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Shenoy A, Marwaha PK, Worku DA. CD8 Encephalitis in HIV: A Review of This Emerging Entity. J Clin Med 2023; 12:jcm12030770. [PMID: 36769419 PMCID: PMC9917721 DOI: 10.3390/jcm12030770] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/12/2023] [Accepted: 01/12/2023] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Encephalitis is a life-threatening neurological condition with multiple causes in the setting of Human Immunodeficiency Virus (HIV). CD8 Encephalitis (CD8E) is a newly recognised condition which can present in an acute manner, with pertinent features including classical radiological findings with an intense brain parenchymal infiltration of CD8+ T cells. This review attempted to clarify the symptomatology, distribution and determinants of this condition, as well as to examine its vast unknowns. METHODS A literature review was undertaken in July 2022, utilising the PubMed and Google Scholar databases. Papers published between 2006-2022 were reviewed. Eighteen papers, totalling 57 patients, were found and analysed. Statistical analysis was undertaken using Chi-squared and Wilcoxon rank-sum tests as appropriate, with p < 0.05 deemed significant. RESULTS In this review, 57 patients were identified, with a female (61%, 34/56) and Black African (70%, 40/57) preponderance. Females were more likely to present with headache (p = 0.006), and headache was more likely to be present in those who died (p = 0.02). There was no statistically significant association between baseline CD4 count (p = 0.079) and viral load (p = 0.72) with disease outcome. Overall, 77% (41/53) of patients had classical imaging findings, including bilateral gadolinium-enhancing punctate and perivascular white matter lesions. However, many patients (23/57) required a brain biopsy as part of their diagnostic workup. Corticosteroid treatment was commonly prescribed in patients (64%, 35/55) and had a mortality benefit, with an overall survival in this group of 71% (p = 0.0008). In those who died, median survival was 5.5 months. In rare instances, recurrence of the disease was noted, which responded poorly to treatment. DISCUSSION CD8E represents a new and complex condition with few risk factors identified for its occurrence. The presenting symptoms are broad, but headache appears to be more common in females and more significantly associated with death. Though rare, CD8E is likely under-diagnosed, possibly due to overlapping features with other illnesses and lack of physician experience in its recognition and management. Corticosteroids demonstrate a clear mortality benefit, but more studies are required to determine their optimal dosing and duration, as well as the use of steroid-sparing agents. Further reviews should help to better determine the risk factors for the condition, as well as non-invasive biomarkers, to aid in diagnosis and help to predict poor prognosis and disease recurrence.
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Affiliation(s)
- Aniruddh Shenoy
- Haematology, Christie Hospital, Manchester M20 4BX, UK
- Correspondence: (A.S.); (D.A.W.)
| | - Pavan Kaur Marwaha
- Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK
| | - Dominic Adam Worku
- Infectious Diseases, Morriston Hospital, Swansea SA6 6NL, UK
- Public Health Wales, Cardiff CF10 4BZ, UK
- Correspondence: (A.S.); (D.A.W.)
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Czech T, Shah P, Lee G, Watanabe G, Ogasawara C, Noh T. Cerebral toxoplasmosis in a patient with combined variable immunodeficiency. Surg Neurol Int 2022; 13:354. [PMID: 36128152 PMCID: PMC9479566 DOI: 10.25259/sni_532_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 07/24/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Cerebral toxoplasmosis is an opportunistic infection in patients but has rarely been described in the setting of compromised humoral immunodeficiency. Prompt diagnosis and treatment of the infection is critical in the care of these patients. Medical management is the mainstay of treatment of the infection. There have been very few reports of surgical management of cerebral toxoplasmosis. Case Description: We describe the case of a 40-year-old male who presented with headache, memory deficits, weight loss, and left-sided weakness in the setting of a known but undiagnosed brain lesion identified 1 month prior. Imaging demonstrated a right basal ganglia lesion which was initially presumed to be malignancy. On further workup including a positive serum test and biopsy including polymerase chain reaction analysis, diagnosis was confirmed as toxoplasmosis. On further investigation, he was found to have deficiencies in immunoglobulins consistent with common variable immunodeficiency (CVID). The patient underwent craniotomy with surgical debulking as repeat imaging showed increased size of mass with new satellite lesions and worsening hydrocephalus. Conclusion: Cerebral toxoplasmosis is an important differential to consider in cases of intracerebral lesions and should not necessarily be excluded in the absence of compromised cellular immunity. In cases where there is no immunocompromised state and malignancy cannot immediately be established, CVID should be considered as an etiology. Due to the subtlety of CVID diagnosis, careful attention should be paid to history taking and workup for CVID should be considered as soon as possible. Surgical removal of these lesions in conjunction with medications is an effective treatment option.
