Neurologic Complications of Hepatitis C

Exploring Stroke Risk Factors and Outcomes in Sexual and Gender Minority People

Background and Objectives

Cerebrovascular disease in sexual and gender minority (SGM) people remains poorly understood. Our primary objective was to describe the epidemiology and outcomes in a sample of SGM people with stroke. As a secondary objective, we compared this group with non-SGM people with stroke to assess for significant differences in risk factors or outcomes.

Methods

This was a retrospective chart review study of SGM people admitted to an urban stroke center with primary diagnosis of stroke (ischemic or hemorrhagic). We evaluated stroke epidemiology and outcomes, summarizing with descriptive statistics. We then matched 1 SGM person to 3 non-SGM people by year of birth and year of diagnosis to compare demographics, risk factors, inpatient stroke metrics, and outcomes.

Results

A total of 26 SGM people were included in the analysis: 20 (77%) had ischemic strokes, 5 (19%) intracerebral hemorrhages, and 1 (4%) subarachnoid hemorrhage. Compared with non-SGM people (n = 78), stroke subtypes showed a similar distribution (64 (82%) ischemic strokes, 12 (15%) intracerebral hemorrhages, 1 (1%) subarachnoid hemorrhage, and 1 nontraumatic subdural hematoma, p > 0.05) but suspected ischemic stroke mechanisms had a different distribution (χ² = 17.56, p = 0.01). Traditional stroke risk factors were similar between the 2 groups. The SGM group seemed to have higher rates of nontraditional stroke factors, including HIV (31% vs 0%, p < 0.01), syphilis (19% vs 0%, p < 0.01), and hepatitis C (15% vs 5%, p < 0.01) but were more likely to be tested for these risk factors (χ² = 15.80, p < 0.01; χ² = 11.65, p < 0.01; χ² = 7.83, p < 0.01, respectively). SGM people were more likely to have recurrent strokes (χ² = 4.39, p < 0.04) despite similar follow-up rates.

Discussion

SGM people may have different risk factors, different mechanisms of stroke, and higher risk of recurrent stroke compared with non-SGM people. Standardized collection of sexual orientation and gender identity would enable larger studies to further understand disparities, leading to secondary prevention strategies.

Refractory Mononeuritis Multiplex Due to Hepatitis C Infection and Cryoglobulinemia: Efficient Response to Rituximab

BACKGROUND

Mononeuritis multiplex due to hepatitis C infection and cryoglobulinemia has no specific treatment guidelines. Despite the favorable evolution of the liver disease after treatment with interferon and ribavirin, neurological symptoms might not respond very efficiently to antiviral therapy.

CASE REPORT

We report the case of a 50-year-old woman, with a mononeuritis multiplex related to cryoglobulinemia and hepatitis C virus infection, who was treated with rituximab. Hepatitis C virus infection was treated successfully with interferon-α and ribavirin, but the neurological symptoms were still worsening until rituximab therapy. Significant improvement of paraparesis and painful hypoesthesia were evident after the fourth infusion of rituximab. However, every 6 months, the neurological symptoms relapsed and the patient was subjected to a new cycle of rituximab therapy, with the disappearing of the paraparesis and hypoesthesias.

CONCLUSIONS

This case highlights the potential use of rituximab in immune-mediated neuropathies, especially the mononeuritis multiplex associated with hepatitis C infection.

Longstanding spastic paraparesis in a patient infected with hepatitis C virus and seropositive for aquaporin-4 antibody - Case report and review of the literature

