MENINGOENCEPHALITIS DUE TO VARICELLA ZOSTER VIRUS IN AIDS PATIENTS. REPORT OF ELEVEN CASES AND REVIEW OF THE LITERATURE

Neurological complications of varicella-zoster virus (VZV) are infrequent and include various clinical pictures. The reactivation of VZV in patients with AIDS is generally associated with an acute and severe meningoencephalitis. We report the epidemiological, clinical and virological data from 11 consecutive patients with diagnosis of HIV/AIDS and central nervous system (CNS) involvement due to VZV. All patients were male and seropositive for HIV. The primary risk factor for HIV infection was unprotected sexual contact. The median of CD4 T cell count was 142 cells/µL. All of them presented signs and symptoms of meningoencephalitis. Six patients (54.5%) presented pleocytosis; they all showed high CSF protein concentrations with a median of 2.1 g/dL. Polymerase chain reaction of cerebrospinal fluid specimen was positive for VZV in all of them and they were treated with intravenous acyclovir at doses of 30/mg/kg/day for 21 days. Overall survival was 63% (7 of 11 patients). The four dead patients had low cellular counts in CSF, below the median of this parameter. VZV should be included among the opportunistic pathogens that can involve CNS with a diffuse and severe meningoencephalitis in patients with advanced HIV/AIDS disease.     

Detection of human immunodeficiency virus DNA using the polymerase chain reaction in a well-characterized group of homosexual and bisexual men

The polymerase chain reaction (PCR) for human immunodeficiency virus type 1 (HIV-1) DNA was performed on specimens from 197 homosexual and bisexual men enrolled in studies of HIV-1 infection. Thirty cycles of amplification were conducted, followed by detection with probes corresponding to two gag primer pairs (SK 38/39 and SK 101/145). Of 107 men who were HIV-1 antibody-negative, 105 (98%) were PCR-negative. Two who were initially PCR-positive antibody-negative were PCR- and antibody-negative on repeat testing of both the same specimen and specimens drawn 8-10 months later; this suggests that the first PCR results were false-positive. Of 90 men who were antibody-positive, PCR was positive in 87 (97%), including all 13 with AIDS, all 22 with AIDS-related conditions, all 11 with generalized lymphadenopathy only, and 41 (93%) of 44 without signs or symptoms of HIV-1 infection. On repeat testing, all 3 PCR-negative, antibody-positive men were PCR-positive. In this population and with this technique, PCR had excellent agreement with the HIV-1 antibody test.     

Diagnosis and monitoring of human cytomegalovirus diseases in patients with human immunodeficiency virus infection by use of a real-time PCR assay.

We used a real-time PCR assay to measure human cytomegalovirus (HCMV) DNA load in whole blood and plasma of 70 patients who were infected with human immunodeficiency virus type 1. Break points of 3.0 x 10(3) copies/mL in whole blood and 1.0 x 10(3) copies/mL in plasma were well-correlated with the existence of definite HCMV disease (sensitivity, 93% and 86%; specificity, 89% and 85%; positive predictive value, 70% and 63%; and negative predictive value, 98% and 95%, respectively). In patients with < 50 cells/microL of CD4(+) T lymphocytes, positive predictive values increased to 78% and 71%, respectively. The viral loads of all patients who received anti-HCMV therapy declined to < or =2.0 x 10(2) copies/mL in parallel with the improvement of clinical symptoms. These findings show that the HCMV DNA load quantified with our method is a useful tool for diagnosis of HCMV diseases and for monitoring the disease activity in patients infected with HIV-1.     

Detection of human cytomegalovirus retinitis and monitoring of ganciclovir treatment using conjunctival swab with polymerase chain reaction in AIDS patients

This report studies the accuracy of conjunctival swab polymerase chain reaction (CS-PCR) for the diagnosis of human cytomegalovirus retinitis (HCMV) in AIDS patients. PCR and virus culture were used for the detection of HCMV in conjunctival swab, serum, and urine specimens from 38 AIDS patients between April 1996 and April 1998. The clinical utility of the identification of HCMV retinitis by these 6 different methods was demonstrated by their prediction power to estimate AIDS patients at risk of contracting HCMV retinitis. The sensitivity, specificity, positive predictive value, and negative predictive value of CS-PCR for the detection of HCMV retinitis were 91.5%, 80.9%, 60.8%, and 92.7%, respectively; for serum PCR were 74.3%, 81.7%, 57.2%, and 90.3%; for urine PCR were 100%, 17.3%, 20.4%, and 100%; for conjunctival swab culture were 22.7%, 100%, 100%, and 86%; for serum culture were 27.3%, 98.1%, 75%, and 86.4%; and for urine culture were 90.9%, 44.2%, 25.6%, and 95.8%.     