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Affiliation(s)
- Torrey Czech
- Department of Internal Medicine, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii, United States
| | - Parthav Shah
- Department of Internal Medicine, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii, United States
| | - Gunnar Lee
- Department of Neurological Surgery, John A. Burns School of Medicine, Honolulu, Hawaii, United States
| | - Gina Watanabe
- Department of Medicine, John A. Burns School of Medicine, Honolulu, Hawaii, United States
| | - Christian Ogasawara
- Department of Medicine, John A. Burns School of Medicine, Honolulu, Hawaii, United States
| | - Thomas Noh
- Neurosurgery, John A. Burns School of Medicine, Honolulu, Hawaii, United States
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Santos M, Roque R, Rainha Campos A, Albuquerque L, Pimentel J. Impact of brain biopsy on management of nonneoplastic brain disease. BRAIN AND SPINE 2022; 2:100863. [PMID: 36248174 PMCID: PMC9560663 DOI: 10.1016/j.bas.2022.100863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/09/2022] [Accepted: 01/16/2022] [Indexed: 11/09/2022]
Abstract
Introduction Diagnostic yield of brain biopsy in neoplastic brain disease is high and its clinical impact is well established. In nonneoplastic brain disease with negative conventional investigation, decision to undergo invasive procedures is difficult due to its inherent risk and known lower diagnostic yield. Research question: What is the clinical impact of brain biopsy results on management of nonneoplastic brain disease ? Material and methods A multidisciplinary team retrospectively reviewed and included all nonneoplastic brain disease cases submitted to biopsy between 2009 and 2019, in a tertiary hospital in Lisbon. Baseline characteristics were registered, including immunosuppression status, diagnostic workup, and treatment prior to biopsy. Diagnostic yield, clinical impact and in-hospital complication rates were assessed. Results Sixty-four patients were included, 20 (31.3%) of them immunosuppressed (15 HIV + patients). Thirty-five (67.7%) were previously treated with steroids or antiinfectious agents, with higher percentage (93.3%) in the immunosuppressed group. Biopsy results were diagnostic in 46 (71.9%) cases. More frequent diagnosis was infectious in 20 (31.2%), neoplastic in 12 (18.8%) and inflammatory diseases in 8 (12.5%). Brain biopsy resulted on impact on patient's clinical management in 56 (87.5%), of which 37(57.8%) were submitted to treatment change. In-hospital complications were registered in 4 (6.6%) patients. Discussion and conclusion Brain biopsy had clinical impact, including a change in treatment, in most patients studied, and may be considered a useful diagnostic option in nonneoplastic brain disease. However, associated complication rate is not negligible, and previous thorough workup, patient selection and risk-benefit assessment are important. In selected cases, diagnostic success of brain biopsy in nonneoplastic brain disease is high. Most diagnosis had a significant clinical impact on patient management. Although not neglectable, procedure-related complication rate was low.
