Co-infection by Cryptococcus neoformans and Mycobacterium avium intracellulare in AIDS. Clinical and epidemiological aspects

In the observation of various opportunistic pathogens in HIV-positive persons, co-infection by Cryptococcus neoformans together with Mycobacterium avium intracellulare was found if there was a CD4 lymphocyte count as low as 3-20/microliters. In 1540 HIV-positive patients under treatment at a Berlin hospital (Auguste-Viktoria-Krankenhaus) during 1985-1994, all AIDS-relevant diseases were examined in a multivariate analysis as variables of influence on the manifestation of a systemic Mycobacterium avium complex (MAC) infection. The analysis involved data on 36 cases of cryptococcosis and 202 cases with a typical clinical course in whom MAC had been detected at sterile body sites. As significant and independent factors of influence, the following were identified: C. neoformans infection, wasting syndrome, lower age, low CD4 lymphocyte count and preceding Pneumocystis carinii pneumonia (PcP) prophylaxis. Cryptococcosis ranged first with an ods ratio of 2.75. The concomitant manifestation of cryptococcosis and systemic MAC infection in six patients is shown. Because both opportunists, C. neoformans and avian mycobacteria, may have their common habitat in droppings of defined species of pet birds, a common source of infection deserves further clinical and epidemiological attention.

[Nevus cell aggregates in axillary lymph nodes in simultaneous mucinous breast carcinoma]

Nevus cell aggregates in lymph nodes are uncommon. This benign phenomenon may be difficult to differentiate from metastatic neoplasia. We report the case of a 56-year-old patient who underwent breast biopsy, followed by radical mastectomy including lymphadenectomy. Histological examination revealed solid cell aggregates as foreign tissue in the capsule of 1 of 11 identified lymph nodes devoid of any keratin immunoreaction. Strong immunohistological staining for the S-100 protein confirmed the diagnosis of nevus cell aggregates.

Prenatal hippocampal granule cells in primary cell culture form mossy fiber boutons at pyramidal cell dendrites

Mossy fiber boutons are the sites of synaptic signalling between hippocampal granule and pyramidal neurons. We studied the formation and localization of these terminals during development of prenatal hippocampal neurons in primary culture. Using the synaptic vesicle membrane proteins synaptophysin and synaptoporin as markers we observed that both proteins were mainly localized in perikarya and processes of fetal hippocampal neurons during the first days in vitro (DIV). Following DIV 6 synaptophysin was present in small terminals. After DIV 20 in addition large terminals immunoreactive for synaptophysin and synaptoporin were found, which were identified by electron microscopy as mossy fiber boutons impinging on pyramidal neuron dendrites. Synaptic vesicles and endosomes in the mossy fiber boutons were labeled when incubated with exogenous horseradish peroxidase, indicating that they were competent for exo-endocytosis. Taken together, our data show that hippocampal granule neurons grown in dissociated primary cultures form mossy fiber boutons containing synaptophysin and synaptoporin at pyramidal cell dendrites. Since the composition and the characteristic morphology of mossy fiber boutons formed in vitro is the same as observed in vivo we conclude that their development follows an intrinsic program.

[Disseminated cryptococcosis with extensive cutaneous involvement in AIDS]

BACKGROUND

Diagnosis of an ulceratively decaying indolent papule in the skin of an AIDS patient.

CASE REPORT

In a 36-year-old HIV-positive man with a CD4 lymphocyte count of 60/microliters, a diagnosis of disseminated cryptococcosis was established based on a biopsy of an ulceratively decaying indolent papule in the skin of the left side gluteal region. In additional papulopustular skin lesions of neck, upper arm, upper thigh, and rima ani, Cryptococcus neoformans var. neoformans was detected by specific culture. The Cryptococcus neoformans antigen titre in serum was 1:160. The extensive cryptococcal skin involvement was accompanied by symptoms of meningeal cryptococcosis like hearing at an abnormal sound volume, a sensation of high pressure in the head and a change of behaviour, but absence of cephalgia and stiff neck. Attention is drawn to the importance of biopsy for the differential diagnosis of the skin lesions and to the significance of a specific cultural detection of Cryptococcus neoformans in view of the therapy and epidemiology of this mycosis. Under a combination therapy, consisting of amphotericin B, flucytosine and fluconazole, a healing of the skin lesions and disappearance of the neurological symptoms followed by negative cultural and serological tests were seen. Specific comments on the epidemiology of cryptococcosis in AIDS are made.