Nervous system involvement in Hepatitis C virus infection (HCV) has been associated to neuro-immunological deregulation, particularly in interferon-alpha treated patients. We present a case of optic and brainstem demyelinating disorder associated with aquaporin-4 (AQP4) antibodies. A 48 year-old woman, with previous diagnosis of non-treated hepatitis C, presented with a 10-year history of long-standing gait disturbance. Neurological examination disclosed a grade 4 spastic paraparesis, lower limb hyperreflexia, right positive Hoffmann sign, bilateral Babinski sign and spastic gait only possible with bilateral support. Spinal cord magnetic resonance imaging (MRI) was normal. Brain MRI showed an asymmetric, bilateral pontine and left mesencephalic hypersignal in T2 and FLAIR, with no gadolinium enhancement. Visual evoked potential revealed bilateral pre-chiasmatic conduction delay. Blood tests showed a positive anti-HCV antibody and a positive AQP4 antibody. Cerebrospinal fluid (CSF) analysis was normal, with no oligoclonal bands. The patient started intravenous (IV) methylprednisolone followed by oral prednisolone; simultaneously, interferon-alpha and ribavirin. There was a slight clinical improvement within the first weeks. There are 7 cases describing association between HCV infection and central nervous system (CNS) demyelination with positive AQP4 antibody, 4 patients under interferon-α. AQP4 antibodies should be tested in patients infected with HCV and CNS demyelination.

Frailty and Pre-Frailty in a Contemporary Cohort of HIV-Infected Adults

OBJECTIVES

To determine the prevalence of pre-frailty among HIV-infected persons and associations with pre-frailty and frailty in this population.

DESIGN, SETTING AND PARTICIPANTS

From a contemporary, prospective observational cohort of HIV-infected persons (SUN Study), we determined, using a cross-sectional analytic study design, the proportions of non-frail, pre-frail, and frail persons by the respective presence of 0, 1-2, and ≥ 3 of 5 established frailty criteria: unintentional weight loss, exhaustion, physical-inactivity, weak-grip and slow-walk. We evaluated associations with pre-frailty/frailty using multivariate analysis.

RESULTS

Of 322 participants assessed (79% men, 58% white non-Hispanic, median age 47 years, 95% on combination antiretroviral therapy [cART], median CD4 + cell count 641 cells/mm3 and 93% HIV RNA < 400 copies/mL), 57% were non-frail, 38% pre-frail, and 5% frail. Age increased from non-frailty through frailty. Notably, however, half of pre-frail and frail participants were < 50 years, and of those, 42% and 100%, respectively, were long-term unemployed (versus 16% of non-frail counterparts). In multivariate analysis, pre-frail/frail participants were more likely to have Hepatitis C seropositivity (adjusted odds ratio [aOR] 3.24, 95% CI: 1.35-7.78), a history of AIDS-defining-illness (aOR 3.51, 95% CI: 1.82-6.76), greater depressive symptoms (aOR 1.16, 95% CI:1.09-1.23), higher D-dimer levels (aOR 2.94, 95% CI:1.10-7.87), and were less likely to be white non-Hispanic (aOR 0.35, 95% CI: 0.20-0.61).

CONCLUSIONS

Pre-frailty and frailty are prevalent in the cART era and are associated with unemployment even among persons < 50 years. Pre-frailty appears to be an intermediate state in the spectrum from non-frailty through frailty and our characterization of pre-frailty/frailty suggests complex multifactorial associations.

Tumefactive multiple sclerosis and hepatitis C virus 2a/2C infection: Dual benefit of long-term interferon beta-1a therapy?

Hepatitis C virus (HCV) infection has been implicated in triggering acute disseminated encephalomyelitis but not tumefactive multiple sclerosis. We report the case of a 17-year-old female who presented with a 5-day history of left hemiparesis and hemisensory loss followed by a right third nerve palsy. Tumefactive multiple sclerosis was diagnosed based on the absence of encephalopathic signs, the presence of tumefactive brain lesions, the exclusion of neoplastic and infectious causes of the lesions by biopsy, and the occurrence of relapse after a period of remission. The patient was at risk for HCV infection due to parenteral drug abuse and multiple sexual partners. Serial HCV antibody tests and RNA polymerase chain reaction assays revealed acute HCV infection and genotyping showed HCV genotype 2a/2c. She was treated with high-dose methylprednisolone and discharged with only mild left hand weakness. Interferon beta-1a 30mcg was administered intramuscularly once a week. Remission from HCV infection was achieved in three years without standard anti-HCV therapy. This case suggests that CNS myelin is a potential target of the immune response to HCV 2a/2c infection, the HCV 2a/2c virus may be involved in triggering autoimmune tumefactive brain lesions, and interferon beta-1a is effective against HCV 2a/2c infection. We recommend serial HCV antibody testing and HCV RNA PCR assay, preferably with HCV genotyping, in all patients with acute inflammatory demyelinating diseases of the CNS.