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Riche M, Marijon P, Amelot A, Bielle F, Mokhtari K, Chambrun MPD, Joncour AL, Idbaih A, Touat M, Do CH, Deme M, Pasqualotto R, Jacquens A, Degos V, Shotar E, Chougar L, Carpentier A, Mathon B. Severity, timeline, and management of complications after stereotactic brain biopsy. J Neurosurg 2021; 136:867-876. [PMID: 34507289 DOI: 10.3171/2021.3.jns21134] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/12/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The literature shows discrepancies in stereotactic brain biopsy complication rates, severities, and outcomes. Little is known about the timeline of postbiopsy complications. This study aimed to analyze 1) complications following brain biopsies, using a graded severity scale, and 2) a timeline of complication occurrence. The secondary objectives were to determine factors associated with an increased risk of complications and to assess complication-related management and extra costs. METHODS The authors retrospectively examined 1500 consecutive stereotactic brain biopsies performed in adult patients at their tertiary medical center between April 2009 and April 2019. RESULTS Three hundred eighty-one biopsies (25.4%) were followed by a complication, including 88.2% of asymptomatic hemorrhages. Symptomatic complications involved 3.0% of the biopsies, and 0.8% of the biopsies were fatal. The severity grading scale had a 97.6% interobserver reproducibility. Twenty-three (51.1%) of the 45 symptomatic complications occurred within the 1st hour following the biopsy, while 75.6% occurred within the first 6 hours. Age ≥ 65 years, second biopsy procedures, gadolinium-enhanced lesions, glioblastomas, and lymphomas were predictors of biopsy-related complications. Brainstem biopsy-targeted lesions and cerebral toxoplasmosis were predictive of mortality. Asymptomatic hemorrhage was associated with delayed (> 6 hours) symptomatic complications. Symptomatic complications led to extended hospitalization in 86.7% of patients. The average extra cost for management of a patient with postbiopsy symptomatic complication was $35,702. CONCLUSIONS Symptomatic complications from brain biopsies are infrequent but associated with substantial adverse effects and cost implications for the healthcare system. The use of a severity grading scale, as the authors propose in this article, helps to classify complications according to the therapeutic consequences and the patient's outcome. Because this study indicates that most complications occur within the first few hours following the biopsy, postbiopsy monitoring can be tailored accordingly. The authors therefore recommend systematic monitoring for 2 hours in the recovery unit and a CT scan 2 hours after the end of the biopsy procedure. In addition, they propose a modern algorithm for optimal postoperative management of patients undergoing stereotactic biopsy.
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Affiliation(s)
- Maximilien Riche
- Departments of1Neurosurgery.,2INSERM U 1127, CNRS UMR 7225, Sorbonne University, UMR S 1127, Paris Brain Institute, ICM
| | - Pauline Marijon
- Departments of1Neurosurgery.,2INSERM U 1127, CNRS UMR 7225, Sorbonne University, UMR S 1127, Paris Brain Institute, ICM
| | | | - Franck Bielle
- 2INSERM U 1127, CNRS UMR 7225, Sorbonne University, UMR S 1127, Paris Brain Institute, ICM.,3Neuropathology
| | - Karima Mokhtari
- 2INSERM U 1127, CNRS UMR 7225, Sorbonne University, UMR S 1127, Paris Brain Institute, ICM.,3Neuropathology
| | - Marc Pineton de Chambrun
- 4Internal Medicine 2.,5Intensive Care Medicine.,6INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition
| | | | - Ahmed Idbaih
- 2INSERM U 1127, CNRS UMR 7225, Sorbonne University, UMR S 1127, Paris Brain Institute, ICM.,8Neurology Mazarin
| | - Mehdi Touat
- 2INSERM U 1127, CNRS UMR 7225, Sorbonne University, UMR S 1127, Paris Brain Institute, ICM.,8Neurology Mazarin
| | - Chung-Hi Do
- 9Anesthesia, Critical Care, and Perioperative Medicine, and
| | - Mamadou Deme
- 9Anesthesia, Critical Care, and Perioperative Medicine, and
| | | | - Alice Jacquens
- 9Anesthesia, Critical Care, and Perioperative Medicine, and
| | - Vincent Degos
- 9Anesthesia, Critical Care, and Perioperative Medicine, and.,10Clinical Research Group ARPE, Sorbonne University.,11INSERM UMR 1141, PROTECT, Paris, France
| | - Eimad Shotar
- 12Neuroradiology, APHP, Sorbonne University, La Pitié-Salpêtrière Hospital
| | - Lydia Chougar
- 2INSERM U 1127, CNRS UMR 7225, Sorbonne University, UMR S 1127, Paris Brain Institute, ICM.,12Neuroradiology, APHP, Sorbonne University, La Pitié-Salpêtrière Hospital
| | - Alexandre Carpentier
- Departments of1Neurosurgery.,2INSERM U 1127, CNRS UMR 7225, Sorbonne University, UMR S 1127, Paris Brain Institute, ICM
| | - Bertrand Mathon
- Departments of1Neurosurgery.,2INSERM U 1127, CNRS UMR 7225, Sorbonne University, UMR S 1127, Paris Brain Institute, ICM