CONCLUSION

In case of doubt, papulopustular skin lesions of HIV-positive patients should be biopsied. Cryptococcosis should also be considered.

Fulminant primary manifestation of Crohn's colitis "Hot Crohn's disease"

Following the very short course of a disease with watery diarrhea, fever, nausea, meteorism and a severe feeling of general illness, a 22-year-old patient was diagnosed as having a toxic megacolon, and a subtotal colectomy was carried out. The postoperative progression was uncomplicated and the patient recovered quickly. The examination of the operation specimen revealed a serious ulcerous colitis with relative omission of the rectum and the distal sigmoid colon. After critical evaluation of the histological findings, it was judged to be a fulminant Crohn's colitis and, for the purposes of differential diagnosis, differentiated from ulcerative colitis and colitis indeterminate. The formal pathogenesis of the inflammatory-ulcerous processes is discussed, in particular with regard to the activation of the macrophages and the very short anamnesis in a clinically established primary manifestation of the disease.

Pathological and epidemiological aspects of skin lesions in histoplasmosis. Observations in an AIDS patient and badgers outside endemic areas of histoplasmosis

As a consequence of HIV infection, histoplasmosis is increasingly occurring as an opportunistic infection with a systemic course outside histoplasmosis-endemic areas, e.g. in Europe. Accordingly, questions concerning the epidemiology of this mycosis arise. Two incidents involving histoplasmosis in man and badgers with prevailing involvement of the skin encouraged us to review the pathogenesis and epidemiology of this mycosis in Germany, where so far Histoplasma capsulatum has not been endemic. With a view to prevention, attention is drawn to the avoidance of microfoci of H. capsulatum in the newly introduced concept of biowaste and its composting plants in countries with modern waste management.

Malignant gastrointestinal lymphomas in patients with AIDS

HIV-associated malignant lymphomas are a common complication in late HIV infection, and there is a high percentage of gastrointestinal tract involvement. Non-Hodgkin's lymphoma was found in 108 of 2,750 HIV-positive patients (3.9%) in our institution, whereas gastrointestinal manifestation was diagnosed in 48 of 108 patients (44.4%). 44 of these cases were found during endoscopy of the upper and lower gastrointestinal tract (or by laparotomy or laparoscopy in 4 cases). Endoscopy is a reliable procedure for the diagnosis of lymphoma. Unusual manifestations such as oral, esophageal or perianal lesions and multifocal disease were common findings. Life-threatening complications such as gastrointestinal bleeding, perforation, and obstruction occurred in 37.5%. High-grade B-cell lymphomas were found in all cases including mainly lymphoblastic, immunoblastic, centroblastic and Burkitt subtypes. 52% of the patients had disseminated lymphoma with Ann Arbor stage III or IV. Standard chemotherapy with cyclophosphamide, adriamycin, vincristine and prednisone was started in 25 patients and resulted in a mean survival time of 4.8 months. The prognosis of AIDS patients presenting with malignant gastrointestinal lymphoma depends mainly on the presence or absence of previous AIDS-defining diseases, not CD4 cells, lymphoma-associated gastrointestinal complications or the histopathologic lymphoma type at the time of diagnosis.

Cryptococcosis in HIV infection of man: an epidemiological and immunological indicator?