Early diagnosis of central nervous system aspergillosis using polymerase chain reaction, latex agglutination test, and enzyme-linked immunosorbent assay

To investigate the usefulness of examination of cerebrospinal fluids (CSF) in the diagnosis of central nervous system (CNS) aspergillosis, we examined five patients with either brain abscesses or cerebral infarctions and 11 control patients. CSF samples were subjected to enzyme-linked immunosorbent assay (EIA), latex agglutination test (LA) and polymerase chain reaction (PCR). Cultures of CSF samples were negative in all the patients, but PCR, EIA and LA were positive in five, four and four patients with CNS aspergillosis, respectively. None of these tests were positive in the control patients. CSF examination may be beneficial in the diagnosis of CNS aspergillosis.     

Evaluation of cerebrospinal fluid EBV-DNA and IL-10 as markers for in vivo diagnosis of AIDS-related primary central nervous system lymphoma

Summary. Acquired immunodeficiency syndrome (AIDS)-related primary central nervous system lymphoma (PCNSL) is almost always associated with the Epstein-Barr virus (EBV), and EBV-DNA in cerebrospinal fluid (CSF) has been indicated as a useful tumour marker for this HIV-related neoplasm. AIDS lymphomas also show an enhanced production of IL-10 which is generally associated with the presence of EBV in lymphoma cells. We performed a prospective study in 19 HIV seropositive patients with brain mass lesions, and in 21 other AIDS patients with or without other neurological disorders, to assess the in vivo diagnostic value of EBV-DNA and of IL-10 levels in the CSF for primary lymphoma of the central nervous system (CNS). EBV-DNA was detected by a nested polymerase chain reaction (PCR) in the CSF from seven of eight patients with PCNSL, diagnosed by brain biopsy (875% sensitivity) and in none of the 11 controls with brain mass lesions (100% specificity) and of the other 21 AIDS patients with or without neurological disorders. The only patient with PCNSL without detectable EBV-DNA in the CSF was also negative for EBV-DNA in the lymphoma tissue, whereas the samples of the other seven brain lymphomas were all positive for EBV-DNA by nested PCR. Therefore 100% of patients with an EBV-positive primary CNS lymphoma had detectable EBV-DNA in the CSF. No patient from the control group without PCNSL with EBV-negative CSF developed a lymphoma after a mean follow-up of 157 ± 173 d. IL-10 levels in the CSF from the patients with PCNSL were not significantly different from those in the other groups of patients with AIDS. Due to uniformly high levels in the CSF from AIDS patients, IL-10 is not a useful diagnostic marker for AIDS-related brain lymphoma. The detection of EBV-DNA from the CSF by nested PCR is an extremely sensitive and specific diagnostic tool for AIDS-related PCNSL and should be further evaluated as a possible alternative in patients from whom brain biopsy is not advisable.     

Cytomegalovirus disease in AIDS: the Edinburgh experience.

Retrospective analysis of medical records of 557 HIV positive patients (including 113 with AIDS) revealed 17 patients with an antemortem clinical diagnosis of cytomegalovirus (CMV) disease. This group comprised 7 injection drug users (2 male and 5 female) and 10 homosexual men. Males were significantly older than females, and homosexual men were significantly older than drug users at the time of diagnosis of CMV. All 17 patients had evidence of retinitis, and 6 also had evidence of extraocular disease. CMV retinitis was the AIDS defining diagnosis in two patients, and the attack rate of CMV in all AIDS patients progressively increased with time, with a 3-year CMV-free survival of 57%. Fifteen patients with CMV disease had evidence of previous CMV infection (CMV IgG positive), with 7 also having a positive CMV IgM and 10 a positive viral culture. The mean CD4+ lymphocyte count at diagnosis of CMV was 17 cells/mm3, compared with 68 cells/mm3 at diagnosis of AIDS. Therapy was unsatisfactory, often being complicated by marrow suppression. Relapse occurred in 11 patients after initial improvement but despite this only 3 patients died with severe visual impairment. The mean survival after a diagnosis of CMV was 10.5 months. This study confirms that disease caused by CMV is usually a late manifestation of AIDS, and the increasing prevalence among patients with AIDS implies that, the longer the survival, the greater the risk of disease. Frequent fundoscopy in HIV positive patients is of paramount importance particularly in patients who have a CD4+ lymphocyte count of less than 100 cells/mm3.     

