Neurological complications of acquired immune deficiency syndrome: analysis of 50 patients

Neuropathology of the acquired immune deficiency syndrome (AIDS): a report of 135 consecutive autopsy cases from Switzerland

Neuropathological changes were studied in a consecutive autopsy series of 135 cases, comprising 73% of all patients who died of AIDS in Switzerland between April 1981 and December 1987. Central nervous system involvement was found in 119 patients (88%), 19 of which had multiple concomitant intracerebral lesions. Among the non-viral opportunistic infections, encephalitis due to Toxoplasma gondii was most frequent and occurred in 35 patients (26%), followed by central nervous system infection with Cryptococcus neoformans, which was found in five patients (4%). Cytomegalovirus (CMV) encephalitis was present in 14 patients (10%). Disseminated microglial nodules without morphological or immunocytochemical evidence of CMV was encountered in 18 patients (13%). However, in all but two of these patients there was evidence of extracerebral CMV infection, suggesting that CMV was responsible for these nodular encephalitides. Nine patients (7%) had progressive multifocal leukoencephalopathy (PML); in five of these, demyelination was associated with extensive tissue destruction and cyst formation. HIV-associated encephalopathy was observed in 21 patients (16%) and showed two characteristic morphological patterns: progressive diffuse leukoencephalopathy (PDL) and multifocal giant cell encephalitis (MGCE). PDL was observed in 13 cases and characterized by diffuse pallor and gliosis of the cerebral and cerebellar white matter with scattered multinucleated giant cells, but without significant inflammatory response. MGCE was found in eight patients and characterized by clusters of numerous multinucleated giant cells, rod cells, macrophages, lymphocytic infiltrates and occasional necroses. In our view, PDL and MGCE represent the two opposite variants of HIV-induced encephalopathies, with overlapping intermediate manifestations.

Cerebral toxoplasmosis in the acquired immune deficiency syndrome

We examined the clinical and pathological features of 26 patients who presented with a diagnosis of CNS toxoplasmosis. Patient data was analyzed with respect to demographics, clinical presentation, treatment course and pathology. Patients presented with a wide variety of signs and symptoms. All patients had positive serum antitoxoplasma IgG; ring enhancing lesion(s) were present on all but one brain CT scans. A series of guidelines in the management of CNS toxoplasmosis in AIDS patients are presented. Prior to biopsy, patients with positive serology and characteristic CT scans should receive two weeks of treatment. Biopsy is indicated in those cases with negative serology, atypical presentation, progressive clinical deterioration, or differential response of lesions to empiric therapy.

AIDS and autoimmunity

While much evidence appears to support the hypothesis of AIDS being an autoimmune disease, equally impressive facts negate the theory. At most, one can presently speak only of the "autoimmune features" of this very complex syndrome. AIDS most strikingly presents with various autoantibodies including those directed against both red and white blood cells. These antibodies appear to be - at least in part - responsible for some of the autoimmune features of the disease. Several clinical and serological similarities exist between AIDS and the "classic" autoimmune disease SLE. In fact, following the isolation of HIV, researchers once again began searching for a viral etiology of SLE. It appears that while autoimmune mechanisms may explain some of the clinical and serologic manifestations of the disease, not enough evidence exists as yet to decidedly point either for or against its classification as an autoimmune disease.

Human immunodeficiency virus (HIV)-induced disease of the central nervous system: pathology and implications for pathogenesis

Significant contributions from many different groups during the last 2 or 3 years have characterized relatively uniform neuropathological changes of the CNS in AIDS patients. They feature human immunodeficiency virus (HIV)-induced multinucleated giant cells as a histopathological hallmark and HIV demonstrable by electron microscopy, immunocytochemistry, and in situ hybridization. Unfortunately, a varying and confusing terminology is used to designate these changes which have been reported in surprisingly different incidences. Focal lesions have a microgranulomatous appearance and were designated as multifocal giant cell encephalitis or subacute encephalitis, which may be confused with the nodular encephalitis caused by cytomegalovirus. For some authors, the latter designation also covers characteristic diffuse white matter changes which have been termed progressive diffuse leukoencephalopathy by others, and which may overlap with focal lesions. Pathological features of these HIV-induced syndromes and other data do not support a major cytopathic effect of HIV on neural cells; rather, they suggest secondary pathogenetic events involving the predominant cell type in the lesion, the monocyte/macrophage/microglia. However, low-level, latent, and persisting HIV infections of neural cells cannot be excluded at present; the CNS may then serve as an early infected virus reservoir. A detailed correlation of clinical symptoms and stage of the infection to neuropathological changes is currently lacking but urgently needed. The presence of the HIV-receptor (CD4) molecule on brain cells is controversial; similarly, a putative cross-reaction of HIV proteins with trophic substances and transmitters needs to be substantiated.

