Vasculitic neuropathy in HIV infection: a clinicopathological study

Vasculitis causing peripheral neuropathy may be the first sign of HIV infection. We report four such cases in whom the onset of peripheral neuropathy led to the detection of HIV infection. Two patients presented with features of mononeuritis multiplex, while the other two had a lumbosacral polyradiculopathy. A prior history of blood transfusion was forthcoming in one of the patients. Sural nerve biopsies in all the four cases and the muscle biopsy in two, histologically showed evidence of vasculitis. Immunohistochemically, the viral antigen was not demonstrable in any of the biopsies, but on electron microscope, virus-like particles were identifiable in the Schwann cell cytoplasm and the perivascular macrophages in one case. To the best of our knowledge, this is the only report that has documented the virus in the Schwann cells as well as the perivascular macrophages lending credence to the fact that these viruses are neurotropic as well as lymphotropic. Immunoglobulin deposits were not demonstrable in any of the cases, suggesting that direct viral invasion may have a role in the pathogenesis of peripheral nerve vasculitis.     

Recurrent cerebrovascular ischaemic events in patients with interatrial septal abnormalities: a follow-up study

Abstract The aim of this study was to evaluate the risk of recurrent ischaemic cerebrovascular events (stroke or transient ischaemic attack (TIA)) in patients with patent foramen ovale (PFO) or atrial septal aneurysm (ASA) treated with different therapeutic regimens. We enrolled 86 patients aged 18–60 years with an unexplained ischaemic stroke or TIA referred to our inpatient department in the period May 1994–December 1999. Follow-up lasted until April 2003. Patients were excluded if the stroke or TIA was related to large-artery atherosclerosis, small artery occlusion, major cardiac sources of embolism or other uncommon causes. During a follow-up (mean±SD) of 64.1±28.8 months (range 8.1–105.6) a recurrent ischaemic cerebrovascular event occurred in 11/86 patients (12.8%) (5 TIA and 6 strokes). Eight events (4 TIA, 4 strokes) occurred in the 59 patients with PFO alone, three (1 TIA, 2 strokes) in the 21 with PFO plus ASA and none in the 6 patients with ASA alone. In the overall population the cumulative risk of recurrent stroke/TIA was 1.2% at 2 years, 5.5% at 4 years, 7.6% at 6 years and 23.6% at 8 years, and was similar in patients with PFO alone vs. patients with PFO plus ASA (9.0% vs. 6.1% at 6 years, 26.0% vs. 23.1% at 8 years; p>0.05). Nine cerebral ischaemic events (4 TIA, 5 strokes) occurred in the 48 patients treated with antiplatelet drugs (7 in patients with PFO, 2 in patients with PFO plus ASA), and two (1 TIA, 1 stroke) in the 17 patients treated with oral anticoagulants (1 with PFO, 1 with PFO plus ASA). No events occurred in patients submitted to transcatheteral closure.     

Small-vessel vascular disease in human immunodeficiency virus infection: the Hawaii aging with HIV cohort study

BACKGROUND: This study is designed to determine the relationship between age and occurrence of cerebral manifestations of small-vessel ischemic vascular disease in human immunodeficiency virus (HIV)-seropositive individuals. METHODS: Periventricular leukoaraiosis severity and white matter lesion volume were determined by magnetic resonance imaging of the brain of 57 HIV-seropositive individuals. RESULTS: Cerebral small-vessel ischemic vascular disease manifestations correlated with age and systolic blood pressure, but not with HIV infection-related parameters. CONCLUSIONS: These findings suggest that, in the era of highly active antiretroviral therapy, leukoaraiosis severity and white matter lesion volume may be more indicative of small-vessel ischemic vascular disease than HIV-related CNS pathology, and support the need for aggressive treatment of vascular risk factors in HIV-seropositive individuals.     

Comorbidity of schizophrenia and infection: a population-based cohort study

Purpose

In this paper, we investigate the hypothesis that there is an overlap between infection and schizophrenia. Infections have been identified as a risk factor for schizophrenia, but the possible overlap between schizophrenia and infections remains unidentified so far. Here, we describe the use of the comorbidity index, a method for objectively integrating associations into a single measure estimating overlap.