Blastomycosis in patients with the acquired immunodeficiency syndrome.

OBJECTIVE: To describe the clinical, demographic, radiographic, diagnostic, and therapeutic aspects of blastomycosis in patients with the acquired immunodeficiency syndrome (AIDS). DESIGN: A retrospective survey. SETTING: Ten university medical centers and community hospitals, six in geographic areas endemic for Blastomyces dermatitidis, and four outside the endemic area. PATIENTS: We identified 15 patients with blastomycosis and positive serologic test results for human immunodeficiency virus (HIV). MEASUREMENTS: A diagnosis of blastomycosis was based on a positive culture (14 patients) or typical histopathologic features (one patient) for B. dermatitidis in clinical specimens. RESULTS: Twelve of 15 patients had a previous or concomitant AIDS-defining illness at the time of diagnosis of blastomycosis, and only one patient had a CD4 lymphocyte count of greater than 200 cells/mm3. Two patterns of disease emerged: localized pulmonary involvement (seven patients), and disseminated or extrapulmonary blastomycosis (eight patients). Central nervous system involvement was common (40%). Six patients died within 21 days of presentation with blastomycosis, including four patients with disseminated and two with fulminant pulmonary disease. Among the nine patients who survived longer than 1 month, all received amphotericin B as initial antifungal therapy, and most received subsequent therapy with ketoconazole. Only two of these nine patients died with evidence of progressive blastomycosis. CONCLUSIONS: Blastomycosis is a late and frequently fatal infectious complication in a few patients with AIDS. In these patients, overwhelming disseminated disease including involvement of the central nervous system is common, and it is associated with a high early mortality. Initial therapy with amphotericin B is appropriate in patients with AIDS and presumptive blastomycosis.     

Rapid detection of cytomegalovirus DNA in cerebrospinal fluid of AIDS patients with neurologic disorders.

A polymerase chain reaction (PCR)-based method was used to detect cytomegalovirus (CMV) DNA in 82 cerebrospinal fluid (CSF) samples from 67 patients infected by human immunodeficiency virus (HIV). The test was positive for 14 patients, 8 of whom had CMV-related neurologic disease proven by viral culture of CSF or histologic examination. Encephalitis was the most frequent manifestation in patients with positive PCR results, but CMV DNA was also present in some patients with peripheral neuropathy or polyradiculomyelitis. All patients with proven CMV neurologic disease were positive by PCR. In contrast, viral culture was negative for 4 of the 8 patients and pathologic studies were available only for 5. The specificity of the PCR-based assay could not be assessed precisely because of the lack of a reference standard, but the results correlated well with clinical course and results of the other methods. These findings suggest that the PCR-based method may be a useful noninvasive tool for the rapid diagnosis of CMV-related neurologic disease.     

Stem cell transplantation in poor-risk chronic lymphocytic leukemia: assessment of post-transplant minimal residual disease using four- and six-color flow cytometry and allele-specific RQ-PCR

A total of 178 bone marrow samples were taken for minimal residual disease (MRD) analysis after 34 stem cell transplantations for poor-risk chronic lymphocytic leukemia, and 86 of them were analyzed in parallel by flow cytometry and allele-specific oligonucleotide-PCR (ASO-PCR). ASO primer was successfully designed for all patients whose frozen diagnosis samples were available. Flow cytometry and ASO-PCR were concordant, i.e. both either positive or both negative, in 78% of the analyses. Flow cytometry did not detect MRD in any of the samples that were PCR-negative cases. In contrast, ASO-PCR detected MRD in samples that were negative for MRD by flow cytometry in 22% of the analyses. In one patient, the immunophenotype but not the IgV_H gene sequence had changed during a course of the disease, and MRD could not be followed by flow cytometry. In the remaining cases, the discrepancy was due to a higher sensitivity of ASO-PCR. Autologous stem cell transplantation resulted in clinical complete response in 87% (20/23) of the patients. By flow cytometry, 35% (8/23) of autotransplanted patients became MRD-negative, but only 12.5% (2/16) PCR-negative (sensitivity of ASO-PCR <0.001 and <0.01, respectively). All allotransplanted patients achieved or maintained hematological CR, and five out of nine patients (56%) became PCR-negative (sensitivity of PCR between <0.001 and <0.003), two of them having non-myeloablative conditioning. None of the patients who became PCR-negative after allogeneic transplantation have relapsed.     