Cryptococcosis is an epidemiological and immunological indicator due to the absence of Cryptococcus neoformans as a saprophyte in immunocompetent humans and the advantage of specific C. neoformans culture. On this basis, a report is presented on the CD4 lymphocyte count of 36 AIDS patients suffering from cryptococcosis and other concomitant or missing opportunistic AIDS-defining infections. In 26 out of 36 patients, i.e. 72%, a CD4 lymphocyte count of < or = 50/microL (mean value 39.5%) was found. Cryptococcosis as the sole opportunistic infection was diagnosed in 5 cases (13.9%). In 31 cases, various combinations of AIDS-associated diseases were found: Pneumocystis carinii pneumonia (PCP) (n = 19), cytomegalovirus infection (CMV) (n = 10), Kaposi's sarcoma (n = 6), Mycobacterium avium intracellulare infection (MAI) (n = 5), pneumonia (n = 2), toxoplasmosis (n = 2), Candida esophagitis (n = 1), tuberculosis (n = 1), lambliasis (n = 1), salmonellosis (n = 1) and wasting syndrome (n = 5). The conspicuous simultaneous occurrence or succession of pneumocystosis and cryptococcosis and the contrasting absence of aspergillosis and mucormycosis (zygomycosis) are commented. Based on the present observations in HIV-infected persons in Berlin, a CD4 lymphocyte count of < 150/microL may be used as a parameter indicating a predisposition for cryptococcosis as an airborne AIDS-defining infection. Attention is drawn to bird droppings as the sole habitat of C. neoformans and accidental niche of various other microorganisms.

Brown-red pigment formation by the mycelial phase of a clinical isolate of Histoplasma capsulatum on Staib agar. A preliminary report

In an HIV-positive patient, the suspected diagnosis of histoplasmosis capsulatum (being the first opportunistic infection indicating AIDS) on the basis of histopathological findings in biopsy material could be proved by culture on Staib agar (syn. Guizotia abyssinica creatinine agar, bird seed agar, etc.). On Staib agar, after 4 weeks at 26 degrees C, there was a cockade-like colony growth, consisting of a white centre, followed by a brown-red pigmented zone surrounded by a border of submerged mycelial growth of tan to brownish colour. Morphologically, there was a moderate formation of tuberculate macroconidia and a heavy formation of microconidia. On neutral Sabouraud's dextrose agar, there was a colony formation without pigment (albino type) free of tuberculate macroconidia and microconidia. Proposals for further investigation of these preliminary observations are made.

[67Ga scintigraphy in retroperitoneal fibrosis (RPF): indications, application and clinical relevance--report of five patients]

AIM

The aim of the study was to evaluate the indication for 67Ga-citrate imaging and its clinical impact on patients with retroperitoneal fibrosis (RPF).

METHOD

The scanning with ventral and dorsal projections was done 48 an 72 h after i.v.-injection of 370 Mbq 67Ga-citrate.

RESULTS

In the 5 patients with idiopathic RPF included in the study, there was a remarkably high correlation between the clinical symptoms, the surgical and histologic findings, the activity of the disease and the results of 67Ga-scintigraphy.

CONCLUSION

While CT and--maybe even better--MRI might perfectly show the extension, shape and contour of the fibrotic tissue, Gallium-67 scan appears to be superior in assessing the intensity and activity of the disease process.

CD4 lymphocyte count in HIV-positive persons exposed to Cryptococcus neoformans

A report is presented on four HIV-positive homosexual men examined after several months of exposure during cleaning of a flat from masses of pigeon droppings heavily colonized by Cryptococcus neoformans. Only one out of the four persons, with a CD4 lymphocyte count of 50/microL, fell sick from systemic cryptococcosis, but not the others, with CD4 lymphocyte counts of 180, 250, and 630/microL, respectively; they remained clinically and mycologically inconspicuous and free from C. neoformans. Open questions in view of the epidemiology of opportunistic pathogens in AIDS are discussed with regard to the CD4 cell count as a parameter indicating a predisposition for cryptococcosis as an airborne AIDS-defining opportunistic infection. This has been confirmed by specific cultural diagnosis of the agent in both the environment and the patient. Already in 1987/88, the probable source of infection had been the subject of epidemiological studies on C. neoformans in Berlin.

Simultaneous Position-Resolved Determination of Phase and Stress Distributions by means of an X-ray Diffractometer with a Two-Dimensional Position-Sensitive Detector

With an X-ray area detector and a suitable Soller-plate collimator in the scattered radiation field, it is possible to realize a versatile X-ray diffractometer. The local diffraction information of a sample can be registered simultaneously and visualized with a spatial resolution better than 0.5 mm, maintaining reasonable measuring times of a few minutes. Results of measurements applied to local phase analysis (distribution of retained austenite and carbon on a cross section of case-hardened steel), to the determination of lateral stress distributions (laser-hardened track on C45 steel) and to the analysis of crystallite orientation (coarse-grained YBa2Cu3O δ ) are presented.