Methods

Data were drawn from three population-based registers, the Civil Registration Register, the Danish Psychiatric Central Research Register, and the Danish National Hospital Register. We selected a cohort of 1,403,183 persons born in Denmark 1977–2002.

Results

Our results indicate that persons who have had a hospital contact with an infection (IRR 1.53, CI 1.46–1.61) are more likely to develop schizophrenia than persons who have not had such a contact. Persons who have had a diagnosis with schizophrenia are more likely to have had a hospital contact with an infection (IRR 1.73, 95 % CI 1.57–1.91) than persons who have had no schizophrenia diagnosis. A comorbidity index of 1.40 (95 % CI 1.34–1.46) was found, indicating an overlap between schizophrenia and infection.

Conclusion

Our findings indicate that schizophrenia and infections overlap and that they share risk factors. The comorbidity index showed that the co-occurrence of schizophrenia and infection was 40 % higher than if the two disorders had occurred independently. Although the incidence of schizophrenia and infection was associated with each factor, the overlap could not be explained by urbanicity, parental history of psychiatric admission and infection.

     

Electroencephalogram and HIV infection: a prospective study in 100 patients

In order to study the correlation between central nervous system (CNS) involvement and EEG abnormalities in HIV infection we studied 100 consecutive HIV patients. Patients were divided into 4 groups; Group I: 42 neurologically asymptomatic subjects; Group II: 6 patients with peripheral neuropathies; Group III: 28 patients with AIDS Dementia Complex; Group IV: 24 patients with secondary CNS involvement. The results of this study emphasize that abnormal EEGs are correlated with CNS involvement. Neurologically asymptomatic patients showed no abnormal tracings, but the presence of borderline EEGs (33%) in asymptomatic patients should be evaluated prospectively.     

Stressful life events and symptom onset in HIV infection.

OBJECTIVE: The authors' goal is to provide basic epidemiologic data on the issue of reactivity to stress and HIV symptom onset by studying the relationship between a broad set of naturally occurring stressor events and HIV natural history in a large longitudinal community sample of HIV-seropositive homosexual men. METHOD: Subjects were recruited from a cohort of 1,011 homosexual men enrolled in the Chicago site of the Multicenter AIDS Cohort Study who also participated in the Coping and Change Study. The men were given self-administered questionnaires assessing behavioral, psychological, and psychosocial variables. Relationships between reports of stressful life events and longitudinal biomedical data measuring illness progression were examined. Life events were assessed by reports on the numbers of lovers, friends, and acquaintances who were diagnosed with AIDS or had died of AIDS and by scores on a checklist of 24 more general serious stressor events. The variables indicating progression of illness among initially asymptomatic men were a drop in T-helper lymphocyte percent (CD4%) between pairs of examinations of at least 25% and onset between examinations of thrush and/or fever lasting a minimum of 2 weeks. RESULTS: The authors found no evidence that serious stressor events have any meaningful effect on symptom onset indicated by either a drop in CD4% or onset of fever or thrush. CONCLUSIONS: There is no need for asymptomatic people with HIV infection to restrict their lives in order to avoid exposure to stressful life experiences or to develop special skills for coping with stress to forestall the progression of HIV illness.     

Symptomatic thromboembolic events in patients treated with intravenous-immunoglobulins: Results from a retrospective cohort study

Aims

To estimate the incidence and predictors of symptomatic arterial and venous thromboembolic events (TEE) from intravenous immunoglobulin (IVIg) therapy according to its indications.

Methods

We performed a retrospective cohort study of patients seen at our institution and treated with IVIg over a 36-month period. Indications, comorbility and comedication associated with TEE were identified by a stepwise logistic regression analysis.