Central nervous system histoplasmosis. An unappreciated complication of the acquired immunodeficiency syndrome

Involvement of the central nervous system (CNS) by Histoplasma capsulatum is a rare event. It is usually not included in the differential diagnosis of CNS lesions in patients with acquired immunodeficiency syndrome (AIDS). Herein are described four patients with AIDS and progressive disseminated histoplasmosis who had CNS involvement. Histoplasmosis in the CNS may produce meningitis, single or multiple brain abscesses, and may present with either a clinical picture of obtundation or a deteriorating space-occupying CNS lesion. Three of the four patients were treated with amphotericin B and had initial clinical response, but ultimately, all experienced a relapse and died from their infection.     

Polymerase chain reaction for diagnosis of cerebral toxoplasmosis in cerebrospinal fluid in HIV-positive patients

It is important but sometimes difficult to establish a diagnosis of toxoplasma encephalitis (TE) in an HIV-positive immunodeficient patient. The most promising non-invasive method is polymerase chain reaction (PCR) for Toxoplasma gondii in cerebrospinal fluid (CSF). In a retrospective study PCR was used to analyse CSF for the presence of T. gondii DNA in 5 HIV-infected patients with a clinical suspicion of TE (group 1), 8 patients with other HIV-associated symptoms (group 2) and 7 other patients with neurological disorders (group 3). PCR was positive in 2/4 patients with a final diagnosis of TE and negative in all remaining patients in all 3 groups. The 2 patients with positive PCR had a fulminant course and experienced treatment failure. The albumin index was elevated in 4/5 patients in group 1, of whom 3/4 had a final diagnosis of TE, with suspected TE in 1. This small study confirms earlier data indicating that the PCR test has a low sensitivity but a high specificity.     

Monitoring of human cytomegalovirus infections and ganciclovir treatment in heart transplant recipients by determination of viremia, antigenemia, and DNAemia.

Fourteen heart transplant recipients were monitored for human cytomegalovirus (HCMV) infection based on determination of antigenemia, viremia, and DNAemia (by polymerase chain reaction [PCR]) in peripheral blood polymorphonuclear leukocytes (PMNL). Three patients had symptomatic primary, 10 had recurrent (3 asymptomatic), and 1 (seronegative) had no HCMV infection. Severe clinical symptoms appeared when levels of viremia/antigenemia were greater than 50 infected PMNL/2 x 10(5) cells examined. Of 200 blood samples examined, 93 (46.5%) were positive for viremia/antigenemia and DNAemia, whereas 48 (24.0%) were positive for DNAemia only; 59 (29.5%) were negative in all assays. Follow-up of HCMV infections in heart transplant recipients showed that PCR can detect viral appearance in blood 7-10 days earlier than assays for antigenemia/viremia. On the other hand, viral disappearance from blood, as assessed by PCR, occurred weeks or months later than revealed by other assays. Detection of virus by PCR only was never associated with overt HCMV-related clinical symptoms. Of the 8 symptomatic patients treated with ganiclovir, 2 became PCR-negative at the end of treatment and 1 cleared virus from blood in the following weeks, whereas 5 showed persistent or recurrent infection.     

Cerebrospinal fluid beta-2-microglobulin: a reliable index of leukaemic infiltration of central nervous system

Cerebrospinal fluid (CSF) beta-2-microglobulin (B2m) has been proposed as a marker of central nervous system (CNS) involvement in myelo-lymphoproliferative diseases. Recently its reliability has been put in question because of false positive and false negative results. In our study, B2m was measured in 574 CSF samples collected from 74 patients affected by ALL, ANLL or lymphomas; 20 of these patients had CNS-involvement while they were under observation. There was a significant difference in CSF B2m between the patients with and without CNS-involvement (p less than 0.001). No false positive or false negative results were obtained. In 4 cases the rising of CSF B2m was observed 8, 6, 4 and 4 wk before the clinical and laboratory diagnosis of CNS-involvement. In all patients the clinical and laboratory improvement of the neurological disease was associated with a progressive decrease of CSF B2m. Some hypotheses about the origin of CSF B2m are discussed. The authors conclude that CSF B2m is a useful and reliable marker of CNS-involvement in myelo-lymphoproliferative disease.     