Disseminated toxoplasmosis in AIDS patients--report of 16 cases

Between June 1986 and October 1992, disseminated toxoplasmosis was diagnosed in 16 AIDS patients. 13 cases were diagnosed at autopsy where multiple organ involvement was documented in all 13. Three patients were diagnosed intra vitam. All 3 survived with appropriate treatment. Clinical features indicative of disseminated toxoplasmosis were: fever of unknown origin between 39 degrees and 40 degrees C in 16 cases, clinical signs suggestive of sepsis or septic shock in 15, with progression to multiorgan failure in 10, disseminated intravascular coagulopathy in 6, confusion, disorientation or apathy in 13 and lack of a systemic pneumocystis carinii prophylaxis in all 16. Typical laboratory markers were: CD4 cell counts below 100 x 10(6)/l in 16 cases, elevation of serum lactic dehydrogenase in 16 and creatine phosphokinase (in 4/6), normal or only slightly elevated C-reactive protein (in 9/11), positive Toxoplasma gondii IgG antibodies in 15/16 and negative IgM antibodies in all 16. Lesions indicative of cerebral toxoplasmosis were visualized on cranial computerized tomography in only 3/10 evaluated patients. In patients with advanced HIV infection presenting with a systemic illness, including the clinical and laboratory features described above, systemic Toxoplasma gondii infection must be included in the differential diagnosis. In these patients, specific and if warranted, invasive diagnostic procedures followed by early vigorous therapeutic intervention should be considered.

Severe toxoplasmic ventriculomeningoencephalomyelitis in two AIDS patients following treatment of cerebral toxoplasmic granuloma

Two patients with acquired immunodeficiency syndrome (AIDS) who were successfully treated for cerebral toxoplasmosis presented a few weeks later with neurologic abnormalities. Brain CT scan showed ventricular dilatation, ependymitis, and meningoencephalitis. Both patients died despite extensive treatment. Neuropathological examination showed enlargement of the cerebral ventricles, severe ventriculoencephalitis with large ependymal and subependymal necrosis, and numerous pseudomembranes within the ventricle lumen. Microscopic examination revealed severe necrotizing ventriculoencephalitis, meningoencephalitis and myelitis. Immunohistochemical studies revealed the presence of miriads of tachyzoites within and around the necrotic areas. Such form of toxoplasmosis as a diffuse meningo-encephalo-ventriculo-myelitis appear unique to AIDS and, to our knowledge, have not been previously documented.

[Histoplasmosis of the skin as an initial opportunistic infection in AIDS]

A 55-year-old homosexual Indonesian (last stay in Indonesia 2 years previously), known to be HIV positive since 1986, developed desquamating, in part ulcerating, skin eruption over the face and shoulder region. On admission his temperature was 38.2 degrees C, erythrocyte sedimentation rate 72/95 mm, white cell count 3.100/microliters, and the CD4 cell count 30/microliters. Examination of lung, oesophagus, stomach, duodenum and colon for possible opportunistic infections was negative. Fundoscopy revealed an infiltrate in the right eye with destruction of the vitreous. Skin biopsy suggested histoplasmosis, confirmed by culturing H. capsulatum varietas capsulatum. It is likely that this was the reactivation of a latent, previously symptom-free infection, in this case the first opportunistic infection in the presence of AIDS. For 30 days he received infusions of amphotericin B (initially 0.1 mg/kg daily, after the 5th day 0.5 mg/kg), resulting in rapid healing of the skin lesions. Subsequently he has received (for 6 months so far) itraconazole, 400 mg daily, without further complications.

Anergic disseminated toxoplasmosis in a patient with the acquired immunodeficiency syndrome

Cerebral toxoplasmosis is the most common cause of focal brain disease in patients with the acquired immunodeficiency syndrome. A 24-year-old human immunodeficiency virus-infected woman with two previous episodes of Pneumocystis carinii pneumonia presented with diarrhea and fever. Despite antibiotic treatment, septic shock developed, and she died 3 weeks after the symptoms began. Histologic and histochemical studies revealed an anergic toxoplasmosis with dissemination in all examined organs. There were multiple foci of toxoplasmic cysts and free tachyzoites, sometimes with minute areas of necrosis, but no inflammatory reaction at all. Since effective treatment of toxoplasmosis is available, the occurrence of this rare form of toxoplasmosis should be kept in mind.