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.

Neurodevelopmental delay and focal seizures as presenting symptoms of human immunodeficiency virus I infection

Three children presenting with neurological symptoms were subsequently diagnosed as being infected with the human immunodeficiency virus I (HIV). All children showed normal development for about 12-18 months of age but later developed psychomotor and developmental regression. One child presented with generalised hypotonia, another with focal seizures, and the third with spastic quadriplegia. Two of the children showed areas of abnormal brain density on computed tomography and in one case there was calcification of the basal ganglia. In two of the children cerebrospinal fluid contained reduced amounts of total folate and elevated concentrations of neopterin. The possibility of a link between the deranged folate metabolism and the neurological symptoms in HIV infection is discussed.

Psychosocial services for AIDS patients in the general hospital

Ninety consecutive non-repeating hospital admissions of patients with AIDS were studied. The rates of psychosocial service utilization were quite high for consultation psychiatry (24.4%), social work (42.2%), and home care (discharge planning) nursing (24.4%). The presence of psychiatric co-morbidities and social needs were associated with increased length of stay. In addition, psychiatric co-morbidities were associated with increased charges for pharmacy and laboratory.

Hemichorea-hemiballismus associated with acquired immune deficiency syndrome and cerebral toxoplasmosis

A young woman had hemichorea-hemiballismus subsequently found to be secondary to a cerebral toxoplasmosis infection complicating human immunodeficiency virus infection. This patient had the sixth reported case of acquired immune deficiency syndrome (AIDS) with hemichorea-hemiballismus, and each has been secondary to cerebral toxoplasmosis. The presence of hemichorea-hemiballismus in a young patient should suggest a diagnosis of AIDS and in particular the diagnosis of secondary cerebral toxoplasmosis. Other movement disorders that occur in AIDS are discussed.

Cell association of HIV in AIDS-related encephalopathy and dementia

The presence of HIV gag and env proteins (HIV Ag) and virus replicating cells was studied by immunohistochemistry and in situ hybridization, respectively, in brain specimens from five HIV infected patients. HIV antigens were detected in 3 of 5 brains in micronodular areas characterized by increased cellularity and the presence of multinuclear giant cells. By double immunostaining, HIV Ag positive cells were shown to express markers common to macrophages and microglia i.e. Leu M5+, My4+, HLA-Dr+, RCA-1+, and to a lesser extent CD4+ (Leu3+). Another macrophage specific marker, KiM6, was found only on HIV+ cells in HIV infected specimens and not in uninfected, control brains. Medium-sized, virus replicating cells were found exclusively in micronodular areas, but in much smaller quantities than HIV Ag+ cells. Our observations provide further evidence to support the hypothesis that macrophages play an important role in CNS infection by HIV and additionally support the concept that reactive microglial originate from activated macrophages infiltrating the brain. Both direct effects of viral components and cell mediated reactions can be implicated from our findings as mechanisms involved in the pathogenesis of the CNS lesions.

Viruses, immunity and mental disorder

Are viruses the cause of mental illness, or does stress or mental disorder produce impaired immunity, with increased susceptibility to infection? These two separate but not unrelated questions have been debated periodically and there has been much renewed interest recently, with increased sophistication in immunology and widespread topical concern about immunodeficiency. The neuropsychiatry of the acquired immunodeficiency syndrome (AIDS) (Snider et al, 1983; Carne & Adler, 1986; Wortis, 1986; Burton, 1987; Fenton, 1987) and the validity of a ‘post-viral fatigue syndrome’ as a clinical entity (Behan, 1983; Southern & Oldstone, 1986; Dawson, 1987; David et al, 1988) are not discussed here, but have been dealt with in the editorials and reviews cited.

Periodic lateralized epileptiform discharges in acquired immunodeficiency syndrome

A patient with AIDS, who exhibited periodic lateralized epileptiform discharges, is described. The possible implications are discussed.