Diagnosis of leptomeningeal disease in diffuse large B‐cell lymphomas of the central nervous system by flow cytometry and cytopathology

Reliable detection of leptomeningeal disease has the potential of facilitating the diagnosis of central nervous system (CNS) lymphoma and is important for therapeutic considerations. Currently, the standard diagnostic procedure for the detection of lymphoma in the cerebrospinal fluid is cytopathology. To improve the limited specificity and sensitivity of cytopathology, flow cytometry has been suggested as an alternative. Here, we evaluated multi‐parameter flow cytometry in combination with conventional cytopathology in cerebrospinal fluid (CSF) samples from 30 patients with primary CNS lymphoma and seven patients with secondary CNS lymphoma. Overall, in 11 of 37 (29.7%) patients with CNS lymphoma, lymphoma cells were detected in CSF by flow cytometry, while cytopathology was less sensitive displaying unequivocally malignant CSF cells in only seven of all 37 (18.9%) patients. Six (16.2%) patients showed cytopathological results suspicious of lymphoma; however, in only one of these patients, the diagnosis of CSF lymphoma cells could be confirmed by flow cytometry. In primary CNS lymphomas (PCNSL), seven of 30 (23.3%) patients were positive for CSF lymphoma cells in flow cytometry, in contrast to four (13.3%) patients with PCNSL with definitely positive cytopathology. In summary, our results suggest that multi‐parameter flow cytometry increases the sensitivity and specificity of leptomeningeal disease detection in CNS lymphomas. Both methods should be applied concurrently for complementary diagnostic assessment in patients with CNS lymphoma.     

Detection of Toxoplasma gondii, Epstein-Barr virus, and JC virus DNAs in the cerebrospinal fluid in acquired immunodeficiency syndrome patients with focal central nervous system complications.

OBJECT: Toxoplasmic encephalitis (TE), primary central nervous system lymphoma (PCNSL) and progressive multifocal leukoencephalopathy (PML) are major central nervous system (CNS) diseases in patients with acquired immunodeficiency syndrome (AIDS). We assessed the diagnostic value of polymerase chain reaction (PCR) in the detection of DNAs of Toxoplasma gondii (T. gondii), Epstein-Barr virus (EBV) and JC virus (JCV) in the cerebrospinal fluid (CSF). METHODS: We compared the PCR results with those of pathological findings at autopsy. PATIENTS OR MATERIALS: The present study included 23 autopsies representing those in whom CSF samples were obtained before death while the patient was hospitalized or at autopsy. RESULTS: The threshold levels for PCR detection were 4 tachyzoites of T. gondii, 5-15 genomes of EBV and 10 genomes of JCV. We identified T. gondii DNA in 4 out of 5 autopsy-defined cases of TE, EBV DNA in 5 out of 5 cases with PCNSL, and JCV DNA in 2 out of 2 cases with PML. The specificity of PCR was 100% in TE, 78% in PCNSL, and 100% in PML. CONCLUSION: Although the number of cases was relatively small in this study, PCR correctly identified T. gondii DNA in those cases in which PML or PCNSL was the sole clinical diagnosis. Our results indicate that PCR examination of CSF is a clinically useful tool for the diagnosis of focal brain lesions in patients with AIDS.     