Treatment for cryoglobulinemic and non-cryoglobulinemic peripheral neuropathy associated with hepatitis C virus infection

BACKGROUND

Peripheral neuropathy is the most common neurologic complication of hepatitis C virus (HCV) infection. The pathophysiology of the neuropathy associated with HCV is not definitively known; however, proposed mechanisms include cryoglobulin deposition in the vasa nervorum and HCV-mediated vasculitis. The optimal treatment for HCV-related peripheral neuropathy has not been established.

OBJECTIVES

To assess the effects of interventions (including interferon alfa, interferon alfa plus ribavirin, corticosteroids, cyclophosphamide, plasma exchange, and rituximab) for cryoglobulinemic or non-cryoglobulinemic peripheral neuropathy associated with HCV infection.

SEARCH METHODS

On 26 August 2014, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, and EMBASE. We also searched two trials registers, the Networked Digital Library of Theses and Dissertations (NDLTD) (October 2014), and three other databases. We checked references in identified trials and requested information from trial authors to identify any additional published or unpublished data.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) and quasi-RCTs involving participants with cryoglobulinemic or non-cryoglobulinemic peripheral neuropathy associated with HCV infection. We considered any intervention (including interferon alfa, interferon alfa plus ribavirin, corticosteroids, cyclophosphamide, plasma exchange, and rituximab) alone or in combination versus placebo or another intervention ('head-to-head' comparison study design) evaluated after a minimum interval to follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration. The planned primary outcome was change in sensory impairment (using any validated sensory neuropathy scale or quantitative sensory testing) at the end of the follow-up period.  Other planned outcomes were: change in impairment (any validated combined sensory and motor neuropathy scale), change in disability (any validated disability scale), electrodiagnostic measures, number of participants with improved symptoms of neuropathy (global impression of change), and severe adverse events.

MAIN RESULTS

Four trials of HCV-related cryoglobulinemia fulfiled selection criteria and the review authors included three in quantitative synthesis. All studies were at high risk of bias. No trial addressed the primary outcome of change in sensory impairment. No trial addressed secondary outcomes of change in combined sensory and motor impairment, disability, or electrodiagnostic measures. A single trial of HCV-related mixed cryoglobulinemia treated with pegylated interferon alfa (peginterferon alfa), ribavirin, and rituximab versus peginterferon alfa and ribavirin did not show a significant difference in the number of participants with improvement in neuropathy at 36 months post treatment (risk ratio (RR) 4.00, 95% confidence interval (CI) 0.27 to 59.31, n = 9). One study of interferon alfa (n = 22) and two studies of rituximab (n = 61) provided adverse event data. Severe adverse events were no more common with interferon alfa (RR 7.00, 95% CI 0.38 to 128.02) or rituximab (RR 3.00, 95% CI 0.13 to 67.06) compared to the control group.

AUTHORS' CONCLUSIONS

There is a lack of RCTs and quasi-RCTs addressing the effects of interventions for peripheral neuropathy associated with HCV infection. At present, there is insufficient evidence from RCTs and quasi-RCTs to make evidence-based decisions about treatment.

Neurologic manifestations of acute and chronic liver disease

PURPOSE OF REVIEW

This article summarizes the most common neurologic sequelae of acute and chronic liver failure, liver transplantation, and other treatments for liver disease, and outlines the pathogenesis, neurologic manifestations, and treatment of Wilson disease.