Detection of antibodies against myelin basic protein and increased levels of HIV-IgG antibodies and HIV antigen after solubilization of immune complexes in sera and CSF of HIV infected patients

Fifteen HIV seropositive patients were studied. It was possible to enhance detection of HIV antigen and HIV and myelin basic protein (MBP) antibodies after dissociation of immune complexes by acid hydrolysis. HIV p24 antigen was then detected in four patients, three of whom were previously antigen negative. In 14 patients the treatment resulted in increased anti-HIV IgG subclass levels. Anti-MBP IgG was detected in 12 patients. Intrathecal synthesis of anti-MBP IgG subclasses was found in eight patients, five of whom had symptoms from the central nervous system.

Ocular toxoplasmosis in patients with the acquired immunodeficiency syndrome

In seven of eight cases of presumed ocular toxoplasmosis in patients with AIDS, the diagnosis was supported by a reduction or resolution of intraocular inflammation and healing of necrotic retinal lesions after initiation of antiparasitic drug therapy including one or more of the following medications: pyrimethamine, sulfadiazine, clindamycin, tetracycline, or spiramycin. In two cases the diagnosis was confirmed histologically. The cases differed clinically and histopathologically from those in immunocompetent patients. There was no evidence that disease originated in preexisting retinochoroidal scars. Lesions frequently were bilateral and multifocal. Vitreous inflammatory reaction was a common clinical finding, but histopathologic examination demonstrated scant retinal inflammation in areas of necrosis. Ocular toxoplasmosis in these patients with AIDS probably resulted from newly acquired infection or dissemination of organisms from nonocular sites of disease. Infections became clinically inactive with drug therapy in all treated patients, but reactivation and progression of disease occurred when therapy was stopped in two of three patients. Severe retinal necrosis led to retinal tears or detachment in three cases. Ocular lesions were the first manifestation of Toxoplasma gondii infection in four of five patients with evidence of multisystem infection.

Primary and secondary involvement of the CNS in HIV infection

The neurologic sequelae of human immunodeficiency virus (HIV) infection may be divided into primary (= HIV-induced) and secondary (= opportunistic infections and malignancies) manifestations. Our experience with 215 HIV-infected patients indicates that major clinical symptoms are due to a few, albeit important, neurologic diseases, although in a given patient rare and sometimes multiple complications have to be considered. The clinical features of acquired immunodeficiency syndrome (AIDS) encephalopathy and CNS toxoplasmosis that represent the major primary and secondary neurologic manifestations of AIDS are discussed in detail.

Clinical course of subacute HIV encephalitis

A subacute encephalitis is increasingly recognized to be the most frequent cerebral manifestation of human immunodeficiency virus (HIV) infection. Contradictory reports are given in the literature concerning its clinical course. In the present study, a group of 19 patients with subacute encephalitis was followed for an average of 210 days. A steady progression of the disease was documented using the Karnofsky index. An advanced disease, rated according to the Walther Reed staging classification, but not isolated immunological parameters such as the ratio of OKT4/8 subsets are associated with more rapid progression of the encephalitis. Age, social status, duration of HIV positivity and antibody titers to cytomegalovirus could not be identified as contributing factors.

Nature, incidence and prognosis of neurological involvement in the acquired immunodeficiency syndrome in central London

Clinical neurological involvement at various times throughout the illness was recorded in 52% of 122 patients seen in central London who died from acquired immunodeficiency syndrome (AIDS). Various metabolic encephalopathies, dementias, focal encephalopathies, retinopathies and peripheral nerve pathology were the most frequent manifestations. Seven of 9 patients with a neurological presentation had no other major systemic illness. The median time from diagnosis of AIDS to death was 9 months and from onset of neurological symptoms to death 4 months. Human immunodeficiency virus dementia, central nervous system opportunistic infections, presence of Kaposi sarcoma, neurological presentations and minor symptoms were not associated with major change in survival time.

