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

Cerebral toxoplasmosis with neurological co-infection in people living with AIDS/HIV: results of a prospective cohort in São Paulo, Brazil

BACKGROUND

Concomitant neurological diseases in people living with HIV/AIDS (PLWHA) is a challenging subject that has been insufficiently evaluated by prospective clinical studies. The goal of the present study was to identify the clinical characteristics and outcomes of PLWHA with cerebral toxoplasmosis and neurological co-infections.

METHODS

We conducted a prospective observational cohort study at a tertiary teaching center in São Paulo, Brazil, from January to July 2017. Hospitalized PLWHA aged ≥ 18 years with cerebral toxoplasmosis were consecutively enrolled. A standardized neurological examination was performed at admission and weekly until discharge or death. Diagnosis and treatment followed institutional routines; neuroradiology, molecular diagnosis, neurosurgery, and the intensive care unit (ICU) were available. The main outcomes were neurological coinfections and in-hospital death.

RESULTS

We included 44 (4.3%) cases among 1,032 hospitalized patients. The median age was 44 (interquartile range [IQR]: 35-50) years, and 50% (n = 22) of the patients were male. The median CD4+ T lymphocyte count was of 50 (IQR: 15-94) cells/mm³. Multiple lesions on computed tomography were present in 59% of the cases. Neurological coinfections were diagnosed in 20% (n = 9) of the cases, and cytomegalovirus was the most common etiology (encephalitis: n = 3; polyradiculopathy: n = 2). Longer hospital stays (30 versus 62 days; p = 0.021) and a higher rate of ICU admissions (14% versus 44%; p = 0.045) were observed among PLWHA with neurological coinfections in comparison to those without them. The rate of in-hospital mortality was of 13.6% (n = 6) (coinfection group: 33%; no coinfection group: 8.6%; p = 0.054).

CONCLUSION

Neurological c-infections were common among PLWHA with cerebral toxoplasmosis, and cytomegalovirus was the main copathogen. The group of PLWHA with neurological co-infections underwent longer hospital stays and more frequent intensive care unit admissions. Additionally, this group of patients tended to have higher in-hospital mortality rate.

Impact of Plant-Based Foods and Nutraceuticals on Toxoplasma gondii Cysts: Nutritional Therapy as a Viable Approach for Managing Chronic Brain Toxoplasmosis

Toxoplasma gondii is an obligate intracellular parasite that mainly infects warm-blooded animals including humans. T. gondii can encyst and persist chronically in the brain, leading to a broad spectrum of neurological sequelae. Despite the associated health threats, no clinical drug is currently available to eliminate T. gondii cysts. In a continuous effort to uncover novel therapeutic agents for these cysts, the potential of nutritional products has been explored. Herein, we describe findings from in vitro and in vivo studies that support the efficacy of plant-based foods and nutraceuticals against brain cyst burden and cerebral pathologies associated with chronic toxoplasmosis. Finally, we discuss strategies to increase the translatability of preclinical studies and nutritional products to address whether nutritional therapy can be beneficial for coping with chronic T. gondii infections in humans.

Immune Reconstitution Inflammatory Syndrome with Recurrent Paradoxical Cerebellar HIV-Associated Progressive Multifocal Leukoencephalopathy

Progressive multifocal leukoencephalopathy (PML), presenting as immune reconstitution inflammatory syndrome (IRIS), is a known complication of antiretroviral therapy (ART) in people living with HIV (PLWH). Typically preceded by ART initiation, IRIS may appear simultaneously/unmasked (PML-s-IRIS) or as a delayed/worsening/paradoxical (PML-d-IRIS) presentation of known PML disease. Primary cerebellar tropism continues to be a rare presentation, and paradoxical cerebellar involvement of PML-IRIS syndrome can be a challenge for both diagnosis and management. Steroids have been suggested as a possible therapy in severe cases but the duration of steroid therapy remain elusive. Our case is that of a 34-year-old man with newly diagnosed HIV simultaneously found to have cerebellar PML. His PML lesions however worsened after initiation of ART (PML-d-IRIS) with evidence of increased intracranial pressure. Despite initial favorable response to a short duration of steroids, he had multiple recurrence of his PML lesions after steroids were discontinued. The presence of predominant cerebellar lesions and the question of how long steroids should be provided to prevent or minimize PML recurrence is the highlight of our case. This report emphasizes the need for more controlled studies to assist clinicians in the optimal diagnosis and management of PML-IRIS in PLWH.

Injection with Toxoplasma gondii protein affects neuron health and survival

Toxoplasma gondii is an intracellular parasite that causes a long-term latent infection of neurons. Using a custom MATLAB-based mapping program in combination with a mouse model that allows us to permanently mark neurons injected with parasite proteins, we found that Toxoplasma-injected neurons (TINs) are heterogeneously distributed in the brain, primarily localizing to the cortex followed by the striatum. In addition, we determined that cortical TINs are commonly (>50%) excitatory neurons (FoxP2+) and that striatal TINs are often (>65%) medium spiny neurons (MSNs) (FoxP2+). By performing single neuron patch clamping on striatal TINs and neighboring uninfected MSNs, we discovered that TINs have highly aberrant electrophysiology. As approximately 90% of TINs will die by 8 weeks post-infection, this abnormal physiology suggests that injection with Toxoplasma protein-either directly or indirectly-affects neuronal health and survival. Collectively, these data offer the first insights into which neurons interact with Toxoplasma and how these interactions alter neuron physiology in vivo.

Initial diagnosis of HIV/AIDS in patients presenting to the emergency department: Imaging and clinical findings at a single institution

PURPOSE

To evaluate the clinical, laboratory, and imaging findings along with treatment and outcomes associated with patients presenting to the emergency department (ED) who were subsequently diagnosed with HIV/AIDS.

METHODS

591 patients with HIV and available imaging studies presenting to our hospital's ED between 2004 and 2019 were identified in the medical record. Following initial review, we identified 19 patients who were diagnosed with HIV within one week after an initial ED visit and also had received CT imaging during the ED visit. Demographic, clinical, treatment, imaging, and outcome data were reviewed and recorded for each patient.