RECENT FINDINGS

The neurologic manifestations of liver disease are caused by the liver's failure to detoxify active compounds that have deleterious effects on the central and peripheral nervous systems. In addition, treatments for liver disease such as liver transplantation, transjugular intrahepatic portosystemic shunt, and antiviral medications can also be neurotoxic. Wilson disease affects the liver and nervous system simultaneously and may often initially be diagnosed by a neurologist; treatment options have evolved over recent years.

SUMMARY

Acute and chronic liver diseases are encountered commonly in the general population. Neurologic dysfunction will eventually affect a significant number of these individuals, especially if the disease progresses to liver failure. Early recognition of these neurologic manifestations can lead to more effective management of these patients.

Clinical assessment of the sensory ataxias; diagnostic algorithm with illustrative cases

Ataxia is a common neurological syndrome resulting from cerebellar, vestibular or sensory disorders. The recognition and characterisation of sensory ataxia remains a challenge. Cerebellar ataxia is the more common and easier to identify; sensory ataxia is often mistaken for cerebellar ataxia, leading to diagnostic errors and delays. A coherent aetiological work-up is only possible if clinicians initially recognise sensory ataxia. We discuss ways to separate sensory from cerebellar ataxia, the causes of sensory ataxia and the clinico-neurophysiological syndromes causing the sensory ataxia syndromes. We summarise a logical tiered approach as a diagnostic algorithm.

Hepatitis C virus-associated neuropathy accompanied by eosinophilic vasculitis and granuloma formation

We herein report the case of a patient with hepatitis C virus (HCV)-associated neuropathy with atypical pathological findings of a biopsied sural nerve. A 48-year-old man was admitted for a gait disturbance. Purpura and edema on the legs and hyperalgesia on the distal extremities were noted. The plasma HCV viral load was high, and cryoglobulin was positive. In the biopsied sural nerve, perivascular eosinophilic infiltration was associated with extravascular granuloma formation in the epineurium. The patient's symptoms disappeared following treatment with interferon-α and ribavirin. The present case suggests that HCV infection can lead to peripheral neuropathy associated with eosinophilic infiltration and granuloma formation.

Central nervous system vasculitis associated with hepatitis C virus infection: a brain MRI-supported diagnosis

BACKGROUND

The Hepatitis C virus (HCV) infection is associated with various extrahepatic manifestations, being the Central Nervous System (CNS) rarely involved.

CASE REPORT

We report a case of a 54 year-old black man with arterial hypertension who presented with progressively worsening headaches, apathy, somnolence and left hemiparesis. Brain MRI showed an acute ischemic lesion in the left anterior cerebral artery (ACA) and an old ischemic infarct in the right ACA territory. Brain MRI with gadolinium revealed mural thickening and contrast enhancement of the A1 and A2 segments of the ACAs, of the middle and distal basilar artery and of the P1 segment of the left posterior cerebral artery, suggesting active vasculitis. Digital angiography confirmed those irregularities and stenosis. Laboratory evaluation revealed ESR (73 mm/h), transaminase elevation, elevated HCV viral load genotype 2, positive IGRA, negative cryoglobulins, CSF protein elevation with oligoclonal bands (mirror pattern) and no pleocytosis; investigation excluded other infectious causes. Pegylated interferon alpha-2a and ribavirin, corticotherapy and tuberculosis prophylaxis were started with clinical and imagiological improvement.

CONCLUSION

The typical inflammation signs of the vascular wall demonstrated by the gadolinium-enhanced MRI strengthened the hypothesis of CNS vasculitis. The association with HCV infection is rare but should be investigated once specific therapeutic is required.

Neurological complications of hepatitis C infection

Though well-known as a cause of liver disease, Hepatitis C virus infection is emerging as a cause of a variety of peripheral and central nervous system disorders. The virus causes chronic persistent infection with complex immune responses in the majority of individuals. Viral infection may have the potential to generate neurological illness through direct infection of neural cells or through immune-mediated mechanisms, including enhancement of autoimmune responses. Moreover, the mainstay of antiviral treatment of hepatitis C infection, interferon-alpha, is itself associated with neurological morbidity. Thus neurologists are increasingly faced with diagnosing or even predicting a wide spectrum of neurological complications of hepatitis C infection and/or its treatment.