Abnormalities of peripheral nerve in patients with human immunodeficiency virus infection

The purpose of this study was to assess systematically morphology of peripheral nerves from patients with human immunodeficiency virus infection (acquired immunodeficiency syndrome [AIDS] and AIDS-related complex) examined at autopsy. Sural nerve specimens were taken from 25 patients (mean age 44 years) and evaluated by routine procedures used in our laboratory. In 13 cases no detectable abnormality was seen. Twelve patients (48%) showed loss of myelinated fibers with disproportionately greater loss of large myelinated fibers. Three of these patients showed severe myelinated fiber loss; 2 had no documented symptoms and no other known predisposing factors for a peripheral neuropathy. Changes suggestive of wallerian degeneration were occasionally seen, as were epineurial and endoneurial inflammatory infiltrates. Segmental demyelination was not identified in any nerve examined. Electron microscopy revealed thickened basement membranes around small blood vessels, Schwann cells, and fibroblasts. Peripheral nerve abnormalities in patients with AIDS or ARC are frequent and their pathogenesis remains unclear.

Immunity assessment in the early stages of amyotrophic lateral sclerosis: a study of virus antibodies and lymphocyte subsets

Serum and CSF from 32 patients with idiopathic ALS, 30 age-matched controls and 30 MS patients were investigated regarding immunoglobulin concentration and virus-specific antibodies, the lymphocytes in the peripheral blood and lymphocyte subsets were also investigated. ALS patients' results were compared with findings in MS and controls. The ALS patients had significantly higher IgG concentration in serum than the controls, marked lymphopenia, reduction of CD2, CD8 and Leu 7 positive cells and increase of the CD4/CD8 ratio and of SIg-positive lymphocytes. Compared with the MS patients, the ALS patients showed similarity in T-subset distribution with a lower standard deviation. No HTLV-I and HIV antibodies were found in any group and no significant differences in antibody distribution to Toxoplasma G, herpes simplex, cytomegalovirus, measles and mumps viruses were evident. All ALS patients were investigated at an early disease stage, therefore, our findings seem to support the conclusion that the immune alterations are related to the mechanisms of the disease and not to complications of its evolution.

Antibodies to HIV are produced within the central nervous system of all subjects with all categories of HIV infection

Anti-HIV antibodies were found in the cerebrospinal fluid of all 41 subjects tested whose serum contained these antibodies. To ensure that locally produced antibody was being detected, a sensitive assay was used to demonstrate the integrity of the blood-brain barrier. Antibodies to ubiquitous adenovirus group antigens were sought, simultaneously, in CSF and serum. A lack of adenovirus antibodies in CSF of subjects seropositive for adenovirus was required before CSF anti-HIV antibodies could be considered to be produced within the central nervous system. Of the 41 subjects tested eight were asymptomatic, eight were clinically well but had persistent lymphadenopathy, 14 were immunodeficient and had constitutional symptoms (AIDS-related complex or ARC) and 11 had AIDS. Oligoclonal banding was detected in the CSF of 16 subjects and a pleocytosis was present in 24. Neither finding clustered with a particular stage of infection. It appears that HIV infection of T lymphocytes and the central nervous system occurs simultaneously, early in the course of the infection. All HIV infected subjects are at risk of developing primary neurological as well as immunological sequelae. Currently poorly understood resistance factors must protect both lymphocytes and nervous system tissue from damage by the HIV virus, as to date, the majority of infected subjects have not become immunodeficient or developed neurological disease.

Computed tomographic findings in cerebral toxoplasmosis in adults

The clinical and computerized tomographic (CT) findings in 10 patients with cerebral toxoplasmosis are reviewed. All patients with cerebral toxoplasmosis were homosexuals and/or intravenous drug users, and all patients had other manifestations of AIDS. Two presented with focal seizures, 4 presented with focal neurological deficit which progressively worsened, and 4 had evidence of diffuse neurological dysfunction (altered consciousness, generalized seizures). CT showed a single lesion in 3 patients and multiple lesions in 7 patients. Two patients had hypodense nonenhancing lesions(s). Eight patients had hypodense lesions with peripheral or nodular enhancement. The lesions were more commonly located in the cerebral hemispheres and subcortical gray matter nuclear masses (thalamus, basal ganglia). The finding of a hypodense lesion with a central slightly hyperdense noncalcified region that showed dense nodular homogeneous enhancement was quite characteristic of cerebral toxoplasmosis, but this pattern may also be seen in other neurological conditions including brain lymphomas.

AIDS-related dementia: a case report of rapid cognitive decline

Little is known psychometrically about the pattern of cognitive decline associated with acquired immunodeficiency syndrome (AIDS)-related dementia. Pre- and posttest results are presented to illustrate a case example of rapid cognitive decline. Increased psychometric assessment is recommended with additional examination of inconsistent results, which may be dismissed mistakenly as related to psychiatric symptoms. Implications for clinical practice and the role of the psychologist are discussed.