RESULTS

Among this 19-patient cohort, the most common indication for HIV testing was oral/esophageal candidiasis (n = 8, 42%). 12 patients presented with an AIDS-defining illness upon initial diagnosis; the most common were esophageal candidiasis (4) and Pneumocystis jiroveci pneumonia (PJP) (3). 10 patients (59%) presented with CD4+ counts <200 cells/L. The most common imaging findings were liver abnormalities (n = 9, 47%). Five of the 19 patients were confirmed deceased at the time of this study, with the median time from diagnosis to death of 5.6 months (range 8 days-14 months).

CONCLUSION

Our series demonstrates the breadth of potential imaging findings and clinical presentations of late-stage HIV in the emergency setting, including common AIDS-defining illnesses such as PJP and PML. Although the incidence of these conditions is decreasing, maintaining awareness of their clinical and imaging findings, as well as the potential for multi-organ involvement, is essential due to the possibility of rapid decline in these patients.

Review of the neurological aspects of HIV infection

There are almost 40 million people in the world who live with the human immunodeficiency virus (HIV). The neurological manifestations associated with HIV contribute to significant morbidity and mortality despite the advances made with anti-retroviral therapy (ART). This review presents an approach to classification of neurological disorders in HIV, differentiating diseases due to the virus itself and those due to opportunistic infection. The effects of antiretroviral therapy are also discussed. The emphasis is on the developing world where advanced complications of HIV itself and infections such as tuberculosis (TB), toxoplasmosis and cryptococcal meningitis remain prevalent.

AIDS-related Cryptococcus neoformans choroiditis

We describe a case of Cryptococcal choroiditis in a person with advanced HIV/AIDS. A 29-year-old male with AIDS presented with fever, photophobia, and ataxia secondary to cryptococcal and toxoplasma meningoencephalitis. Dilated fundoscopic examination revealed bilateral and multifocal posterior infiltrates consistent with cryptococcal choroiditis. Treatment with parenteral and intravitreal liposomal amphotericin B, oral flucytosine, and oral trimethoprim-sulfamethoxazole led to resolution of his symptoms and improvement in his vision. Our case documents a rare, intraocular opportunistic infection and highlights the importance of ophthalmologic examination in immunocompromised hosts with visual symptoms and invasive fungal infection. We discuss diagnostic and treatment considerations in cryptococcal choroiditis.

Simian Immunodeficiency Virus-Infected Memory CD4+ T Cells Infiltrate to the Site of Infected Macrophages in the Neuroparenchyma of a Chronic Macaque Model of Neurological Complications of AIDS

Simian immunodeficiency virus (SIV)-infected nonhuman primates can serve as a relevant model for AIDS neuropathogenesis. Current SIV-induced encephalitis (SIVE)/neurological complications of AIDS (neuroAIDS) models are generally associated with rapid progression to neuroAIDS, which does not reflect the tempo of neuroAIDS progression in humans. Recently, we isolated a neuropathogenic clone, SIVsm804E-CL757 (CL757), obtained from an SIV-infected rhesus macaque (RM). CL757 causes a more protracted progression to disease, inducing SIVE in 50% of inoculated animals, with high cerebral spinal fluid viral loads, multinucleated giant cells (MNGCs), and perivascular lymphocytic cuffing in the central nervous system (CNS). This latter finding is reminiscent of human immunodeficiency virus (HIV) encephalitis in humans but not generally observed in rapid progressor animals with neuroAIDS. Here, we studied which subsets of cells within the CNS were targeted by CL757 in animals with neurological symptoms of SIVE. Immunohistochemistry of brain sections demonstrated infiltration of CD4+ T cells (CD4) and macrophages (MΦs) to the site of MNGCs. Moreover, an increase in mononuclear cells isolated from the brain tissues of RMs with SIVE correlated with increased cerebrospinal fluid (CSF) viral load. Subset analysis showed a specific increase in brain CD4+ memory T cells (Br-mCD4), brain-MΦs (Br-MΦs), and brain B cells (Br-B cells). Both Br-mCD4s and Br-MΦs harbored replication-competent viral DNA, as demonstrated by virus isolation by coculture. However, only in animals exhibiting SIVE/neuroAIDS was virus isolated from Br-MΦs. These findings support the use of CL757 to study the pathogenesis of AIDS viruses in the central nervous system and indicate a previously unanticipated role of CD4s cells as a potential reservoir in the brain.IMPORTANCE While the use of combination antiretroviral therapy effectively suppresses systemic viral replication in the body, neurocognitive disorders as a result of HIV infection of the central nervous system (CNS) remain a clinical problem. Therefore, the use of nonhuman primate models is necessary to study mechanisms of neuropathogenesis. The neurotropic, molecular clone SIVsm804E-CL757 (CL757) results in neuroAIDS in 50% of infected rhesus macaques approximately 1 year postinfection. Using CL757-infected macaques, we investigate disease progression by examining subsets of cells within the CNS that were targeted by CL757 and could potentially serve as viral reservoirs. By isolating mononuclear cells from the brains of SIV-infected rhesus macaques with and without encephalitis, we show that immune cells invade the neuroparenchyma and increase in number in the CNS in animals with SIV-induced encephalitis (SIVE). Of these cells, both brain macrophages and brain memory CD4+ T cells harbor replication-competent SIV DNA; however, only brain CD4+ T cells harbored SIV DNA in animals without SIVE. These findings support use of CL757 as an important model to investigate disease progression in the CNS and as a model to study virus reservoirs in the CNS.

Risk of Progressive Multifocal Leukoencephalopathy in the Combination Antiretroviral Therapy Era in the French Hospital Database on Human Immunodeficiency Virus (ANRS-C4)

Background

Risk factors for progressive multifocal leukoencephalopathy (PML) in individuals with human immunodeficiency virus (HIV) infection are poorly documented in the era of combination antiretroviral therapy (cART).

Methods

We studied HIV-1-infected individuals aged ≥15 years who had no history of PML and were prospectively followed up between 1997 and 2011 in the French Hospital Database on HIV (FHDH-ANRS CO4) cohort. Cox models were used to calculate adjusted hazard ratios (HRs), focusing on sub-Saharan origin, suggested to be protective, and recent cART initiation, potentially associated with an increased risk of PML.