High prevalence of an active cytomegalovirus infection in the appendix of immunocompetent patients with acute appendicitis

BACKGROUND: Appendicitis is a very common surgical diagnosis with unclear pathology. Human cytomegalovirus (HCMV) can modulate our immune system and has been associated with inflammatory bowel disease (IBD) and various other inflammatory diseases. METHODS: We investigated the association between HCMV and acute appendicitis in 14 immunocompetent patients. Tissue sections from 10 AIDS patients with verified HCMV infection were used as positive controls, and uninflamed intestinal tissue sections from 12 patients were used as negative controls. RESULTS: Cells double positive for HCMV early antigens and IL-6/IL-8 were observed in the appendices of 64.3% of appendicitis patients (9 of 14) by immunohistochemical analysis. HCMV late antigen was found in the appendices of 42.9% of the acute appendicitis patients (6 of 14). Latent HCMV appendix infection, as verified by in situ hybridization, as well as HCMV IgG, was observed in 78.6% of patients (11 of 14). The study samples from all 6 healthy appendices were negative for HCMV early and late antigens, although 50% (3 of 6) were HCMV IgG and HCMV DNA positive. CONCLUSIONS: We have shown that HCMV infection of the appendix is associated with acute appendicitis (P = 0.002) and possibly with the severity of the disease. Our study identified HCMV as a pathogen to be sought for in the appendicitis patient group, possibly allowing further medical treatment of these patients.     

Possible role of human cytomegalovirus in pouchitis after proctocolectomy with ileal pouch-anal anastomosis in patients with ulcerative colitis

AIMTo detect the presence of human cytomegalovirus(HCMV)proteins and genes on the ileal pouch of patients with ulcerative colitis who have undergone proctocolectomy with ileal pouch-anal anastomosis(IPAA).METHODSImmunohistochemistry,polymerase chain reaction(PCR)and PCR sequencing methods were utilized to test the presence of HCMV in pouch specimens taken from 34 patients in 86 endoscopies.RESULTSHCMV genes and proteins were detected in samples from 12(35.2%)patients.The rate of detection was significant in the endoscopies from patients diagnosed with pouchitis(5 of 12,41.6%),according to the Japanese classification of pouchitis,in comparison to patients with normal pouch(7 of 62,11.2%;P = 0.021).In all patients with pouchitis in which the HCMV was detected,it was the first episode of pouchitis.The virus was not detected in previous biopsies taken in normal endoscopies of these patients.During the followup,HCMV was detected in one patient with recurrent pouchitis and in 3 patients whose pouchitis episodes improved but whose positive endoscopic findings persisted.CONCLUSIONHCMV can take part in the inflammatory process of the pouch in some patients with ulcerative colitis who have undergone proctocolectomy with IPAA.     

Chagasic meningoencephalitis: case report of a recently included AIDS-defining illness in Brazil

Recently, reactivation of Chagas disease (meningoencephalitis and/or myocarditis) was included in the list of AIDS-defining illnesses in Brazil. We report a case of a 52-year-old patient with no history of previous disease who presented acute meningoencephalitis. Direct examination of blood and cerebrospinal fluid (CSF) showed Trypanosoma cruzi. CSF culture confirmed the diagnosis. Serological assays for T. cruzi and human immunodeficiency virus (HIV) were positive. Despite treatment with benznidazol and supportive measures, the patient died 24 hours after hospital admission. In endemic areas, reactivation of Chagas disease should always be considered in the differential diagnosis of meningoencephalitis among HIV-infected patients, and its presence is indicative of AIDS.     

Use of PCR and culture for detection of Mycobacterium tuberculosis in specimens from patients with normal and slow responses to chemotherapy

In order to examine the utility of PCR as a tool for monitoring the response to short-course chemotherapy, clinical data from 162 tuberculosis patients with drug-susceptible cultures and variables associated with a slow response to antibiotic treatment were retrospectively evaluated. Initial samples were positive by smear in 106 patients and by PCR in 156 patients. A rapid response to therapy was found in 132 patients who had both smear and culture-negative results after 2 months of treatment. After 6 months of therapy, 5 other patients in this group were considered clinically cured but 20 patients had positive cultures. For these 20 patients with a slow response to therapy, treatment was continued for an additional 2-4 months and 15 patients were subsequently cured. However, of all the cured patients 7 had PCR-positive samples at the end of treatment. When these cases were correlated with therapeutic outcome, it was found that 3 of the PCR-positive but none of the PCR-negative patients had a clinical relapse during subsequent follow-up. We conclude that culture and PCR tests are highly informative when used to control the rate of response to therapy. A post-treatment positive result on PCR may be associated with a poor clinical outcome or may predict the likelihood of clinical relapse. Culture and PCR tests, as opposed to smear results, may be the key parameters for individually guiding the duration of treatment in TB patients with a poor response to standard therapy.