Infectious neuropathies

PURPOSE OF REVIEW

The purpose of this review is to address bacterial, viral, and other infectious causes of neuropathy or neuronopathy, with an emphasis on clinical manifestations and treatment.

RECENT FINDINGS

Most infectious neuropathies have been well described for some time and treatments are well established. An exception is HIV-associated distal symmetric polyneuropathy, which is an area of active research. Current work in this area focuses on epidemiology, risk factors, and underlying mechanisms.

SUMMARY

Infectious diseases are an important part of the differential diagnosis of peripheral nerve disorders because they are among the most amenable to treatment. However, diagnosis of infectious peripheral neuropathy may be challenging because of variability in a number of factors, including the pattern of deficits, geographic distribution of pathogens, length of time from the onset of infection to the development of neuropathy, and mechanism of nerve injury.

Effects of hepatitis C and HIV on cognition in women: data from the Women's Interagency HIV Study

OBJECTIVE

To compare neuropsychological scores in women infected with HIV, women infected with both HIV and hepatitis C, and uninfected subjects.

BACKGROUND

Some, but not all, studies have demonstrated that dual infection with Hepatitis C virus (HCV) and HIV has worse effects on cognition than infection with HIV alone.

DESIGN/METHODS

The Women's Interagency HIV Study is an ongoing prospective study of the natural history of HIV in women where participants are reevaluated every 6 months. In a cross-sectional analysis, we evaluated the effects of active HIV and HCV infections on scores on symbol-digit modalities test, the Stroop interference test, and trails A and B after controlling for age, ethnicity, education, depression, liver disease, and current or past substance abuse.

RESULTS

Data were available for 1338 women-17.8 % had detectable hepatitis C virus and 67% were HIV seropositive. In fully adjusted general linear models, HCV viremia was not associated with scores on any of the cognitive tests.

CONCLUSIONS

In this large sample of women, active HCV infection was not associated with scores on a small battery of neuropsychological tests.

Association of Bell's Palsy with Hepatitis E Virus Infection: A Rare Entity

Hepatitis E virus (HEV) infection is a common cause of acute hepatitis in India and other developing countries. The data regarding the neurologic manifestation of HEV infection are limited. The neurologic disorders including Guillain-Barré syndrome, polyradiculopathy, neuralgic amyotrophy, encephalitis, bilateral brachial neuritis, ataxia/proximal myopathy, and acute transverse myelitis have been described. Bell's palsy and other cranial nerve involvement in hepatitis A virus (HAV) and HEV infection are rare. We present the second case of Bell's palsy associated with HEV.

Restless legs syndrome--theoretical roles of inflammatory and immune mechanisms

Theories for restless legs syndrome (RLS) pathogenesis include iron deficiency, dopamine dysregulation and peripheral neuropathy. Increased prevalence of small intestinal bacterial overgrowth (SIBO) in controlled studies in RLS and case reports of post-infectious RLS suggest potential roles for inflammation and immunological alterations. A literature search for all conditions associated with RLS was performed. These included secondary RLS disorders and factors that may exacerbate RLS. All of these conditions were reviewed with respect to potential pathogenesis including reports of iron deficiency, neuropathy, SIBO, inflammation and immune changes. A condition was defined as highly-associated if there was a prevalence study that utilized an appropriate control group. Small case reports were recorded but not included as definite RLS-associated conditions. Fifty four diseases, syndromes and conditions have been reported to cause and/or exacerbate RLS. Of these, 38 have been reported to have a higher prevalence than age-matched controls, 9 have adequate sized reports and have general acceptance as RLS-associated conditions and 7 have been reported in case report form. Overall, 42 of the 47 RLS-associated conditions (89%) have also been associated with inflammatory and/or immune changes. In addition, 43% have been associated with peripheral iron deficiency, 40% with peripheral neuropathy and 32% with SIBO. Most of the remaining conditions have yet to be studied for these factors. The fact that 95% of the 38 highly-associated RLS conditions are also associated with inflammatory/immune changes suggests the possibility that RLS may be mediated or affected through these mechanisms. Inflammation can be responsible for iron deficiency and hypothetically could cause central nervous system iron deficiency-induced RLS. Alternatively, an immune reaction to gastrointestinal bacteria or other antigens may hypothetically cause RLS by a direct immunological attack on the central or peripheral nervous system.