[Carcinosarcoma of the urinary bladder]

A female patient is presented who had a large carcinosarcoma of the urinary bladder that became clinically manifest only 2 months before treatment. The initial treatment by transurethral resection was followed by radical cystectomy; 7 months postoperatively the patient died of local tumour recurrence with widespread metastases. Carcinosarcoma of the urinary bladder is a rare tumour with a poor prognosis. The majority of such tumours are not diagnosed until tumour growth is already far advanced. Owing to the small number of cases there is no clinically proven form of management. In contrast with superficial transitional cell carcinoma of the bladder, superficial carcinosarcoma of the bladder has always invaded the lamina propria, since in addition to the carcinomatous degeneration of the mucosa, sarcomatous degeneration of the underlying submucosal stroma is also present. Any local surgical treatment, such as TUR or partial cystectomy, involves the risk of incomplete tumor removal, because the sarcomatous elements typically invade the submucosa while the overlying mucosa remains intact. Therefore, radical cystectomy appears to be the treatment of choice for both superficial and invasive carcinosarcoma of the urinary bladder.

Hyaline globules reacting positively with zidovudine antibody in brain and spinal cord of AIDS patients

Histology of the central nervous system in nine AIDS showed extracellular hyaline globules in the white matter of the brain and the spinal cord. In immunohistochemical studies with a battery of antibodies, the only positive reaction of these globules was with an antibody to zidovudine. High-performance liquid chromatography showed the presence of a zidovudine isomer in eluates of brain tissue from these patients.

[Intestinal spirochetosis in HIV infection: prevalence, isolation and morphology of spirochetes]

The prevalence of intestinal spirochaetosis was investigated in 39 HIV-positive homosexual males (mean age 39 [24-65] years) in different stages of HIV infection (3 with the lymphadenopathy syndrome, 8 with AIDS-related complex and 28 with AIDS). Biopsies for cultural and histological demonstration of spirochaetes were obtained during routine ileoscopies. At the time of examination 35 of the 39 patients had intestinal symptoms. 27 patients had had no previous antimicrobial treatment. In 12 of the 27 previously untreated patients with intestinal symptoms spirochaetes were demonstrated, to different extent, from the terminal ileum to the rectum, while the treated group of eight and the control group of four were negative. There were no significant inflammatory changes histologically. Treatment with metronidazole in most cases improved symptoms. In their ultrastructure the microorganisms showed several complete convolutions, cone-shaped cell endings, cell length of 4-18 microns, cell diameter of 0.21-0.35 microns and five subterminal flagella. Morphological considerations favour the inclusion of these microorganisms in the genus Treponema rather than Brachyspira.

Vacuolar myelopathy in AIDS. A morphological analysis

Between 1986 and 1988 we studied the spinal cord of 40 patients dying of AIDS. Transverse and longitudinal sections from a minimum of four levels of the spinal cord were examined by means of conventional histology, immunohistochemistry and electron microscopy. Out of 22 cases there were 6 showing a mild, 11 a moderate and 5 a severe myelopathy. Among these cases with severe myelopathy, vacuolar degeneration of the posterior, lateral, and anterior columns of the white matter, which are typical findings of vacuolar myelopathy (VM), were present. Cervical and thoracic cords were affected in all cases, the lumbal cord, however, in only two. Fusiform vacuoles, 30 to 180 microns in diameter and 200 to 500 microns in length, could be seen rising between the axolemma and the myelin sheath. Most of them were still containing an axon cylinder. Foamy phagocytic cells, phagocytosing axons of apparently preserved structure were found within the vacuoles. These foamy macrophages contained rests of axons in their cytoplasm. However, only one case with severe tissue disruption exhibited myelin debris as well. Our morphological findings suggest that in VM of AIDS a process of phagocytosis directed against the axon cylinders occurs simultaneously with vacuolar degeneration of the white matter of the spinal cord. The results suggest furthermore that VM, especially its moderate form, appears to be a more frequent condition than previously assumed.