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Comparison of frame-less robotic versus frame-based stereotactic biopsy of intracranial lesions. Clin Neurol Neurosurg 2021; 207:106762. [PMID: 34153776 DOI: 10.1016/j.clineuro.2021.106762] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Robotic guidance might be an alternative to classic stereotaxy for biopsies of intracranial lesions. Both methods were compared regarding time efficacy, histopathological results and complications. METHODS A retrospective analysis enrolling all patients undergoing robotic- or stereotactic biopsies between 01/2015 and 12/2018 was conducted. Trajectory planning was performed on magnetic resonance imaging (MRI). With the Robotic Surgery Assistant (ROSA), patient registration was accomplished using a facial laser scan in the operating room (OR), immediately followed by biopsy. In stereotaxy, patients were transported to the CT for Leksell Frame registration, followed by biopsy in the OR. RESULTS The average overall procedure time amounted in robotics to 169 min and in stereotaxy to 179 min (p = 0.005). The difference was greatest for temporal targets, amounting in robotics to 161 min and in stereotaxy to 188 min (p = 0,0007). However, the average time spent purely in the OR amounted in robotics to 140 min and in stereotaxy to 113 min (p < 0.001). In 150 robotic biopsies, diagnostic yield amounted to 98%, in 266 stereotactic biopsies to 91%. Symptomatic postoperative hemorrhages were observed in 3 patients (2%) in robotic biopsy and 7 patients (2,7%) in stereotactic biopsy. CONCLUSION Robotics showed a shorter overall procedure time as there is no need for a transport to the CT whereas the pure OR time was shorter in stereotaxy due to skipping the laser registration process. Diagnostic yield was higher in robotics, most likely due to case selection, complication rates were equal.
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Mathon B, de Chambrun MP, Le Joncour A, Amelot A. Letter to the Editor. Brain biopsy in children and adults with neurological diseases of unknown etiology: two sides of the same coin? J Neurosurg Pediatr 2021; 27:120-122. [PMID: 33096520 DOI: 10.3171/2020.7.peds20619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Bertrand Mathon
- 1AP-HP, La Pitié-Salpêtrière - Charles Foix University Hospital, Paris, France
- 2Sorbonne University, Paris, France; and
- 3Brain and Spine Institute, Paris, France
| | - Marc Pineton de Chambrun
- 1AP-HP, La Pitié-Salpêtrière - Charles Foix University Hospital, Paris, France
- 2Sorbonne University, Paris, France; and
| | - Alexandre Le Joncour
- 1AP-HP, La Pitié-Salpêtrière - Charles Foix University Hospital, Paris, France
- 2Sorbonne University, Paris, France; and
| | - Aymeric Amelot
- 1AP-HP, La Pitié-Salpêtrière - Charles Foix University Hospital, Paris, France
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Toxoplasmic Encephalitis Followed by Primary EBV-Associated Post-Transplant Lymphoproliferative Disorder of the Central Nervous System in a Patient Undergoing Allogeneic Hematopoietic Stem Cell Transplant: A Case Report. Transplant Proc 2020; 52:2858-2860. [PMID: 32873410 DOI: 10.1016/j.transproceed.2020.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 08/02/2020] [Indexed: 11/22/2022]
Abstract
Toxoplasmic encephalitis (TE) and post-transplant lymphoproliferative disorder of the central nervous system (CNS-PTLD) are major complications after allogeneic hematopoietic stem cell transplant (allo-SCT); both are fatal without timely diagnosis and disease-specific treatment. Differential diagnosis of TE and CNS-PTLD can be challenging because brain biopsy, a gold standard for diagnosis, is sometimes not possible, owing to poor patient condition after allo-SCT. Here, we describe a case of isolated CNS-PTLD arising during the therapeutic course of TE. A 51-year-old man was admitted with mental abnormalities and fever on Day 106 after allo-SCT to treat myelodysplastic syndrome. Magnetic resonance imaging (MRI) revealed multiple nodular and ring-enhanced lesions in the brain, and the result of polymerase chain reaction (PCR) for Toxoplasma gondii in cerebrospinal fluid was positive; therefore, he was diagnosed with TE. Anti-Toxoplasma therapy led to clinical improvement, and the result of subsequent PCR was negative. However, he developed left-sided hemiplegia on Day 306. Head MRI revealed a new lesion and a growing lesion, presenting as ring-enhanced nodules. Brain biopsy was performed, and a pathologic diagnosis of Epstein-Barr virus-associated CNS-PTLD was made. There was no evidence of TE. He was treated successfully by reducing immunosuppressants, followed by rituximab administration and a donor lymphocyte infusion, resulting in complete remission. While T.gondii-specific PCR has great value for diagnosis of TE, CNS-PTLD can be diagnosed only by brain biopsy; hence, brain biopsy may be warranted in cases of suspected PTLD.