Results

PML developed in 555 individuals, in 57 during the first 6 months of cART. From 1997-2000 to 2009-2011, the incidence fell from 1.15 (95% confidence interval [CI], .98-1.31) to 0.49 (.37-.61) per 1000 person-years. Sub-Saharan African origin had no clear influence (HR, 0.80; 95% CI, .58-1.11). Compared with men who have sex with men, injection drug users (IDUs) were at higher risk (HR, 1.80 [95% CI, 1.32-2.45] for male and 1.68 [1.13-2.48] for female IDUs). When IDUs were excluded, hepatitis C virus seropositivity was associated with an increased risk (HR, 1.40; 95% CI, 1.02-1.93). Compared with no cART initiation, initiation <6 months previously was associated with PML onset (HR, 4.91; 95% CI, 2.42-9.95).

Conclusions

Recent cART initiation is associated with an increased risk of PML, as are injection drug use and hepatitis C virus seropositivity. Sub-Saharan African origin had no protective effect.

Presence of Toxoplasma gondii infection in brain as a potential cause of risky behavior: a report of 102 autopsy cases

Toxoplasmosis was linked to impairment in brain function, encompassing a wide range of behavioral and neuropsychiatric changes. Currently, the precise localization of Toxoplasma gondii in the human brain is limited and the parasite DNA was not found in population-based screening of autopsy cases. The aim of proposed study was to identify the presence of parasite DNA within the brain and its association with risky behavior and alcohol consumption in postmortem examination. Preliminarily, 102 cases with certain circumstances of death at time of forensic autopsy was included. Due to high risk of bias, the females were excluded from the analysis and final study group consists 97 cases divided into three groups: risky behavior, inconclusively risky behavior, and control group. The obtained tissue samples for Nested PCR covered four regions of the brain: symmetric left/right and anterior/posterior horns of lateral ventricles comprising lining ependyma and hippocampus. The second type of material comprised blood evaluated for antibodies prevalence using ELISA and alcohol concentration using HS-GC-FID. Analysis demonstrated 16.5% prevalence concerning the parasite DNA presence in examined brain tissue samples without specific distribution and association with age at death or days after death until an autopsy was performed. Results have shown correlation between occurrence of risky behavior leading to death and higher proportions of positive parasite DNA presence within the brain. Correlation was not observed between parasite DNA presence and excessive alcohol consumption. Conducted screening demonstrated correlation between parasite DNA presence in the brain with risky behavior and provided new information on possible effects of latent toxoplasmosis.

Progressive multifocal leukoencephalopathy

Progressive multifocal leukoencephalopathy (PML) is a relatively common complication of HIV disease. In this chapter changes to the epidemiology are discussed along with an update in its pathogenesis and treatment. Immune reconstitution inflammatory syndrome is increasingly frequent in PML; accordingly management strategies and prognosis are detailed.

Toxoplasma gondii: Entry, association, and physiological influence on the central nervous system

Toxoplasma gondii is one of the world’s most successful parasites, in part because of its ability to infect and persist in most warm-blooded animals. A unique characteristic of T. gondii is its ability to persist in the central nervous system (CNS) of a variety of hosts, including humans and rodents. How, what, and why T. gondii encysts in the CNS has been the topic of study for decades. In this review, we will discuss recent work on how T. gondii is able to traverse the unique barrier surrounding the CNS, what cells of the CNS play host to T. gondii, and finally, how T. gondii infection may influence global and cellular physiology of the CNS.

Polyomaviruses

Over the last 10 years, the number of identified polyomaviruses has grown to more than 35 subtypes, including 13 in humans. The polyomaviruses have similar genetic makeup, including genes that encode viral capsid proteins VP1, 2, and 3 and large and small T region proteins. The T proteins play a role in viral replication and have been implicated in viral chromosomal integration and possible dysregulation of growth factor genes. In humans, the Merkel cell polyomavirus has been shown to be highly associated with integration and the development of Merkel cell cancers. The first two human polyomaviruses discovered, BKPyV and JCPyV, are the causative agents for transplant-related kidney disease, BK commonly and JC rarely. JC has also been strongly associated with the development of progressive multifocal leukoencephalopathy (PML), a rare but serious infection in untreated HIV-1-infected individuals and in other immunosuppressed patients including those treated with monoclonal antibody therapies for autoimmune diseases systemic lupus erythematosus, rheumatoid arthritis, or multiple sclerosis. The trichodysplasia spinulosa-associated polyomavirus (TSAPyV) may be the causative agent of the rare skin disease trichodysplasia spinulosa. The remaining nine polyomaviruses have not been strongly associated with clinical disease to date. Antiviral therapies for these infections are under development. Antibodies specific for each of the 13 human polyomaviruses have been identified in a high percentage of normal individuals, indicating a high rate of exposure to each of the polyomaviruses in the human population. PCR methods are now available for detection of these viruses in a variety of clinical samples.

Spinal cord toxoplasmosis in human immunodeficiency virus infection/acquired immunodeficiency syndrome

Neurological complications in patients with human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) are still common, even in the era of highly active antiretroviral therapy. Opportunistic infections, immune reconstitution, the virus itself, antiretroviral drugs and neurocognitive disorders have to be considered when establishing the differential diagnosis. Toxoplasmic encephalitis remains the major cause of space-occupying lesions in the brain of patients with HIV/AIDS; however, spinal cord involvement has been reported infrequently. Here, we review spinal cord toxoplasmosis in HIV infection and illustrate the condition with a recent case from our hospital. We suggest that most patients with HIV/AIDS and myelitis with enhanced spine lesions, multiple brain lesions and positive serology for Toxoplasma gondii should receive immediate empirical treatment for toxoplasmosis, and a biopsy should be performed in those cases without clinical improvement or with deterioration.

Altered structural brain changes and neurocognitive performance in pediatric HIV

Pediatric HIV patients often suffer with neurodevelopmental delay and subsequently cognitive impairment. While tissue injury in cortical and subcortical regions in the brain of adult HIV patients has been well reported there is sparse knowledge about these changes in perinatally HIV infected pediatric patients. We analyzed cortical thickness, subcortical volume, structural connectivity, and neurocognitive functions in pediatric HIV patients and compared with those of pediatric healthy controls. With informed consent, 34 perinatally infected pediatric HIV patients and 32 age and gender matched pediatric healthy controls underwent neurocognitive assessment and brain magnetic resonance imaging (MRI) on a 3 T clinical scanner. Altered cortical thickness, subcortical volumes, and abnormal neuropsychological test scores were observed in pediatric HIV patients. The structural network connectivity analysis depicted lower connection strengths, lower clustering coefficients, and higher path length in pediatric HIV patients than healthy controls. The network betweenness and network hubs in cortico-limbic regions were distorted in pediatric HIV patients. The findings suggest that altered cortical and subcortical structures and regional brain connectivity in pediatric HIV patients may contribute to deficits in their neurocognitive functions. Further, longitudinal studies are required for better understanding of the effect of HIV pathogenesis on brain structural changes throughout the brain development process under standard ART treatment.