A review of opioid prescribing practices and associations with repeat opioid prescriptions in a contemporary outpatient HIV clinic

OBJECTIVES

Among persons in current HIV outpatient care, data on opioid prescribing are lacking. This study aims to evaluate predictors of repeat opioid prescribing and to characterize outpatient opioid prescribing practices.

METHODS

Retrospective cross-sectional study of persons ≥18 years in HIV outpatient care who completed an annual behavioral assessment between June 2008 and June 2009. Persons were grouped by ≤1 and ≥2 opioid prescriptions (no-repeat-opioid and repeat-opioids, respectively). Independent predictors for repeat-opioids were evaluated. Opioid prescribing practices were characterized in a sub-study of persons prescribed any opioid.

RESULTS

Overall, 659 persons were included, median age 43 years, 70% men, and 68% African American. Independent predictors of repeat-opioids (88 [13%] persons) included opportunistic illnesses (both current and previous), depression, peripheral neuropathy, and hepatitis C coinfection (P<0.05). In the subgroup, 140 persons received any opioid prescription (96% short-acting, 33% tramadol). Indications for opioid prescribing were obtained in 101 (72%) persons, with 97% for noncancer-related pain symptoms. Therapeutic response was documented on follow-up in 67 (48%) persons, with no subjective relief of symptoms in 63%. Urine drug screens were requested in 6 (4%) persons, and all performed were positive for illicit drugs.

CONCLUSIONS

Advanced HIV disease and greater medical and neuropsychiatric comorbidity predict repeat opioid prescribing, and these findings reflect the underlying complexities in managing pain symptoms in this population. We also highlight multiple deficiencies in opioid prescribing practices and nonadherence to guidelines, which are of concern as effective and safe pain management for our HIV-infected population is an optimal goal.

Immune-mediated myelitis associated with hepatitis virus infections

Virus-induced spinal cord damage results from a cytolytic effect on anterior horn cells or from predominantly cellular immune-mediated damage of long white matter tracts. Infection with the hepatitis virus group, most notably hepatitis C virus, has infrequently been associated with the occurrence of myelitis. The pathogenesis of hepatitis virus-associated myelitis has not been clarified: virus-induced autoimmunity (humoral or cell-mediated, possibly vasculitic) seems the most likely disease mechanism. Limited available information offers no evidence of direct hepatitis virus infection of the spinal cord. Virus neuropenetration may occur after virus-infected mononuclear cells penetrate the blood-brain barrier, but a true neurolytic effect has not been demonstrated. Attacks of acute myelitis usually respond favorably to immunomodulatory therapy. Antiviral therapy plays no confirmed role in the treatment of acute bouts of myelitis, but may limit the relapsing course of HCV-associated myelitis.

Neurotoxic effects of the HCV core protein are mediated by sustained activation of ERK via TLR2 signaling

Hepatitis C virus (HCV) infection is a serious problem among those co-infected with human immunodeficiency virus; however, its impact in the central nervous system (CNS) remains unclear. This study aimed to investigate the mechanisms underlying HCV core protein-mediated neurodegeneration. Analysis of human HCV seropositive cases demonstrated widespread damage to neuronal dendritic processes and sustained activation of extracellular signal-related kinase (ERK); analogous pathologies were observed in wild type injected with HCV core protein into the hippocampus. In vitro analysis in neuronal cells exposed to HCV core demonstrated retraction of the neuronal processes in an ERK/Signal Transducer and Activator of Transcription 3 (STAT3)-dependent manner dependent on toll-like receptor 2 (TLR2) signaling activation. These results indicate that HCV core protein neurotoxicity may be mediated by the sustained activation of ERK/STAT3 via TLR2-IRAK1 signaling pathway. These pathways provide novel targets for development of neuroprotective treatments for HCV involvement of the CNS.