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Abstract
PURPOSE OF REVIEW Space-occupying lesions represent a diagnostic challenge among people with the human immunodeficiency virus, acquired immunodeficiency syndrome (HIV/AIDS). To determine the best diagnostic approach to the wide array of possible etiologies and provide a thorough interpretation of neuroimaging in order to narrow a hierarchical differential diagnosis among these patients. Given that there is no pathognomonic neuroimaging pattern in this clinical setting, we searched results from brain biopsies to best determine the etiology of commonly found lesions. RECENT FINDINGS Multimodal brain MRI and MRI spectroscopy (MRS) often provide the most valuable information in the study of focal masses among people with HIV/AIDS. Brain biopsy appears safe and provides high diagnostic yields in these patients. Among patients with HIV/AIDS who present with space-occupying intracranial lesions, brain MRI and MRS are useful tests. However, in cases of diagnostic uncertainty, brain biopsy is a safe procedure and should be performed. The role of metabolic studies like 201Th-SPECT or PET is useful in the detection of primary central nervous system lymphoma.
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Affiliation(s)
- Isabel Elicer
- Hospital Dr. Sótero del Río, Neurology Service, Av. Concha y Toro 3459, Puente Alto, Santiago, Chile. .,Clinica Las Condes, Lo Fontecilla 441, Las Condes, Santiago, Chile. .,Red Salud UC Christus, Lira 85, Santiago, Chile.
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Harypursat V, Zhou Y, Tang S, Chen Y. JC Polyomavirus, progressive multifocal leukoencephalopathy and immune reconstitution inflammatory syndrome: a review. AIDS Res Ther 2020; 17:37. [PMID: 32631361 PMCID: PMC7338111 DOI: 10.1186/s12981-020-00293-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 06/29/2020] [Indexed: 01/15/2023] Open
Abstract
The human neurotropic virus JC Polyomavirus, a member of the Polyomaviridae family, is the opportunistic infectious agent causing progressive multifocal leukoencephalopathy, typically in immunocompromised individuals. The spectrum of underlying reasons for the systemic immunosuppression that permits JCV infection in the central nervous system has evolved over the past 2 decades, and therapeutic immunosuppression arousing JCV infection in the brain has become increasingly prominent as a trigger for PML. Effective immune restoration subsequent to human immunodeficiency virus-related suppression is now recognized as a cause for unexpected deterioration of symptoms in patients with PML, secondary to a rebound inflammatory phenomenon called immune reconstitution inflammatory syndrome, resulting in significantly increased morbidity and mortality in a disease already infamous for its lethality. This review addresses current knowledge regarding JC Polyomavirus, progressive multifocal leukoencephalopathy, progressive multifocal leukoencephalopathy-related immune reconstitution inflammatory syndrome, and the immunocompromised states that incite JC Polyomavirus central nervous system infection, and discusses prospects for the future management of these conditions.
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Affiliation(s)
- Vijay Harypursat
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Geleshan Town, Shapingba District, Chongqing, 400036, People's Republic of China
| | - Yihong Zhou
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Geleshan Town, Shapingba District, Chongqing, 400036, People's Republic of China
| | - Shengquan Tang
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Geleshan Town, Shapingba District, Chongqing, 400036, People's Republic of China
| | - Yaokai Chen
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Geleshan Town, Shapingba District, Chongqing, 400036, People's Republic of China.