Results

Of 303 patients included with at least one infusion of IVIg over three years, TEE were identified in a total of 50 patients treated with IVIg, for an incidence of 16.9% (CI 95%: 13.0–21.6); 27 (54%) arterial (9.1%;CI 95%: 6.3–13.0%) and 23 (46%) venous TEE (7.8%; CI95%: 5.2–11.4%), overall mortality was 32%. Per indication there were more patients with autoimmune conditions, secondary immunodeficiency, dysimmune neuropathies, acute rejection of solid organ transplantation and sepsis. Patients with TEE were significantly older, were more likely to be men, they had more comorbid conditions; the doses of IVIg were high (589.4 mg/kg/day vs 387.0 mg/kg/day, p < 0.001) and differences in comedication were found. The stepwise logistic regression analysis retained high doses of IVIg (OR 3.03; CI 95%: 1.49–5.67) and diuretics therapy (OR 1.69; CI 95%: 1.06–3.97) when combined with the usual comorbid confounders.

Conclusions

The incidence of TEE from IVIg therapy remains high at one in six patients treated. The most remediable factor is a high daily IVIg load. Decreasing the daily IVIg dose together with carefully weighing diuretics therapy and comorbid risk factors may be the keys to saving lives.     

CT findings in different stages of HIV infection: a prospective study

Summary In the acquired immunodeficiency syndrome (AIDS), different patterns of CT findings have been described. In a prospective and unselected CT study we examined 200 patients in different stages of HIV-1 infection, 14% of whom had focal lesions, 37% atrophic changes and 49% normal findings. The differential diagnosis is discussed. Depending on the patient's complaints and clinical findings, even when the CT scan is normal there may be treatable complications that must be detected by other diagnostic techniques, such as lumbar puncture.     

Suicidal behaviour in HIV infection: A case-control study of deliberate self-harm in people with HIV infection

A group of 22 individuals with HIV infection who had made acts of self-harm were compared with a sex and age-matched control group of individuals without known HIV infection who had also being involved in acts of deliberate self-harm (DSH). Compared with all DSH individuals referred to the deliberate self-harm service during the same period. men were over-represented amongst HIV subjects. Compared with matched controls, HIV subjects were more likely to include gay/bisexual men, and not be employed. Individuals with HIV infection were more likely to be receiving outpatient psychiatric care at the time of DSH. and to have received it in the past A diagnosis of depression was given mom frequently to HIV subjects, while alcohol misuses was more often diagnosed in controls. Concerns about their physical health were prominent amongst HIV seropositives. Psychiatric follow-up was offered to HIV subjects more often than to controls. The results indicate that HIV disease is a potential contributing factor to deliberate self-harm. and highlight the need for efforts to identify individuals with HIV infection at risk of deliberate self-harm, ant to develop effective interventions to prevent suicidal behaviour in this group of individuals.     

Obstructive sleep apnea and influenza infection: a nationwide population-based cohort study

ObjectivesInfluenza infection could trigger acute myocardial infarction. Obstructive sleep apnea (OSA) increases risk for myocardial infarction. Evidence evaluating the risk of influenza in patients with OSA is limited. We aimed to investigate the association between OSA and influenza using a nationwide population-based data set.MethodsA total of 5483 individuals with OSA were enrolled from January, 2000, to December, 2012, and compared with a control group of 21,932 individuals who had never been diagnosed with OSA (at a 1:4 ratio propensity score matched by age, sex, index years, and comorbidities) in the context of subsequent influenza infection. Cox proportional hazard regression analysis was conducted to analyze the association between OSA and influenza incidence. We conducted sensitivity analyses to examine our finding.ResultsDuring the 1.81 (±2.12) years of the follow-up period, the incidence rate of influenza infection was higher in the OSA group compared with the non-OSA group (36.40 and 30.09 per 100 person-years). After adjusting for age, sex, comorbidities, outpatients visits, the risk of influenza infection among patients with OSA was significantly higher (hazard ratio = 1.18; 95% confidence interval = 1.14–1.23; P < 0.001). Sensitivity analyses showed consistent positive association. Males with OSA had increased risk of influenza infection compared with males without OSA (adjusted HR, 1.21; 95% CI, 1.16–1.27; P value for interaction = 0.03).ConclusionsThis study found a significantly higher risk of influenza infection in patients with OSA, and sex acted as an effect modifier between OSA and risk of influenza infection.     