Circulating antigen of Toxoplasma gondii in patients with AIDS: significance of detection and structural properties

232 sera and 40 cerebrospinal fluid samples of altogether 125 patients in stages III or IV of a HIV-infection were tested for circulating antigen of Toxoplasma gondii by means of a three-layer enzyme-linked immunosorbent assay. Circulating antigen was detected in 32 sera of 20 patients (= 16% of all persons investigated). These ELISA results were reexamined by an Immunoblot following a SDS-PAGE and confirmed in most cases. In addition, this test system led to a partial characterization of the circulating antigen; it consists of at least two proteins with atomic mass units of 27 and 57 kd respectively. The antigenemia was correlated with IgG- and IgM-antibody titres, with clinical symptoms, and with pathological findings also. Our results indicate that the detection of circulating antigen in sera offers a rapid and efficient method for the diagnosis of an acute toxoplasmosis in AIDS-patients.

Brainstem ocular motility defects and AIDS

Ocular motility manifestations of focal brainstem dysfunction were the initial clinical features in three patients with human immunodeficiency virus (HIV) infection. These included conjugate gaze palsy with ipsilateral facial paresis, bilateral abducens palsy and a gaze paresis, and homolateral internuclear ophthalmoplegia and abducens nerve paresis. Two patients had focal brainstem lesions as evidenced on neuroimaging. The third showed concurrent infection with Treponema pallidum.

Neuronal cell killing by the envelope protein of HIV and its prevention by vasoactive intestinal peptide

The clinical manifestations of AIDS (acquired immune deficiency syndrome) often include neuropsychiatric and neurological deficits, including early memory loss and progressive dementia. HIV (human immunodeficiency virus), the aetiological agent of AIDS, is probably carried by infected macrophages in the central nervous system. The virus enters cells by binding its envelope glycoprotein gp120 to the CD4 antigen present on brain and immune cells. From the data reported in this paper, we now suggest that the neuronal deficits associated with HIV may not be entirely a result of infectivity, but that gp120 shed from HIV could directly produce the neuropathology as a result of its interference with endogenous neurotrophic substances. It is known that an analogue of a sequence contained in vasoactive intestinal peptide (VIP) occurs in all known sequenced gp120 isolates and that VIP is important for neuronal survival in cell culture. Here we show that purified gp120 from two diverse HIV isolates and a recombinant gp120 from a third isolate were all potent in specifically producing significant neuronal cell death in dissociated hippocampal cultures derived from fetal mice, and that this could be reduced by monoclonal antibodies against the murine CD4 antigen and completely antagonized by VIP.

Occlusive hypertrophic arteritis as the cause of discrete necrosis in CNS toxoplasmosis in the acquired immunodeficiency syndrome

Brain specimens from five immunocompromised patients with CNS toxoplasmosis were studied with immunostaining for toxoplasma antigens and electron microscopy. The tachyzoites or toxoplasma antigens were predominantly localized in walls of hypertrophic, often thrombosed, arteries and adjacent brain tissue at the hyperemic rims of centrally necrotic lesions. This study suggests that in CNS toxoplasmosis of immunocompromised hosts, the organisms primarily invade and spread along segments of small artery walls, causing hypertrophy of arterial walls, thrombotic occlusion of lumens, circumscribed but expansive ischemic necrosis, and extravasation of organisms. Rapid response to chemotherapy can be explained by this preferential parasitism to the arterial walls. Early definitive diagnosis on brain biopsy specimens can be attained by immunostaining.

Histo- and immunopathological features of terminal AIDS. An autopsy case of a Japanese man with neurological signs as initial symptoms

An autopsy case of a 37-year-old Japanese man, confirmed as an AIDS patient infected by an undetermined route of transmission, is presented. The initial symptoms of full-blown AIDS in this case were neurological, and the patient died of severe pneumonia 9 months after onset. The main histo- and immunopathological features were a marked depletion of helper-inducer T cells and dendritic reticulum cells in the lymphoid tissues, opportunistic infections, and some neuropathologic changes. Very few cells, possibly macrophages, immunoreactive with a monoclonal antibody (VAK-5) against HIV-gag protein P24 were found in the mediastinal lymph nodes. Numerous pathogens had induced opportunistic infections in many organs: severe and generalized cytomegalovirus infection, Pneumocystis carinii pneumonia, bronchopneumonia (possibly due to Pseudomonas aeruginosa), candidiasis in the tongue and oral cavity, and atypical mycobacteriosis in the pulmonic hilar lymph nodes. Vascular proliferation was found in the perinodal regions of some lymph nodes, but this was not neoplastic vascular proliferation compatible with that of localized Kaposi's sarcoma.