Anti-glutamic Acid decarboxylase antibody-associated ataxia as an extrahepatic autoimmune manifestation of hepatitis C infection: a case report

Extrahepatic immunological manifestations of hepatitis C virus (HCV) are well described. In addition, antiglutamic acid decarboxylase (GAD) antibody-associated cerebellar ataxia is well-established entity. However, there have been no reports in the literature of anti-GAD antibody-associated ataxia as an extrahepatic manifestation of HCV infection. We report the case of a young woman with chronic hepatitis C virus and multiple extrahepatic autoimmune diseases including Sjögren syndrome and pernicious anemia who presented with subacute midline cerebellar syndrome and was found to have positive antiglutamic acid decarboxylase (GAD) antibody in the serum and cerebrospinal fluid. An extensive diagnostic workup to rule out neoplastic growths was negative, suggesting the diagnosis of nonparaneoplastic antiglutamic acid decarboxylase antibody-associated cerebellar ataxia as an additional extrahepatic manifestation of hepatitis C virus infection. The patient failed to respond to high-dose steroids and intravenous immunoglobulin. Treatment with the monoclonal antibody rituximab stabilized the disease. We postulate that anti-GAD associated ataxia could be an extrahepatic manifestation of HCV infection.

[Achalasia in a patient with HIV/HCV coinfection: detection of HCV in the esophageal tissue]

Esophageal involvement in the context of opportunistic infections in human immunodeficiency virus (HIV) positive patients is a frequent phenomenon. However, worldwide esophageal achalasia has been described only twice in HIV-infected patients.We report the case of a 44-year-old Caucasian patient with HIV and Hepatitis C virus (HIV/HCV) coinfection who, within 2.5 years, displayed a progressive symptomatology with dysphagia, retrosternal pain, regurgitation as well as a considerable loss of weight before achalasia was finally diagnosed. Treatment was performed primarily surgically by means of laparoscopic Heller myotomy with an anterior 180° semifundoplication according to Dor.Histopathology of the specimens taken from the lower esophageal sphincter high-pressure zone proved alterations with abundant connective tissue and only scarce parts of the smooth muscular system without inflammatory infiltrations. In addition, the ganglia cells of the myenteric plexus as well as the interstitial cells of Cajal were significantly reduced. Interestingly, specific gene sequences of the hepatitis C virus could be detected in the esophageal tissue specimen. In contrast, analysis of specific HIV-gene sequences in the same tissue revealed a negative result.The possible but previously unknown relationship between esophageal achalasia and coinfection with HIV and HCV, also described as neurotropic viruses, will be discussed.

Acute canine distemper encephalitis is associated with rapid neuronal loss and local immune activation

For most virus infections of the central nervous system (CNS), immune-mediated damage, the route of inoculation and death of infected cells all contribute to the pathology observed. To investigate the role of these factors in early canine distemper neuropathogenesis, we infected ferrets either intranasally or intraperitoneally with the neurovirulent canine distemper virus strain Snyder Hill. Regardless of the route of inoculation, the virus primarily targeted the olfactory bulb, brainstem, hippocampus and cerebellum, whereas only occasional foci were detected in the cortex. The infection led to widespread neuronal loss, which correlated with the clinical signs observed. Increased numbers of activated microglia, reactive gliosis and different pro-inflammatory cytokines were detected in the infected areas, suggesting that the presence and ultimate death of infected cells at early times after infection trigger strong local immune activation, despite the observed systemic immunosuppression.