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Structural brain MRI and cognitive assessments were performed in pediatric HIV.

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Pediatric HIV showed altered cortical thickness and subcortical volumes.

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Disrupted structural connectivity was observed in pediatric HIV.

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Altered brain structures and connectivity contribute to deficits in neurocognition.

Diagnostic Value and Safety of Stereotactic Biopsy in Acquired Immune Deficiency Syndrome Patients with Intracranial Lesions: Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the diagnostic value and safety of stereotactic biopsy in acquired immune deficiency syndrome (AIDS) patients with intracranial lesions via meta-analysis.

METHODS

Relevant cohort studies were identified through a literature search in PubMed, Embase, and Ovid from 1985 to October 1, 2016. Appropriate studies were identified per search criteria. Systematic review and meta-analysis were used to assess the diagnostic success rate, changed management rate, clinical improvement rate, mortality rate, morbidity rate, hemorrhage rate, hemorrhage in morbidity rate, and final histologic diagnosis results. Study-specific outcomes were combined per a random effects model. Outcomes were compared between the pre-highly active antiretroviral therapy (HAART) and post-HAART groups. Correlations between outcomes were assessed via meta-regression analysis.

RESULTS

A total of 19 cohort studies with 820 patients were included in this meta-analysis. The weighted proportions per the random effects model were 92.2% (95% confidence interval [CI; 89.3%-94.5%]) for diagnostic success rate, 5.1% (95% CI [2.5%-8.3%]) for morbidity, and 0.7% (95% CI [0%-1.9%]) for mortality. The most common procedure-related morbidity was hemorrhage at 3.3% (95% CI [1.1%-6.3%]). Hemorrhage in morbidity was 78.0% (95% CI [51.4%-97.4%]). Management changed and clinical improvement were 60.4% (95% CI [49.4%-71.0%]) and 34.0% (95% CI [22.2%-46.8%]), respectively. The 4 most common diagnoses were primary central nervous system lymphoma (27.8%; 95% CI [20.2%-36.1%]), progressive multifocal leukoencephalopathy (PML) (21.0%; 95% CI [14.3%-28.4%]), toxoplasma encephalitis (TE) (20.3%; 95% CI [14.3%-27.0%]), and human immunodeficiency virus (HIV) encephalitis (4.1%; 95% CI [1.4%-7.6%]). Multiple diagnoses rate was 1.2% (95% CI [0.0%-3.6%]). HIV encephalitis rate was significantly higher in the post-HAART group than the pre-HAART group (17.9% vs. 3.2%, respectively; P = 0.0024).

CONCLUSIONS

Stereotactic biopsy is a safe and effective way of diagnosing intracranial lesions in patients with AIDS. It is helpful for the differential diagnosis and for choosing a suitable therapy. The 4 most common intracranial lesions in patients with AIDS are lymphoma, PML, TE, and HIV encephalitis.

Application of stereotactic biopsy for diagnosing intracranial lesions in patients with AIDS in China: Report of 7 cases

RATIONALE

The aim of the study was to evaluate stereotactic biopsy for diagnosing intracranial lesions in patients with AIDS.

PATIENT CONCERNS

Seven AIDS patients with an intracranial lesion who underwent stereotactic biopsy were included in this retrospective study (4 males and 3 females, 15 to 49 years old). The patients' disease history ranged from 1 month to 1 year. The samples were examined by hematoxylin-eosin (HE) staining and immunohistochemical examination.

DIAGNOSES, INTERVENTIONS AND OUTCOMES

All patients were successfully sampled, and the histological results showed inflammation in 4 cases, toxoplasma gondii infection in 1 case, astrocytoma in 1 case, and abscess in 1 case. The clinical diagnosis included toxoplasma encephalitis (TE) in 2 cases, cryptococcus encephalitis in 2 cases, cytomegalovirus (CMV) encephalitis in 2 case, tubercular abscess in 1 case, astrocytoma in 1 case, and co-infection of TE with Cryptococcus infection in 1 patient. The clinical diagnosis was made according to the plasma and cerebrospinal fluid (CSF) laboratory testing, the imaging data and the histological findings. The diagnostic yield was 100%, and the post-operation morbidity was 14.3% (1/7) with an asymptomatic haemorrhage and seizure in 1 case. There was no operation-related mortality. Patients were followed up for 6 months to 6 years; 1 case fully recovered, 4 cases significantly improved in symptoms, and 2 died.

LESSONS

Stereotactic biopsy is a safe and effective way of diagnosing intracranial lesions in patient with AIDS. It is helpful for the differential diagnosis and for choosing a suitable therapy. Due to the broad spectrum of nervous system abnormalities in AIDS, histological findings are very valuable. However, histology is not a unique tool for making a definite diagnosis, whereas the combination of molecular pathology and stereotactic biopsy should play a more important role in the future.

Neuropathology of the Acquired Immune Deficiency Syndrome (AIDS): Report of 39 Autopsies from Vancouver, British Columbia

Neuropathological findings from 39 acquired immune deficiency syndrome (AIDS) autopsies of primarily neurologically symptomatic patients and 7 brain biopsies from AIDS patients performed at St. Paul’s Hospital, Vancouver, British Columbia are reported. Autopsy findings included human immunodeficiency virus-1 (HlV)-type multinucleated giant cell (MNGC)-associated encephalitis seen in 17 patients, toxoplasmosis in 7 patients, and cytomegalovirus encephalitis and/or microglial nodule-associated nuclear inclusions in brain parenchyma in 9 patients. Central nervous system lymphoma was identified in 11 autopsy patients and in 4 of 7 brain biopsies. Infectious processes including HIV encephalitis were seen in 10 of 11 autopsied patients with lymphoproliferative lesions in the brain parenchyma, while 40% of patients without lymphoma had HIV-type MNGC or opportunistic infections. CNS lymphoma was not significantly increased in incidence in patients with a clinical history of zidovudine treatment, but increased duration of survival after the diagnosis of AIDS was associated with increased incidence of lymphoma in both untreated and zidovudine-treated patients. Patients displaying HIV MNGC within microglial nodules had a shorter mean duration of survival after diagnosis of AIDS than those patients with HIV encephalitis with dispersed MNGC, white matter vacuolation, and gliosis.