Human immunodeficiency virus infection of the brain. II. Detection of intrathecally synthesized antibodies by enzyme linked immunosorbent assay and imprint immunofixation

Sera and CSF from 29 patients in early and late stages of HIV infection were analysed for intrathecal antibody production. Elevated CSF-IgG indices indicating intrathecal IgG synthesis were demonstrated in 9 patients while 4 of 18 patients tested had oligoclonal IgG bands in the CSF. Analysis of HIV-specific antibodies by enzyme-linked immunosorbent assay (whole antigen and site-directed ELISA) and calculation of "antibody indices" (CSF/serum antibody quotient divided by CSF/serum albumin quotient) indicated intrathecal HIV antibody synthesis in 19 patients. Analysis of serum and CSF antibodies by an imprint immunofixation (IIF) method showed intrathecal synthesis of predominantly polyclonal HIV-IgG antibodies in 11 of 13 patients examined. IIF analysis of antibodies to six other infectious agents showed no intrathecal antibody production except in one patient who had minor fractions of intrathecally synthesized IgG antibodies to varicella zoster virus. The present results demonstrate that an intrathecal HIV-specific antibody response may be present in both early and late stages of HIV infection, and indicates that HIV may reach the brain at an early stage of infection.

Isolation frequency of human immunodeficiency virus from cerebrospinal fluid and blood of patients with varying severity of HIV infection

Isolation of the human immunodeficiency virus (HIV) has been attempted from the cerebrospinal fluid (CSF) of 63 subjects at different stages of HIV infection, including asymptomatic carriers and patients with or without neurologic or psychiatric complications. In addition blood was collected from 40 of these subjects for virus isolation. HIV could be isolated from the CSF at all clinical stages with an overall frequency of 40%. In contrast, the frequency of HIV isolation from the blood was lower (32%) at the early stages of infection than in patients with severe disease (77%). HIV isolation from the CSF was more frequently positive in patients with neurologic or psychiatric complications than in patients showing no such disturbances (48 and 32%, respectively).

Pathology of the central nervous system in 40 cases of acquired immune deficiency syndrome (AIDS)

The central nervous system was examined in 40 AIDS patients who died between August 1982 and 1987. The cases included two children born to intravenous drug abusers and 38 male adults. The brains of eight patients who had no clinical or radiological evidence of central nervous system involvement showed non-specific changes which included microglial nodules, perivascular mononuclear cuffs, mineralization of blood vessels and granular ependymitis. In 32 brains from patients with neurological symptoms, toxoplasmosis was the most frequent finding (19 cases) manifested by multifocal, necrotic lesions or a diffuse pseudo-encephalitic process. Other opportunistic infections included cytomegalovirus (eight cases), progressive multifocal leucoencephalopathy (two cases), cryptococcosis (one case), aspergillosis (one case), multiple bacterial microabscesses (one case) and Mycobacterium avium intracellulare (one case). Two patients had cerebral lymphoma. Subacute encephalitis with white matter lesions and multinucleated giant cells characteristic of HIV infection was present in 15 cases. Various combinations of all these infections were encountered in the same brain, sometimes in the same area and, occasionally, in the same cell.

Necrotizing vasculitis of the nervous system in a patient with AIDS-related complex

A patient with AIDS-related complex (ARC) presented with a fulminant neurologic syndrome suggestive of ascending myelopathy, and died approximately 48 h after admission to hospital. At necropsy, there was evidence of a severe necrotizing vasculitis affecting the nervous system most severely, with multifocal haemorrhagic necroses of the spinal cord and cauda equina. Although a rare intranuclear inclusion suggestive of herpesvirus infection was seen in the predominantly lympho-histiocytic infiltrate in and around blood vessel walls, the precise aetiology of the angiitis was not apparent. It may represent a response to AIDS virus infection of one or more components of the blood vessel wall.