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Lopes CCB, Crivillari M, Prado JCM, Ferreira CR, Dos Santos PJ, Takayasu V, Laborda LS. Progressive multifocal leukoencephalopathy: a challenging diagnosis established at autopsy. AUTOPSY AND CASE REPORTS 2019; 9:e2018063. [PMID: 30863734 PMCID: PMC6394363 DOI: 10.4322/acr.2018.063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 11/13/2018] [Indexed: 01/19/2023] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a feared entity that occurs most frequently in conditions of extreme immunodeficiency. The diagnosis is often made long after the onset of symptoms due to the physicians’ unfamiliarity, and the unavailability of diagnostic tests in some medical centers. Although the incidence of PML is decreasing among HIV patients with the advent of highly active antiretroviral therapy (HAART), in Brazil this entity is the fourth highest neurological complication among these patients. The authors present the case of a middle-aged man who tested positive for HIV concomitantly with the presentation of hyposensitivity in the face and the right side of the body, accompanied by mild weakness in the left upper limb. The clinical features worsened rapidly within a couple of weeks. The diagnostic work-up pointed to the working diagnosis of PML after brain magnetic resonance imaging; however, the detection of the John Cunningham virus (JCV) in the cerebral spinal fluid was negative. HAART was started but the patient died after 7 weeks of hospitalization. The autopsy revealed extensive multifocal patchy areas of demyelination in the white matter where the microscopy depicted demyelination, oligodendrocytes alterations, bizarre atypical astrocytes, and perivascular lymphocytic infiltration. The immunohistochemistry was positive for anti-SV40, and the polymerase chain reaction of the brain paraffin-embedded tissue was positive for JCV. The authors highlight the challenges for diagnosing PML, as well as the devastating outcome of PML among HIV patients.
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Affiliation(s)
| | | | - José Carlos Mann Prado
- Universidade de São Paulo (USP), Biomedical Sciences Institute, Department of Microbiology, Laboratory of Oncovirology. São Paulo, SP, Brazil
| | - Cristiane Rubia Ferreira
- Universidade de São Paulo (USP), Hospital Universitário, Anatomic Pathology Service. São Paulo, SP, Brazil
| | - Pedro José Dos Santos
- Universidade de São Paulo (USP), Hospital Universitário, Department of Radiology. São Paulo, SP, Brazil
| | - Vilma Takayasu
- Universidade de São Paulo (USP), Hospital Universitário, Internal Medicine Division. São Paulo, SP, Brazil
| | - Lorena Silva Laborda
- Universidade de São Paulo (USP), Hospital Universitário, Internal Medicine Division. São Paulo, SP, Brazil
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Vidal JE. HIV-Related Cerebral Toxoplasmosis Revisited: Current Concepts and Controversies of an Old Disease. J Int Assoc Provid AIDS Care 2019; 18:2325958219867315. [PMID: 31429353 PMCID: PMC6900575 DOI: 10.1177/2325958219867315] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/14/2019] [Accepted: 06/28/2019] [Indexed: 01/06/2023] Open
Abstract
Cerebral toxoplasmosis is the most common cause of expansive brain lesions in people living with HIV/AIDS (PLWHA) and continues to cause high morbidity and mortality. The most frequent characteristics are focal subacute neurological deficits and ring-enhancing brain lesions in the basal ganglia, but the spectrum of clinical and neuroradiological manifestations is broad. Early initiation of antitoxoplasma therapy is an important feature of the diagnostic approach of expansive brain lesions in PLWHA. Pyrimethamine-based regimens and trimethoprim-sulfamethoxazole (TMP-SMX) seem to present similar efficacy, but TMP-SMX shows potential practical advantages. The immune reconstitution inflammatory syndrome is uncommon in cerebral toxoplasmosis, and we now have more effective, safe, and friendly combined antiretroviral therapy (cART) options. As a consequence of these 2 variables, the initiation of cART can be performed within 2 weeks after initiation of antitoxoplasma therapy. Herein, we will review historical and current concepts of epidemiology, diagnosis, and treatment of HIV-related cerebral toxoplasmosis.