Progressive multifocal leukoencephalopathy in a heart transplant recipient following rituximab therapy for antibody-mediated rejection

We report the case of a male heart transplant recipient who developed acute antibody-mediated rejection and was treated with 5 weeks of a rituximab-containing regimen. Two months later he presented with progressive motor and cognitive impairments and was diagnosed with progressive multifocal leukoencephalopathy (PML). He was treated with reduction of his immunosuppressive medications, mirtazapine, IVIG and plasmapheresis. He died within weeks. We reviewed the current literature on PML and its association with immunosuppression, highlighting its impact in the setting of solid organ transplantation and considering the potential effect of newer biologic drugs on the incidence of this devastating disease in the transplant population.

Increased program cell death-1 expression on T lymphocytes of patients with progressive multifocal leukoencephalopathy

The cellullar immune response is important in the containment of progressive multifocal leukoencephalopathy (PML). We examined program cell death-1 (PD-1) expression, a marker of cellular immune exhaustion, on T lymphocytes in PML. PD-1 expression was elevated on total CD4(+) and CD8(+) T cells (medians 36% and 24%) in PML patients compared with healthy control subjects (medians 14% and 18%; P = 0.0015 and P = 0.033). In PML patients, JC virus (JCV)-specific CD8(+) cytotoxic T lymphocytes expressed PD-1 more frequently than total CD8 T lymphocytes (means 39% and 78%, P = 0.0004). Blocking the PD-1 receptor increased JCV-specific T-cell immune response in a subgroup of PML patients.

Aspergillus endocarditis: a case of near complete left ventricular outflow obstruction

A 60-year old woman presented with dyspnoea and fatigue. She was frail and cachectic (BMI 17.5) with a pancytopenia. Previously she had received chemotherapy for chronic lymphatic leukaemia. She relapsed one year ago necessitating a reduced intensity conditioning allogeneic haematopoietic cell transplantation. Subsequently, graft versus host disease required high-dose immunosuppressants. Computerized tomography on admission showed bilateral lung nodules and a suspicious cardiac mass. Bronchial biopsies demonstrated abundant hypae consistent with Aspergillus fumigatus infection. Echocardiography demonstrated a large fungus ball attached to the right coronary cusp of the aortic valve with near complete obliteration of the left ventricular outflow tract. Due to the high risk of embolization this was resected under cardiopulmonary bypass. The mass was attached subvalvularly to the ventricular septal free wall and eroding through it. It peeled off leaving intact aortic leaflets. Unresectable fungal deposits were discovered on the interventricular septum, the left ventricle free wall and posterior aortic wall. High-dose systemic antifungal therapy (Voriconazole and Amphoteracin B) was given for 4 months. After discharge she remained well till a 4-month follow-up, after which she eventually succumbed to her disease. We discuss the clinical difficulties in managing patients with fungal infective endocarditis and present a brief review of cardiac aspergillosis management.

Neuropathology of AIDS: An Autopsy Review of 284 Cases from Brazil Comparing the Findings Pre- and Post-HAART (Highly Active Antiretroviral Therapy) and Pre- and Postmortem Correlation

A retrospective study of central nervous system (CNS) in 284 autopsy AIDS cases in Brazil (1989–2008) divided into 3 groups: A (without antiretroviral treatment: 163 cases); B (other antiretroviral therapies: 76 cases); C (HAART for 3 months or more: 45 cases). In 165 (58.1%) cases, relevant lesions were found, predominantly infections (54.2%); the most frequent was toxoplasmosis (29.9%) followed by cryptococcosis (15.8%), purulent bacterial infections (3.9%), and HIV encephalitis (2.8%); non-Hodgkin lymphomas occurred in 1.4% and vascular lesions in 1.1%. There was no difference when compared the frequency of lesion among the groups; however, toxoplasmosis was less common while HIV encephalitis was more frequent in group C related to A. CNS lesions remain a frequent cause of death in AIDS; however, the mean survival time was four times greater in group C than in A. In 91 (55.1%) of 165 cases with relevant brain lesions (or 32% of the total 284 cases), there was discordance between pre- and postmortem diagnosis; disagreement type 1 (important disease that if diagnosed in life could change the patient prognosis) occurred in 49 (53.8%) of 91 discordant cases (17.6% of the total 284) indicating the autopsy importance, even with HAART and advanced diagnostics technologies.

Emerging roles of pathogens in Alzheimer disease

Chronic spirochetal infection can cause slowly progressive dementia, cortical atrophy and amyloid deposition in the atrophic form of general paresis. There is a significant association between Alzheimer disease (AD) and various types of spirochete (including the periodontal pathogen Treponemas and Borrelia burgdorferi), and other pathogens such as Chlamydophyla pneumoniae and herpes simplex virus type-1 (HSV-1). Exposure of mammalian neuronal and glial cells and organotypic cultures to spirochetes reproduces the biological and pathological hallmarks of AD. Senile-plaque-like beta amyloid (Aβ) deposits are also observed in mice following inhalation of C. pneumoniae in vivo, and Aβ accumulation and phosphorylation of tau is induced in neurons by HSV-1 in vitro and in vivo. Specific bacterial ligands, and bacterial and viral DNA and RNA all increase the expression of proinflammatory molecules, which activates the innate and adaptive immune systems. Evasion of pathogens from destruction by the host immune reactions leads to persistent infection, chronic inflammation, neuronal destruction and Aβ deposition. Aβ has been shown to be a pore-forming antimicrobial peptide, indicating that Aβ accumulation might be a response to infection. Global attention and action is needed to support this emerging field of research because dementia might be prevented by combined antibiotic, antiviral and anti-inflammatory therapy.

JC virus infection of the brain

Since its initial description, there have been significant changes in the epidemiology, pathogenesis, and clinical and imaging manifestations of JCV infection of brain. The most common clinical manifestation is PML. Other recently described CNS manifestations are JCE, JCVGCN, and JCM. Although AIDS is the most common predisposing factor for JCV reactivation, there is increasing incidence of brain manifestations of JCV reactivation in non-HIV settings, including different rheumatologic, hematologic, and oncologic conditions; monoclonal antibody therapy; transplant recipients; primary immunodeficiency syndromes; and even in patients without any recognizable immune deficiency. IRIS may develop secondary to restoration of immunity in HIV-positive patients with PML receiving antiretroviral therapy. This is of profound clinical significance and needs to be diagnosed promptly. Imaging plays a crucial role in the diagnosis of the disease, monitoring of treatment response, identifying disease progression, and predicting prognosis. In this article, current understanding of the epidemiology, pathogenesis, clinical presentations, and all aspects of imaging of JCV infection of the brain have been comprehensively reviewed.