Neuropathology of acquired immunodeficiency syndrome

The nervous system is involved in the acquired immunodeficiency syndrome (AIDS) by infections and infestations, by neoplasms, and by several diseases of uncertain pathogenesis. The most common pathological abnormalities are the changes associated with the HIV agent itself, the 'HIV subacute encephalitis'; the most specific change is demyelination with multinucleate giant cells. Cytomegalovirus (CMV) is the most common secondary virus, but progressive multifocal leucoencephalopathy (PML) is more frequently seen at biopsy. Toxoplasmosis is the most common cause of abscess formation, but fungal infections, especially by cryptococcus, are more often the cause of meningitis. Mycobacterial infections and other opportunistic organisms are relatively rarely seen in the CNS. A vacuolar myelopathy of unknown pathogenesis is seen in AIDS; it involves the dorsal and lateral columns and the thoracic spinal cord most prominently. Endarteritis of unknown cause with resultant infarction is seen in children. Primary CNS lymphoma accounts for a major percentage of the lymphomas seen in AIDS; they are high grade tumours, are most often multiple, and are of B-cell origin. Metastatic Kaposi's sarcoma is very rare. Several peripheral neuropathies occur in AIDS, and recently a myopathy with small rod bodies has been reported.

Anti-HIV antibodies in the CSF of AIDS patients: a serological and immunoblotting study

CSF and serum samples from 16 AIDS patients were tested for the presence of anti-HIV antibodies either by classical serological methods or by an immunoblot technique based on agarose gel isoelectric focusing and transfer of the specific IgG antibodies onto HIV antigens-loaded nitrocellulose sheets. This method enabled the demonstration of an intrathecal synthesis of anti-HIV oligoclonal IgG antibodies, often superimposed on diffuse polyclonal production, in 14 patients. The two negative cases were devoid of neurological signs or symptoms. However, two patients classified in stage II of the disease (asymptomatic infection) displayed an intrathecal synthesis of anti-HIV antibodies.

[EEG recordings in 19 cases of AIDS with encephalic involvement]

Between 1983 and 1987, 19 patients presenting with encephalic involvement of AIDS had an EEG recording during the early neurological examination. In 8 patients, EEGs were repeated 1 to 11 times during the course of the disease. All recordings were abnormal. A good EEG correlation existed with clinical, virological and bacteriological (SF), radiological, and histological data (10 cases). EEG recordings are useful to study the encephalic pathology of AIDS, not only for its secondary, but even more for its primary involvement.

Impairment of cranio-facial nerves due to AIDS. Report of 2 cases

2 cases of disorders of craniofacial nerves resulting from progressive multifocal leucoencephalopathy are described. Clinical symptoms occurred as facial paralysis, hypaesthesia, hemianopsia and deafness. In both patients, the impairment of the central nervous system (CNS) preceded indicative AIDS symptoms. Both patients died about 3 months after the first CNS symptoms had been diagnosed. Clinical and neurohistopathological findings as well as differential diagnoses are discussed.

The spectrum of peripheral neuropathy associated with ARC and AIDS

Peripheral neuropathy is increasingly recognized as a complication of the Acquired Immune Deficiency Syndrome (AIDS) and AIDS-related complex (ARC), but the varied clinical features have been incompletely described. Thirty homosexual men with peripheral neuropathy were evaluated in this study. Twenty-one had ARC and nine had AIDS. Four distinct clinical syndromes were recognized: distal sensorimotor polyneuropathy, chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), mononeuropathy multiplex, and progressive polyradiculopathy. Four patients with clinical, electrophysiologic, and histologic evidence of CIDP and severe progressive weakness improved with plasma exchange, three regaining normal function.

Candida and AIDS: evidence for protective antibody

Clinical observation and animal models of candidosis suggest that, although T lymphocytes are important in preventing superficial candidosis, defence against systemic candidosis depends upon humoral immunity. An antibody response to the immunodominant 47 kD antigen of Candida albicans is invariably associated with recovery. The presence of this antibody in patients with chronic mucocutaneous candidosis and the acquired immunodeficiency syndrome (AIDS) could account for the rarity of disseminated candidal infection in these conditions. Polyclonal B cell activation may be responsible for the frequency with which this antibody is produced in AIDS. Antibody to the 47 kD antigen could be useful in the treatment and prevention of systemic candidosis, though not in the superficial candidosis of AIDS.