Cytomegalovirus encephalitis in an immunocompetent child: a sceptic diagnosis

Early warning signs in misrecognized secondary pediatric psychotic disorders: a systematic review

Childhood psychotic symptoms are not uncommon, but lack an evidence-based diagnostic approach. Hallucinations, delusions and other psychotic symptoms, without endangered vital symptoms, can be the result of a primary psychiatric disorder or can be the presenting symptom of an underlying somatic disease. It is important to discriminate between these origins because their diagnostic and therapeutic approaches differ substantially. We searched the existing literature to present a first overview of warning symptoms of underlying somatic disease in children with psychotic symptoms. We obtained data through a study of major textbooks and guidelines, and through a systematic review in PubMed, Embase and PsycINFO databases. We included case reports, cohort studies, and reviews. Results show that symptoms related to an underlying somatic disease are quite diverse and resemble symptoms of a primary psychotic process to a large extent. So there exist no (new) early warning signs. These findings are, crucial as they are mainly in contrast to current common knowledge and make the differential diagnosis even more critical and complex. A further prospective cohort study is necessary in an attempt to create a diagnostic algorithm for psychotic symptoms in children.

Cytomegalovirus central nervous system compartmentalization in a patient presenting with AIDS

Cytomegalovirus (CMV) central nervous system involvement is uncommon and hardly diagnosed because it can mimic many different conditions. We here present a case of an HIV-positive patient with neurological signs and symptoms (headache, asthenia, confusion, hallucinations, ataxia) with concurrent opportunistic diseases (neurotoxoplasmosis, disseminated Kaposi's sarcoma, disseminated CMV infection). CMV CNS involvement was not initially considered given the observed multiple comorbidities: antiviral treatment duration was probably not adequate given the end-organ disease. Concomitantly, plasma CMV DNA was undetectable while cerebrospinal fluid viral load was 31,340 copies/ml. Ganciclovir treatment followed by oral valganciclovir maintenance was associated with the slow disappearance of symptoms, the improvement of MRI images and the persistent undetectability of CMV DNA. The case here reported highlights the challenges of diagnosing CMV encephalitis in HIV-positive patients (with several cerebral comorbidities), the incomplete knowledge of the appropriate treatment for such a disease and the possibility of CMV replication in the cerebrospinal fluid despite undetectable plasma CMV DNA.

Association between cytomegalovirus antibody levels and cognitive functioning in non-elderly adults

BACKGROUND

Elevated levels of antibodies to Cytomegalovirus (CMV) have been associated with cognitive impairment, but the quantitative relationship between CMV antibody levels and domains of cognitive functioning in younger adults has not been established.

METHODS

We measured IgG class antibodies to Cytomegalovirus in 521 individuals, mean age 32.8 years. Participants were selected for the absence of psychiatric disorder and of a serious medical condition that could affect brain functioning. Cognitive functioning was measured with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), the Wisconsin Card Sorting Test, Trail Making Test part A, and the WAIS III Letter Number Sequencing subtest. Linear regression analyses were used to measure the quantitative association between cognitive scores and Cytomegalovirus IgG antibody level. Logistic regression analyses were used to measure the odds of low cognitive scores and elevated antibody levels defined as an antibody level > = 50th, 75th, and 90th percentile of the group.

RESULTS

Higher levels of CMV antibodies were associated with lower performance on RBANS Total (coefficient -1.03, p<.0002), Delayed Memory (coefficient -0.94, p<.001), Visuospatial/Constructional (coefficient -1.77, p<5×10(-7)), and Letter Number Sequencing (coefficient -0.15, p<.03). There was an incremental relationship between the level of CMV antibody elevation and the odds of a low RBANS Total score. The odds of a low total cognitive score were 1.63 (95th % CI 1.01, 2.64; p<.045), 2.22 (95th % CI 1.33, 3.70; p<.002), and 2.46 (95th % CI 1.24, 4.86; p<.010) with a CMV antibody level greater than or equal to the 50th, 75th, and 90th percentile respectively.

CONCLUSIONS

Higher levels of Cytomegalovirus antibodies are associated with lower levels of cognitive functioning in non-elderly adults. Methods for the prevention and treatment of CMV infection should be evaluated to determine if they result in an improvement in cognitive functioning in otherwise healthy adults.