Progressive multifocal leukoencephalopathy in HIV-1 infection

Progressive multifocal leukoencephalopathy is caused by the JC polyomavirus (JCV) and is one of the most feared complications of HIV-1 infection. Unlike other opportunistic infections, this disease can present when CD4 counts are higher than those associated with AIDS and when patients are receiving combined antiretroviral therapy, either shortly after starting or, more rarely, during long term successful treatment. Clinical suspicion of the disease is typically when MRI shows focal neurological deficits and associated demyelinating lesions; however, the identification of JCV in cerebrospinal fluid or brain tissue is needed for a definitive diagnosis. Although no specific treatment exists, the reversal of immunosuppression by combined antiretroviral therapy leads to clinical and MRI stabilisation in 50-60% of patients with the disease, and JCV clearance from cerebrospinal fluid. A substantial proportion of patients treated with combined antiretroviral therapy develop inflammatory lesions, which can be associated with either a favourable outcome or clinical worsening. The reasons for variability in the natural history of progressive multifocal leukoencephalopathy and treatment responses are largely undefined, and more specific and rational approaches to management are needed.

Cytomegalovirus retinitis: the neglected disease of the AIDS pandemic

The authors describe CMV retinitis in resource-poor settings and suggest possibilities for management.

Neuropathologic contributions to understanding AIDS and the central nervous system

This historical review describes the evolution of the pathogenetic concepts associated with infection by the Human Immunodeficiency Virus (HIV), with emphasis on the pathology of the nervous system. Although the first descriptions of damage to the nervous system in the acquired immunodeficiency syndrome (AIDS) only appeared in 1982, the dramatic diffusion of the epidemic worldwide and the invariably rapidly fatal outcome of the disease, before the introduction of efficient treatment, generated from the beginning an enormous amount of research with rethinking on a number of pathogenetic concepts. Less than 25 years after the first autopsy series of AIDS patients were published and the virus responsible for AIDS was identified, satisfactory definition and classification of a number of neuropathological complications of HIV infection have been established, leading to accurate clinical radiological and biological diagnosis of the main neurological complications of the disease, which remain a major cause of disability and death in AIDS patients. Clinical and experimental studies have provided essential insight into the pathogenesis of CNS lesions and natural history of the disease. The relatively recent introduction of highly active antiretroviral therapy (HAART) in 1995-1996 has dramatically improved the course and prognosis of HIV disease. However, there remain a number of unsolved pathogenetic issues, the most puzzling of which remains the precise mechanism of neuronal damage underlying the specific HIV-related cognitive disorders (HIV dementia). In addition, although HAART has changed the course of neurological complications of HIV infection, new issues have emerged such as the lack of improvement or even paradoxical deterioration of the neurological status in treated patients. Interpretation of these latter data remains largely speculative partly because of the small number of neuropathological studies related to the beneficial consequence of this treatment.

Transforming growth factor beta and monocyte chemotactic protein-1 are elevated in cerebrospinal fluid of immunocompromised patients with HIV-1 infection

Monocyte infiltration of the brain is central to the pathogenesis of HIV-1 encephalitis. The cytokines promoting recruitment of monocytes into the central nervous system during HIV-1 infection are not established. In this study, we evaluated human cerebrospinal fluid from patients with HIV-1 infection for transforming growth factor beta1 (TGFbeta1) and monocyte chemotactic protein-1 (MCP-1) using a quantitative sandwich enzyme-linked immunoassays. Cytokine levels were compared to those from patients with multiple sclerosis and normal controls. In cerebrospinal fluid of patients with HIV-1 infection and CD4<500 cells/mm3, both TGFbeta1 and MCP-1 were significantly elevated compared to those with CD4>500 cells/mm3, multiple sclerosis, and controls.

Neuropathology of human immunodeficiency virus infection: a forensic autopsy study in Dar Es Salaam, Tanzania

The objective of this study was to examine the neuropathological changes in the brain of patients infected with human immunodeficiency virus (HIV) in the Tanzanian capital Dar Es Salaam, and investigate whether the prevalence of different forms of HIV-related neuropathology varies from other countries. The subjects were patients with risk factors for HIV infection in whom forensic autopsies were performed between 1997 and 1999. In Dar Es Salaam, forensic autopsy constitutes more than 90% of all autopsies, because hospital autopsy is limited due to socio-cultural and religious reasons. HIV infection was identified in 52 of 143 patients selected from forensic autopsies. Neuropathological findings were observed in 31 of 52 HIV-infected patients; these include lymphocytic meningitis 19, bacterial meningitis 3, tuberculous brain abscess 3, cryptococcal meningitis 3, basal ganglia calcification 3, and toxoplasma encephalitis 1. HIV encephalitis, lymphoma, and cytomegalovirus encephalitis could not be found in this study. Whereas the findings should be interpreted cautiously because of possible autopsy bias and a low percentage of cases examined compared to the total number of HIV-infected patients in Tanzania, our observations provide information on the likely diagnostic possibilities to be considered in the evaluation and management of HIV-infected patients with neurological symptoms in Tanzania. In the face of decreased hospital autopsy, most studies have focused mainly on the end-stage HIV disease; forensic autopsy is a potential source of materials for studies on HIV disease spectrum at different stages.

AIDS-related progressive multifocal leukoencephalopathy in the era of HAART: report of two cases and review of the literature

Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system. It is caused by the JC virus (JCV), a human polyomavirus replicating in human glial cells. PML is the result of the reactivation of latent JCV infection that usually occurs in the setting of cellular immunodeficiencies such as HIV-1 infection. Epidemiologic data suggest that the impact of highly active antiretroviral therapy (HAART) on the incidence of PML is less profound than seen with other opportunistic infections. Given the lack of an effective and specific therapy for PML, HAART remains the only therapeutic option in patients with PML. However, a significant number of cases appear unresponsive to antiretroviral therapy. Moreover, there is growing data on unexpected inflammatory cases of PML after initiation of HAART. Thus, PML will remain a relevant cause of morbidity and mortality in HIV- 1-infected patients. Here we report two cases of PML, along with a concise review of the literature on this important disease.

