The impact of HIV infection on primary headache. Unexpected findings from retrospective, cross-sectional, and prospective analyses

Headache is one of the most important factors influencing the quality of life in patients infected with the human immunodeficiency virus type 1 (HIV). However, only symptomatic headache but not changes or primary headache types during HIV infection have been studied to date. Therefore, we aimed to determine the impact of an HIV infection on frequency and semiology of different primary headache types. Patients with confirmed HIV type 1 infection underwent a neurological examination, neuroimaging or EEG, and a standardized interview. Time pattern and symptoms of headaches (cross-sectional analysis), changes of headaches preexisting to their infection (longitudinal retrospective analysis), and changes of primary headaches during a 2-year follow-up (longitudinal prospective analysis) were evaluated as were the correlations between these headache patterns and different markers of HIV infection. One hundred thirty-one consecutive HIV-infected patients without evidence of a cerebral manifestation except mild encephalopathy were enrolled. The point prevalence of migraine was 16.0% (confidence interval (CI) 10.1-25.4%), of headache with a semiology of tension-type headache 45.8% (CI 33.7-62.2%), and of other headache types 6.1% (CI 3.0-12.5%). During the natural course of infection, the migraine frequency significantly decreased in the retrospective and in the prospective analyses, whereas the frequency of the headache with a semiology of tension-type headache significantly increased in all three analyses. In 20% of all patients, the tension-type headache could be considered as symptomatic due to the infection but not due to focal or general cerebral lesions. Changes of primary headache were significantly associated with different stages of the infection and with the presence of mild encephalopathy but not with antiretroviral treatment or CD4 cell count. HIV infection seems to be associated with a progressive decrease in migraine frequency and intensity which probably is related to the immunological state of the patients. Tension-type headache becomes more frequent during HIV infection. However, this can in part be related to secondary headache caused by the HIV in less than 50% of patients with tension-type headache. The progressing immunological deficiency of HIV-infected patients seems to influence pain processing of primary headache types in different ways.     

Kryptokokkenmeningoenzephalitis von HIV-infizierten Immigranten¶Diagnostische und therapeutische Aspekte unter Berücksichtigung der “evidence-based medicine”– Ein Überblick

Zusammenfassung Die Kryptokokkenmeningoenzephalitis ist eine der h?ufigsten Meningoenzephalitiden von AIDS-Patienten. Ihre H?ufigkeit betrug vor der Einführung der Triazol-Antibiotika wie Difluconazol 5–10% aller AIDS-Patienten, sank jedoch in den letzten Jahren. Klinisch imponieren meist unspezifische Zeichen einer meningealen Reizung, w?hrend fokale neurologische Symptome selten sind. Prognostisch entscheidend für die mit einer hohen Mortalit?t verbundenen Erkrankung sind eine rechtzeitige, hochdosierte Antimykotikatherapie, die derzeit üblicherweise mit Amphotericin B, Flucytosin und Fluconazol durchgeführt wird. Der Nachweis von Kryptokokken-Antigen im Liquor, die Darstellung von Kryptokokken im Tuschepr?parat und die üblicherweise positive Liquor-Kryptokokkenkultur best?tigen die klinische Verdachtsdiagnose. Aktuelle Entwicklungen zielen auf Optimierung der antimykotischen Therapie. In den letzten Jahren wurde die lebenslange Terti?rpr?vention mit Difluconazol oral etabliert. Mittelfristig wird die Prognose der Patienten von der zugrundeliegenden Immunsuppression bestimmt, so da? nach erfolgreicher Therapie eine moderne antivirale Kombinationstherapie zus?tzlich zur Terti?rpr?vention dringend indiziert ist. Die vorliegende übersicht thematisiert Entscheidungssituationen in der Behandlung von Patienten mit Kryptokokkenmeningoenzephalitis anhand von Prinzipien der “evidence-based medicine”.      

Cidofovir (Vistide®) in der Therapie der Progressiven multifokalen Leukoenzephalopathie (PML) bei AIDSLiteraturübersicht und Beschreibung zweier Fälle

Zusammenfassung Die Progressive Multifokale Leukoenzephalopathie (PML), eine durch das JC-Virus hervorgerufene Enzephalitis, tritt bei etwa 4%–5% aller HIV-1-infizierten Personen auf und hat mit einer mittleren postdiagnostischen überlebenszeit von 3 bis 6 Monaten eine ?u?erst schlechte Prognose. Bis heute existiert keine effektive Therapie der PML, Therapieversuche an kleineren Kollektiven mit a-Interferon, Didanosin und Arabinosid hatten nur wenig Erfolg. In einer kontrollierten Studie mit Cytarabin konnte keine Wirksamkeit dieses Medikamentes gegen die PML beobachtet werden. Erste Einzelfallbeschreibungen über eine Therapie der PML mit Cidofovir (Vistide^?), einem für die Zytomegalie-Retinitis bei AIDS-Patienten ohne renale Dysfunktion zugelassenen Nukleotid-Analogon, zeigten positive Ergebnisse. Wir berichten über zwei weitere F?lle der Behandlung einer AIDS-assoziierten PML mit Cidofovir. Von 22 in der Literatur beschriebenen F?llen einer Behandlung der AIDS-assoziierten PML mit Cidofovir – einschlie?lich der beiden hier beschriebenen F?lle – haben sich 16 Patienten unter der Therapie gebessert, 2 Patienten zeigten eine stabile Symptomatik und nur 4 Patienten verschlechterten sich weiterhin fulminant. Diese Ergebnisse deuten darauf hin, da? Cidofovir einen antiviralen Effekt auch auf das JC-Virus ausübt, der in der Therapie der PML bei Patienten mit AIDS genutzt werden sollte, da bisher kaum therapeutische Alternativen bestehen. Ob andere Faktoren für die klinische Verbesserung der 16 bisher beschriebenen F?lle unter einer Therapie mit Cidofovir mitverantwortlich sind oder ob die klinische Verbesserung ein alleiniger Effekt der Therapie mit Cidofovir ist, mu? letztlich offen bleiben und in einer randomisierten, kontrollierten Studie mit gro?er Patientenzahl gekl?rt werden.      