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Affiliation(s)
- José Ernesto Vidal
- Departamento de Neurologia, Instituto de Infectologia Emílio Ribas, São
Paulo, Brazil
- Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clínicas
HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Laboratório de Investigação Médica em Protozoologia, Bacteriologia e
Resistência Antimicrobiana (LIM 49), Instituto de Medicina Tropical, Universidade de São
Paulo, São Paulo, Brazil
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12
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Acosta MC, Kundro M, Viloria G, Peressín Paz A, Morello F, Latorre F, Seoane E, Toibaro J, Losso M. The role of brain biopsy in the clinical management of HIV-related focal brain lesions. HIV Med 2018; 19:673-678. [PMID: 30004180 DOI: 10.1111/hiv.12646] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Up to 20% of HIV-related focal brain lesion (FBL) diagnoses cannot be determined without invasive procedures. In such cases, brain biopsy is an important step in the evaluation algorithm. The aims of this study were to describe the clinical outcomes of patients with FBL, the proportion of diagnoses confirmed by brain biopsies and their aetiologies, and to analyse the proportion of patients in whom the biopsy motivated a change in therapeutic management. METHODS A retrospective cohort study was performed. The data from clinical records of patients with HIV-related FBL admitted between January 2005 and December 2015 were reviewed. RESULTS A total of 137 patients were included in the study. The median age was 39 years [interquartile range (IQR) 33-44.5 years]. The median CD4 count was 54 cells/μL (IQR 21-124 cells/μL). Cerebral brain biopsy was performed in 21.16% of patients (29 of 137); 68.9% of these individuals (20 of 29) were diagnosed by histology, with results of central nervous system (CNS) lymphoma in 20.6% (six of 29), progressive multifocal leucoencephalopathy in 6.8% (two of 29), toxoplasmosis in 6.8% (two of 29), tuberculoma in 6.8% (two of 29), and other diagnoses in 27.6% (eight of 29). In nine patients, the histology was nonspecific. In 75.8% of patients (22 of 29), the result of the biopsy led to a change in the therapeutic management. We did not observe higher rates of mortality related to the procedure. Overall mortality at 30 and 90 days was similar in patients who were and were not biopsied. CONCLUSIONS In this retrospective cohort study, cerebral biopsy was associated with significant adjustments in therapeutic management for a high percentage of patients.
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Affiliation(s)
- M C Acosta
- HIV Unit, JM Ramos Mejía Hospital, Buenos Aires, Argentina
| | - M Kundro
- HIV Unit, JM Ramos Mejía Hospital, Buenos Aires, Argentina
| | - G Viloria
- HIV Unit, JM Ramos Mejía Hospital, Buenos Aires, Argentina
| | - A Peressín Paz
- Neurosurgery Unit, JM Ramos Mejía Hospital, Buenos Aires, Argentina
| | - F Morello
- Neurosurgery Unit, JM Ramos Mejía Hospital, Buenos Aires, Argentina
| | - F Latorre
- Neurosurgery Unit, JM Ramos Mejía Hospital, Buenos Aires, Argentina
| | - E Seoane
- Neurosurgery Unit, JM Ramos Mejía Hospital, Buenos Aires, Argentina
| | - J Toibaro
- HIV Unit, JM Ramos Mejía Hospital, Buenos Aires, Argentina
| | - M Losso
- HIV Unit, JM Ramos Mejía Hospital, Buenos Aires, Argentina
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Su C, Peng C, Agbodza E, Bai HX, Huang Y, Karakousis G, Zhang PJ, Zhang Z. Publication trend, resource utilization, and impact of the US National Cancer Database: A systematic review. Medicine (Baltimore) 2018; 97:e9823. [PMID: 29489679 PMCID: PMC5851724 DOI: 10.1097/md.0000000000009823] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 01/16/2018] [Accepted: 01/17/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The utilization and impact of the studies published using the National Cancer Database (NCDB) is currently unclear. In this study, we aim to characterize the published studies, and identify relatively unexplored areas for future investigations. METHODS A literature search was performed using PubMed in January 2017 to identify all papers published using NCDB data. Characteristics of the publications were extracted. Citation frequencies were obtained through the Web of Science. RESULTS Three hundred 2 articles written by 230 first authors met the inclusion criteria. The number of publications grew exponentially since 2013, with 108 articles published in 2016. Articles were published in 86 journals. The majority of the published papers focused on digestive system cancer, while bone and joints, eye and orbit, myeloma, mesothelioma, and Kaposi Sarcoma were never studied. Thirteen institutions in the United States were associated with more than 5 publications. The papers have been cited for a total of 9858 times since the publication of the first paper in 1992. Frequently appearing keywords congregated into 3 clusters: "demographics," "treatments and survival," and "statistical analysis method." Even though the main focuses of the articles captured a extremely wide range, they can be classified into 2 main categories: survival analysis and characterization. Other focuses include database(s) analysis and/or comparison, and hospital reporting. CONCLUSION The surging interest in the use of NCDB is accompanied by unequal utilization of resources by individuals and institutions. Certain areas were relatively understudied and should be further explored.