Cardiac Aspergillosis in Patients With Acquired Immunodeficiency Syndrome: A Case Report and Review of the Literature

Cardiac aspergillosis is uncommon in patients with acquired immunodeficiency syndrome (AIDS) in the absence of open heart surgery. We report a unique case of a 62-year-old man with AIDS who developed Aspergillus pancarditis with Aspergillus vegetations on mitral valve without evidence of pulmonary aspergillosis. There was extensive embolization to the brain and multiple foci of Aspergillus infection in kidneys and adrenal glands. There are only 10 documented cases of cardiac aspergillosis in the literature (1966–2003) in severely immunocompromised AIDS patients with CD4 T-lymphocyte counts ranging from 10 to 121 cells/μL. The cardiac aspergillosis could result from invasive pulmonary aspergillosis, either by hematogenous dissemination or by direct invasion, and skin Aspergillus infection can be carried through the bloodstream to the right heart in intravenous drug abusers. Most of the reported cases of cardiac aspergillosis were diagnosed at autopsy. Mortality among AIDS patients with cardiac aspergillosis is 100%, despite appropriate therapy.

HIV-1/AIDS neuropathology in a Canadian teaching centre

BACKGROUND

The nervous system is a major target of HIV-1 infection and site of many complications of AIDS. Most of our knowledge pertaining to the range and frequency of neuropathology in HIV-1/AIDS is from large centres outside Canada in different social and health care settings. The goal of the present study was to describe HIV-1/AIDS-associated neuropathology before and during the era of highly active antiretroviral therapy at a Canadian teaching centre.

METHODS

The records of the Department of Pathology, London Health Sciences Centre were electronically searched for cases of HIV-1/AIDS that came to postmortem examination since 1985. The clinical records and pathological materials were reviewed.

RESULTS

Sixteen autopsies of HIV-1/AIDS were identified. All patients were male. Fourteen contracted HIV-1 through high risk homosexual activity, one through the transfusion of blood products and one through intravenous drug use. Three patients (19%) had pre-mortem evidence of HIV-1 associated dementia. At autopsy, 12 of the 16 cases had neuropathological findings and the most common diagnoses were HIV-1 encephalitis, progressive multifocal leukoencephalopathy, toxoplasmosis, and primary CNS lymphoma.

CONCLUSIONS

High risk homosexual activity was a more prominent factor in acquiring AIDS in cases coming to postmortem examination compared with previous reports from most larger urban centres outside Canada where injection drug use and high risk heterosexual activity factored prominently. The incidence of HIV-1 associated dementia was similar to that reported previously. This study confirms the heavy burden and wide spectrum of disease experienced by the nervous system in HIV-1/AIDS.

JC virus-induced changes in cellular gene expression in primary human astrocytes

Cell-type-specific transcription of the JC virus (JCV) promoter in glial cells initiates a series of events leading to viral replication in the brain and the development of the fatal demyelinating disease progressive multifocal leukoencephalopathy (PML) in patients with neurologic complications due to infection with human immunodeficiency virus type 1. Here we employed an in vitro infection of primary cultures of human astrocytes to compare the transcriptional profile of cellular genes after JCV infection by using an oligonucleotide-based microarray of 12600 genes. Transcription of nearly 355 genes was enhanced and expression of 130 genes was decreased to various degrees. Many transcripts that were increased upon JCV infection were found to encode proteins with properties that suggest their involvement in cell proliferation, including cyclin A and cyclin B1; signaling pathways, such as transforming growth factor beta receptor 1, platelet-derived growth factor receptor and fibroblast growth factor family receptor; and other regulatory events, such as inflammatory responses, including cyclo-oxygenase-2 (Cox-2). Microarray-based data for several cell cycle-regulatory genes were further examined by using Western blot analysis of in vitro infected astrocytes harvested early and late during the infection. Results demonstrate that protein levels of all upregulated genes were found to increase at some point during the infection time course. In parallel, immunohistochemical assessment of cell cycle proteins, including cyclins A, B1, E, and Cdk2, showed positive staining of astrocytes within PML lesions of brain tissue from patients with neuro-AIDS. Microarray analysis was found to be a useful predictor of gene expression in infected cells; however, it may not directly correlate with protein levels during infection with JCV.

Neurologic consequences of HIV infection in the era of HAART

In this brief review, we present a summary of the clinical presentation of HIV-associated dementia (HAD), HAD in the highly active antiretroviral therapy (HAART) era, the immunopathogenesis of HAD, and the possible role of a recently described novel macrophage-derived protein in HAD. Different aspects of the clinical presentation of HAD will be reviewed as well as the results of recent autopsy studies demonstrating that although HAART dramatically decreased the incidence of opportunistic infections and malignancies in the central nervous system, it has reduced but not eliminated HIV encephalopathy. This suggests a direct cytopathic effect of HIV on neuronal tissue. Consequently, the immunopathogenesis of HAD and the role of neurotoxins produced by brain macrophages and microglial cells will be reviewed including the possible role of a recently cloned macrophage-derived proapoptotic factor, soluble HIV apoptotic protein (SHIVA) identified in our laboratory. HAART therapy reduces the incidence of opportunistic infections, the direct pathogenic effect of HIV, especially on neuronal tissue, may become of increasing importance.

Expression of the interferon-induced MxA protein in viral encephalitis

MxA protein accumulates cytoplasmically in response to interferon stimulation, and mediates resistance against several viruses. In order to test whether MxA may serve as a diagnostic tool for viral infections of the central nervous system (CNS), we performed MxA immunohistochemistry on biopsies and autopsies of 57 patients with neurological disorders of known viral and nonviral aetiology. MxA was detectable in all HIV patients with proven opportunistic viral encephalitis, in all patients suffering from isolated viral encephalitis, in one of three HIV patients with cerebral toxoplasmosis, and in one case of micronodular encephalitis. No MxA was detectable in HIV patients with isolated HIV encephalitis or HIV infection accompanied by an opportunistic nonviral disorder. We were unable to show MxA expression in a variety of nonviral inflammatory and noninflammatory disorders of the CNS. Several cases of Rasmussen's encephalitis and multiple sclerosis tested negative, arguing against their possible viral aetiology. Two-colour immunohistochemistry identified macrophages and activated microglia as MxA expressing cells. In all studied cases MxA expression was accompanied by a marked T-cell infiltrate. Therefore, the detection of MxA-protein is a sensitive adjuvant marker for those cases of viral encephalitis which are accompanied by pronounced lymphocytic infiltrates.