"Symptomatic Migraine": Intracranial Lesions Mimicking Migrainous Headache -A Report of Three Cases

Case reports of three headache patients, two with intracerebral meningioma and one with hydrocephalus are presented, in whom the clinical picture fulfilled the criteria of the International Headache Society (IHS) for the diagnosis of migraine. The symptomatic (ie, lesional) nature of the headaches could be detected by neither clinical neurological examination nor routine investigations such as EEG and skull x-ray. On the other hand, brain imaging techniques (CT, MRI) were found to be of particular in value diagnosing the lesions. Our cases indicate that neuroimaging with CT or MRI in the assessment of headache patients should not be handled too restrictively. Compared to CT, however, the additional diagnostic value of MRI in headache seems to be limited.     

Cognitive processing is involved in cluster headache but not in chronic paroxysmal hemicrania.

BACKGROUND: Cognitive processing in migraine is characterized by a loss of habituation during the interval and increased latencies in an attack. No studies are available on event-related potentials (ERPs) in cluster headache or chronic paroxysmal hemicrania. OBJECTIVE: To determine the involvement of cognitive processing in cluster headache and chronic paroxysmal hemicrania as measured by ERPs. METHODS: Visually evoked ERPs were measured in 50 patients with episodic cluster headache, 11 patients with chronic cluster headache, and 12 patients with chronic paroxysmal hemicrania. Measurements were performed in the cluster period outside an attack with and without prophylactic medication and not in the cluster period. RESULTS: Latencies of the endogenous ERP components were significantly increased during the cluster period as compared with outside the cluster period and with healthy subjects. In chronic cluster headache, latencies of both endogenous and exogenous components were increased. Medication with prophylactic drugs normalized the ERP latencies in episodic cluster headache; in chronic cluster headache, ERP latencies were decreased without complete normalization. No changes of ERP latencies and amplitudes could be observed in chronic paroxysmal hemicrania. A loss of cognitive habituation as it is known in migraine could not be observed in either cluster headache or chronic paroxysmal hemicrania. CONCLUSIONS: Our data suggest that central structures generating ERPs are involved in the pathophysiology of cluster headache during the cluster period but not outside the cluster period. This is in concordance with recent neuroimaging findings on the central role of the hypothalamus and the right frontal cortex in cluster headache and supports the hypothesis of a central origin of cluster headache. Furthermore, the data suggest that cluster headache and chronic paroxysmal hemicrania are distinct entities.     

Sleepiness and sleep quality in patients with HIV infection

ObjectivesPatients with HIV infection frequently complain of sleep disturbances and daytime sleepiness. Only few data on these problems evaluated by standardized measures is available.MethodsA sample of 180 consecutive patients with HIV infection referred to the internal and to the neurological HIV clinics at the University of Münster was enrolled in this study. The data were compared to a sample of 120 age- and sex-matched control subjects. We used the Epworth Sleepiness Scale (ESS), the Pittsburgh Sleep Quality Index (PSQI), and the Beck's Depression Inventory (BDI). In addition, the clinical and immunological data of the patients were registered.ResultsAll scores of the ESS, the PSQI, and the BDI were significantly increased in the HIV infected patients as compared to the control group. There were no significant correlations between any of the immune parameters and the scores. Only a higher BDI score was correlated with both the ESS score and the PSQI score.ConclusionsPatients with HIV infection and not using evavirenz show an increased daytime sleepiness and a decreased quality of sleep. These findings could not be related to the immunological state of the patients. The only specific factor influencing daytime sleepiness in HIV infected patients is probably treatment with HAART. The most important factor determining sleepiness and sleep quality in HIV infected patients is depression which was found to be independent from the immunological state and HAART of the patients.     

Hepatic intra-arterial injection of 3-bromopyruvate in rabbit VX2 tumor

PURPOSE: To evaluate the antitumoral effects of an intra-arterial injection of 3-bromopyruvate (3-BrPA) on liver VX2 tumor in rabbits. MATERIAL AND METHODS: Twenty rabbits with surgically implanted liver VX2 tumors were used. The rabbits were divided into three groups: a control, a saline, and a 3-BrPA group. Four rabbits were not treated at all, and they served as the control group. The saline group (n = 6) received only intra-arterial saline injection. The 3-BrPA group (n = 10) received an intra-arterial injection of 3-bromopyruvate through the hepatic artery. The delivered amounts of 3-bromopyruvate were as follows: 25 ml of 0.5 mM in six rabbits, 25 ml of 1.0 mM in two rabbits, and 25 ml of 2.0 mM in two rabbits. Four days after intra-arterial injection, the rabbits were sacrificed and histopathologic analysis of the explanted livers was performed with comparison of the tumor necrosis ratio (a percentage of the necrotic area versus the entire tumorous area) in each group. RESULTS: The mean tumor necrosis ratio was 12.5+/-4.2%, 44.8+/-24.7%, and 49.4+/-14.3% in the control, saline, and 3-BrPA groups, respectively. Between the control and the saline group, and between the control and the 3-BrPA group the mean tumor necrosis ratio appeared to be significantly different (P<0.05). However, there was no statistical difference in the mean tumor necrosis ratio between the saline and the 3-BrPA group (P = 0.416). CONCLUSION: A single session of intra-arterial injection of 3-BrPA showed no better results in terms of tumor necrosis than that of saline injection in a rabbit VX2 tumor model.