Ischaemic stroke in young people: a prospective and long-term follow-up study

BACKGROUND: A few studies have comprehensively assessed the epidemiology, aetiology, prognosis, and secondary prevention of ischaemic stroke in young adults. To gain further information on this field, we have prospectively studied a hospital-based series of young adults with a first-ever episode of cerebral ischaemia (CI). METHODS: Sixty consecutive patients aged 17-45 with ischaemic stroke (55 patients) or transient ischaemic attack within 24 h before hospital admission were recruited and investigated by a standardized rigorous protocol. The patients were followed up for >or=1 year after hospital discharge. Arbitrary doses of aspirin 100 mg/d or ticlopidine 250 mg b.i.d. in case of intolerance to aspirin were given for the secondary prevention. Adjusted-dose oral anticoagulation (INR target 2.5) was used in the presence of cardioembolism or hypercoagulable states. Endpoints included the residual disability, rated by modified Rankin Scale (RS) and Barthel Index (BI), and poststroke recurrence. RESULTS: CI was associated with two or more risk factors in 61.6% of patients. Cigarette smoking was more frequently associated with male gender (p < 0.05) and migraine history with female sex (p < 0.05). The atherothrombotic diagnostic subtype and the subtype from 'other cause' predominated significantly among patients >or=35 years old (p < 0.05) and <35 years (p < 0.025), respectively. The 'other cause' subset was more frequent in female gender (p < 0.05). Transoesophageal echocardiography (TEE) detected potential cardiac sources of emboli (PCSE) at an extent 3 times higher (p < 0.0001) than transthoracic echocardiography. Congenital heart defects were nearly threefold more frequent than acquired ones, with a prevalence of patent foramen ovale. At a mean of 6.1 +/- 2.6 years (confidence interval 5.4 to 6.8), follow-up data were available for only 54 patients, since five patients were lost and one died in the acute phase. Poststroke recurrence rate was low (7.4%) and no event was fatal. General handicap was severe to moderately severe (RS>3) in 11% of the patients, slight to moderate (1>or=RSor=95), 38.9% partially dependent (BI 60 to 86), and 11.1% fully dependent (BI <60). Thirty-seven (68.5%) patients returned to work, although adjustments (other job or part-time employment) were necessary for 10 out of them (27%). CONCLUSIONS: The present study, though limited by the relatively small number of subjects, suggests that the overall prognosis of ischaemic stroke in young adults is good. We strongly recommend TEE in all patients with ischaemic stroke as an essential tool to increase the detection of PCSE and make the therapeutic approach more efficient.     

The management of cerebrovascular events in Senegal

OBJECTIVES: Because of its acuteness and rapid progress to irreversible injury, stroke is a dramatically high priority medical emergency. The purpose of this prospective study was to ascertain the average time limit for primary management of stroke victims referred to the Senegalese national medical center considered as the final link within the country's healthcare organisation. PATIENTS AND METHODS: We reviewed the files of 170 patients aged 25-90 (average 61+/-13 years). The sex ratio was 0.68. Seventy percent of the patients resided in the nation's capital, Dakar. RESULTS: Most of the patients were referred to a medical center late. Admission was before the 6th hour for only one patient and none of the patients were admitted before the 3rd hour. Late treatment was related to the remoteness of medical centers. Among patients residing in Dakar, the first visit occurred between 6 and 24 hours for 30p.cent versus 7.8 p.cent for patients residing in rural areas of the country. Educational level and socio-economic status had no effect on late treatment. None of the patients were given prehospital care. Treatment was essentially symptomatic in patients with hemorrhagic stroke. Anticoagulants or anti-platelet agents were prescribed for patients with ischemic stroke. Only 29.4 p.cent of patients were given rehabilitation care. Mortality was 50.6 p.cent and the rate of dependency 41.7 p.cent. CONCLUSION: In Senegal, stroke victims receive care too late. This situation arises because of insufficiency of human and material resources and inaccessibility to care centers.