HIV-related neuropathology, 1985 to 1999: rising prevalence of HIV encephalopathy in the era of highly active antiretroviral therapy

Postmortem neuropathologic reports for a consecutive series of 436 HIV-seropositive patients who died between 1985 and 1999 were matched with clinical data for 371 of them. Cases were divided into four groups depending on the date of death. The chosen time periods reflected the type of antiretroviral therapy available: before 1987 (before zidovudine); 1987-1992, the period of monotherapy (nucleoside analog reverse transcriptase inhibitors [NRTIs]); 1993-1995, the era of the use of dual NRTI combinations; and 1996-1999, the era of highly active antiretroviral therapy (HAART) containing protease inhibitors. Fifty-seven percent of our cases in this group had been prescribed HAART. In our study population, accessibility to the latest antiretroviral therapy was widespread. The total number of HIV autopsies declined after the advent of combination therapy. The prevalence of opportunistic infections-cytomegalovirus, toxoplasmosis, cryptococcosis, and central nervous system lymphoma-decreased over time. Cerebral tuberculosis, aspergillosis, herpes, and progressive multifocal leukoencephalopathy showed a downward trend, but the numbers were too low for statistical analyses. The incidence of HIV encephalopathy increased over time (p =.014). The rising prevalence of HIV encephalopathy at time of death may reflect a longer survival time after initial HIV infection in the HAART era. Although combination therapies decrease overall mortality and prevalence of CNS opportunistic infections, these therapies may be less active in preventing direct HIV-1 effects on the brain.

Tissue microarrays in the study of non-neoplastic disease of the nervous system

Tissue microarrays (TMAs), also known as "tissue chips," are a recently developed method that allows small cores or discs of tissue from dozens or hundreds of (usually paraffin-embedded) specimens to be re-embedded in a tissue block, which can then be further sectioned. The tissue cores can subsequently be studied using any combination of techniques, including immunohistochemistry, in situ hybridization (ISH). fluorescence ISH, and in situ polymerase chain reaction (PCR). To date, the technique has found greatest use in the analysis of neoplasms, including gliomas. We describe, and provide examples of, how TMAs might be utilized in investigation of autopsy (or biopsy) tissues from individuals with non-neoplastic disease, especially to address questions that require systematic review of multiple (nearly) identical brain regions across dozens or hundreds of cases. Specific questions related to patterns of protein expression (e.g. tau, Abeta, alpha-synuclein) in multiple regions of large numbers of brain specimens (from patients with neurodegenerative diseases) can be efficiently examined using TMA technology. One possible use of TMAs in the area of infectious disease might be to examine patterns of HIV-related brain injury or AIDS-related opportunistic CNS infections in the epochs before and after highly active antiretroviral therapy came into widespread use.

Concomitant progressive multifocal leucoencephalopathy and primary central nervous system lymphoma expressing JC virus oncogenic protein, large T antigen

This report describes the concomitant occurrence of the JC virus (JCV) induced demyelinating disease progressive multifocal leucoencephalopathy (PML) and a primary central nervous system lymphoma (PCNS-L) in a patient with AIDS. Postmortem neuropathological examination revealed characteristic features of PML including multiple lesions of demyelination, enlarged oligodendrocytes with hyperchromatic nuclei (many containing eosinophilic intranuclear inclusions), and enlarged astrocytes with bizarre hyperchromatic nuclei. Immunohistochemical analysis demonstrated the expression of the JCV capsid protein VP-1 in the nuclei of infected oligodendrocytes and astrocytes. The PCNS-L lesion located in the basal ganglia was highly cellular, distributed perivascularly, and consisted of large atypical plasmacytoid lymphocytes. Immunohistochemical examination of this neoplasm identified it to be of B cell origin. Moreover, expression of the JCV oncogenic protein, T antigen, was detected in the nuclei of the neoplastic lymphocytes. This study provides the first evidence for a possible association between JCV and PCNS-L.

Cytologic detection of Toxoplasma gondii tachyzoites in cerebrospinal fluid

We reviewed our case records to see how often Toxoplasma gondii organisms were identified by cytologic evaluation of cerebrospinal fluid (CSF). During a 12-year period, 6,090 CSF specimens were examined, and 2 cases (0.03%) showed tachyzoites. Both patients were immunocompromised. One patient underwent lumbar and ventricular taps, and the other underwent only ventricular tap. Organisms were identified in the ventricular specimens but not in the lumbar sample. Both patients were treated, and subsequent ventricular CSF samples were negative. Toxoplasma gondii can be identified by cytologic examination of CSF. Our results confirm prior observations that in patients with obstructive hydrocephalus, tachyzoites are more likely to be found in ventricular rather than lumbar specimens.

Protease inhibitor-induced carbamazepine toxicity

Neurologic manifestations of HIV infection are quite diverse and can develop into seizures. Because new drug therapies have been developed, it is important to know the interactions between antiretroviral and antiepileptic agents. A 36-year-old patient with HIV developed a set of progressive left hemiparesis and secondarily generalized partial seizures related to progressive multifocal leukoencephalopathy. Phenytoin and carbamazepine were necessary to control the seizures. Instead of diverse antiretroviral therapies, the viral load was increased. Protease inhibitors (ritonavir and saquinavir) were added to the treatment and the patient developed progressive ataxia related to carbamazepine toxicity. Carbamazepine was discontinued and the patient remained asymptomatic. The patient was diagnosed with carbamazepine toxicity related to the introduction of ritonavir. Ritonavir is a potent inhibitor of hepatic cytochrome P450, mainly the CYP3A4 isoform. Carbamazepine is metabolized by this subsystem. Ritonavir acted as a CYP3A4 inhibitor, diminishing carbamazepine metabolism and provoking an increase in serum levels and clinical toxicity. We present a case of interaction between ritonavir and carbamazepine. Interaction between antiepileptic and antiretroviral agents is an emergent problem caused by the increasing association of the two therapies. We recommend strict monitoring of serum antiepileptic drug (AED) levels to avoid toxicity and inadequate seizure control.