ADC的6例AIDS患者进行临床分析。结果所有患者均在清醒状态下表现为近记忆减退及注意力集中困难,其中3例伴有运动障碍。6例ADC患者中2例伴有空泡性脊髓病。诊断为AIDS后,ADC的平均诊断时间为6 5个月。所有患者均死于呼吸衰竭,平均寿命为41 8岁。结论ADC是AIDS患者最常见的神经系统并发症,常发生在AIDS的进展期。ADC通常伴有空泡性脊髓病,预后极差。     

艾滋病合并隐球菌性脑膜炎19例临床分析

目的探讨艾滋病合并新型隐球菌性脑膜炎的临床特征。方法对19例艾滋病合并新型隐球菌性脑膜炎患者的临床资料进行回顾性分析。结果 19例患者临床表现以头痛(100%)、恶心/呕吐(94.7%)、发热(78.9%)、颈强直(84.2%)为主。7例CSF蛋白升高,10例CSF葡萄糖下降及11例CSF压力升高。CD4+细胞计数平均值为(58.9±27.8)/mm3。影像学检查显示多为脑积水、脑梗死、脑萎缩和脑疝。两性霉素B、两性霉素B脂质体、氟康唑和氟胞嘧啶的使用率为31.6%、21.1%、47.4%和47.4%,仅2例接受抗逆转录病毒治疗。19例患者误诊率为31.6%,死亡率为21.1%。结论艾滋病合并新型隐球菌性脑膜炎起病隐匿,临床表现不典型,误诊率较高,及早诊断并早期使用抗真菌/抗逆转录病毒治疗有助于控制其发展。