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Affiliation(s)
- Chang Su
- Department of Radiology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Yale University School of Medicine, New Haven, CT, USA
| | - Cuiying Peng
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | | | - Harrison X. Bai
- Department of Radiology, Hospital of the University of Pennsylvania
| | - Yuqian Huang
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | | | - Paul J. Zhang
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Zishu Zhang
- Department of Radiology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
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Abstract
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.
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Affiliation(s)
- Shaun Zhai
- Department of Neurology, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Bruce James Brew
- Department of Neurology, St. Vincent's Hospital, Sydney, NSW, Australia; Department of HIV Medicine and Peter Duncan Neurosciences Unit, St. Vincent's Centre for Applied Medical Research, St. Vincent's Hospital, Sydney, NSW, Australia.
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Yang M, Sun J, Bai HX, Tao Y, Tang X, States LJ, Zhang Z, Zhou J, Farwell MD, Zhang P, Xiao B, Yang L. Diagnostic accuracy of SPECT, PET, and MRS for primary central nervous system lymphoma in HIV patients: A systematic review and meta-analysis. Medicine (Baltimore) 2017; 96:e6676. [PMID: 28489744 PMCID: PMC5428578 DOI: 10.1097/md.0000000000006676] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND We performed a systematic review and meta-analysis to assess the roles of SPECT, PET, and MRS in distinguishing primary central nervous system lymphoma (PCNSL) from other focal brain lesions (FBLs) in human immunodeficiency virus (HIV)-infected patients. METHODS PubMed, Scopus, and Medline were systematically searched for eligible studies from 1980 to 2016. Two authors extracted characteristics of patients and their lesions using predefined criteria. RESULTS Eighteen studies on SPECT containing 667 patients, 6 studies on PET containing 108 patients, and 3 studies on MRS containing 96 patients were included. SPECT had a pooled sensitivity of 0.92 (95% CI: 0.85-0.96) and specificity of 0.84 (95% CI: 0.74-0.90) in differentiating PCNSL from other FBLs. For the 6 studies that used only pathology and/or serology as the gold standard, the pooled sensitivity was 0.85 (95% CI: 0.72-0.97) and the pooled specificity was 0.73 (95% CI: 0.54-0.92). CONCLUSION SPECT has good diagnostic accuracy for discriminating PCNSL from other FBL-causing disorders in HIV patients. However, the actual sensitivity and specificity of SPECT may be lower than expected if only pathology and/or serology was used as the gold standard. PET may be superior but has less supporting clinical data and is more expensive.
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Affiliation(s)
- Mo Yang
- Department of Neurology, The Second Xiangya Hospital, Changsha City, Hunan Province, China
| | - James Sun
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Harrison X. Bai
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Yongguang Tao
- Cancer Research Institute, Central South University, Changsha City, Hunan Province, China
| | - Xiangqi Tang
- Department of Neurology, The Second Xiangya Hospital, Changsha City, Hunan Province, China
| | - Lisa J. States
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Zishu Zhang
- Department of Radiology, The Second Xiangya Hospital
| | - Jianhua Zhou
- Department of Pathology, The First Xiangya Hospital, Changsha City, Hunan Province, China
| | - Michael D. Farwell
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Paul Zhang
- Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Bo Xiao
- Department of Neurology, The First Xiangya Hospital, Changsha City, Hunan Province, China
| | - Li Yang
- Department of Neurology, The Second Xiangya Hospital, Changsha City, Hunan Province, China
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Ayoade F, Todd J, Al-Delfi F, King J. Extensive brain masses and cavitary lung lesions associated with toxoplasmosis and acquired immunodeficiency syndrome. Int J STD AIDS 2017. [PMID: 28632476 DOI: 10.1177/0956462417696216] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Toxoplasmosis is an important cause of enhancing brain lesions in patients with acquired immunodeficiency syndrome (AIDS), and it is typically associated with low CD4-lymphocyte counts. Extensive toxoplasma encephalitis when the CD4-lymphocyte count is above 100 cells/µl is unusual. Cavitary lung lesions are also not typically associated with toxoplasmosis. Here, we present a case of toxoplasmosis associated with extensive brain masses and cavitary lung lesions, both of which improved with directed toxoplasmosis therapy, in an AIDS patient with a CD4 cell count of 120 cells/µl.
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Affiliation(s)
- Folusakin Ayoade
- Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - John Todd
- Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Firas Al-Delfi
- Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - John King
- Louisiana State University Health Sciences Center, Shreveport, LA, USA
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