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Peters RPH, Nel JS, Sadiq E, Kufa T, Smit DP, Sorour G, Garrett N, Gill K, Makhakhe L, Chandiwana NC, Moran NF, Cohen K, Wattrus C, Moosa MY. Southern African HIV Clinicians Society Guideline for the clinical management of syphilis. South Afr J HIV Med 2024; 25:1577. [PMID: 38725703 PMCID: PMC11079416 DOI: 10.4102/sajhivmed.v25i1.1577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 03/24/2024] [Indexed: 05/12/2024] Open
Abstract
Syphilis, 'the great imitator', caused by Treponema pallidum infection, remains a complex and multifaceted disease with a rich history of clinical diversity. This guideline aims to be a comprehensive guide for healthcare workers in Southern Africa, offering practical insights into the epidemiology, pathogenesis, clinical manifestations, diagnostic testing, therapeutic principles, and public health responses to syphilis. Although the syphilis burden has declined over the years, recent data indicate a troubling resurgence, particularly among pregnant women and neonates. This guideline highlights the diagnostic challenges posed by syphilis, stemming from the absence of a single high-sensitivity and -specificity test. While treatment with penicillin remains the cornerstone of treatment, alternative regimens may be used for specific scenarios. We highlight the importance of thorough patient follow-up and management of sex partners to ensure optimal care of syphilis cases. In the context of public health, we emphasise the need for concerted efforts to combat the increasing burden of syphilis, especially within high-risk populations, including people living with HIV.
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Affiliation(s)
- Remco P H Peters
- Research Unit, Foundation for Professional Development, East London, South Africa
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
- Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Jeremy S Nel
- Division of Infectious Diseases, Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Helen Joseph Hospital, Johannesburg, South Africa
| | - Eitzaz Sadiq
- Helen Joseph Hospital, Johannesburg, South Africa
- Department of Neurosciences, Division of Neurology, University of the Witwatersrand, Johannesburg, South Africa
| | - Tendesayi Kufa
- Centre for HIV and STIs, National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Derrick P Smit
- Division of Ophthalmology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gillian Sorour
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | | | - Lehlohonolo Makhakhe
- Department of Dermatology, University of the Free State, Bloemfontein, South Africa
- The South African Institute of Dermatology, Bloemfontein, South Africa
| | - Nomathemba C Chandiwana
- Wits Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Neil F Moran
- KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Karen Cohen
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Camilla Wattrus
- Southern African HIV Clinicians Society (SAHCS), Johannesburg, South Africa
| | - Mahomed Yunus Moosa
- Southern African HIV Clinicians Society (SAHCS), Johannesburg, South Africa
- Department of Infectious Disease, Division of Internal Medicine, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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Abstract
Dermatologists are familiar with the classic aspects of syphilis. Our objective in this update is to display novel features of sexually acquired syphilis, its pathophysiology, natural history, atypical clinical variants, skin of color, clinical pearls, and prospects. Textbook knowledge, congenital syphilis, epidemiology, and historical data are excluded.
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Affiliation(s)
- Jorge Navarrete
- Department of Dermatology, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile; Department of Dermatology and Sexually Transmitted Infections Clinic, Hospital Padre Hurtado, Santiago, Chile.
| | - Stephanie Saavedra-Portales
- Department of Dermatology and Sexually Transmitted Infections Clinic, Hospital San Juan de Dios, Santiago, Chile
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Marra CM. Infectious and Postinfectious Vasculopathies. Neuroimaging Clin N Am 2024; 34:13-21. [PMID: 37951699 DOI: 10.1016/j.nic.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Stroke is a complication of many central nervous system (CNS) infections, but only a few present with stroke without other symptoms or signs of CNS infection. Chief among these are varicella zoster virus (VZV) and syphilis. Delayed cerebral vasculopathy after successful treatment of bacterial meningitis, most commonly pneumococcal, is an emerging entity with uncertain pathogenesis.
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Affiliation(s)
- Christina M Marra
- Department of Neurology, University of Washington, Seattle, WA, USA.
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Shorer EF, Zauchenberger CZ, Govender S, Shorer GE, Geragotellis AA, Centner CM, Marais S. Neurological manifestations of syphilis-HIV coinfection in South Africa. J Neurol Sci 2023; 455:122798. [PMID: 37979416 DOI: 10.1016/j.jns.2023.122798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 10/27/2023] [Accepted: 11/12/2023] [Indexed: 11/20/2023]
Abstract
OBJECTIVE Syphilis and HIV coinfection is highly prevalent in South Africa, and both can cause neurological complications. We describe the clinical presentation and outcome of neurosyphilis in patients with and without HIV coinfection diagnosed at a tertiary facility, Groote Schuur Hospital (GSH), in South Africa. METHODS We retrospectively analyzed folders of adults with positive cerebrospinal fluid (CSF) fluorescent treponemal antibody absorption test in 2018 and 2019, with follow-up data collected until 2022. RESULTS HIV-coinfection was identified in 35% of the 69 included patients. Patients with HIV-coinfection were more likely to be female (58% vs 25% female, p < 0.01), and present earlier (median age = 31 years vs. 40 years, p < 0.001). Neuropsychiatric manifestations (confusion, dementia, psychosis), and strokes were the commonest clinical presentations in both groups. Those with HIV-coinfection were significantly less likely to be diagnosed with neurosyphilis by the treating clinician (71% vs. 91%, p < 0.05), as were those with a negative CSF Venereal Disease Research Laboratory (74% vs. 94%, p < 0.05). Accurate diagnosis of neurosyphilis was associated with an increased 12-month survival (alive: N = 36 [63%]) relative to those who did not receive an accurate diagnosis (alive: N = 2 [17%], p < 0.05). Those who were optimally treated with antibiotics had significantly higher 12-month survival (alive: N = 33, 63%) compared to those with suboptimal treatment (alive: N = 5, 29%), p < 0.01. CONCLUSION Neurosyphilis presented similarly in those with and without HIV-coinfection. Accurate identification and optimal antibiotic treatment of neurosyphilis, particularly in CSF VDRL negative patients and those with HIV-coinfection, is necessary to improve patient survival.
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Affiliation(s)
- E F Shorer
- Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA.
| | - C Z Zauchenberger
- Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa
| | - S Govender
- Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa
| | - G E Shorer
- Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa
| | - A A Geragotellis
- Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa
| | - C M Centner
- Division of Medical Microbiology, University of Cape Town; National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | - S Marais
- Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; Neuroscience Institute, UCT, South Africa
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Ramchandani MS, Cannon CA, Marra CM. Syphilis. Infect Dis Clin North Am 2023; 37:195-222. [PMID: 37005164 DOI: 10.1016/j.idc.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
Syphilis is an important public health problem in the U.S. and many high-income nations. The rates of syphilis continue to increase and there is an urgent need for medical providers of a variety of backgrounds to recognize this disease. In this review, we cover the key clinical findings of syphilis and provide an overview of the diagnosis and management of this disease in adults.
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Lima MA, Freitas DFS, Oliveira RVC, Fichman V, Varon AG, Freitas AD, Lamas CC, Andrade HB, Veloso VG, Almeida-Paes R, Almeida-Silva F, Zancopé-Oliveira RM, de Macedo PM, Valle ACF, Silva MTT, Araújo AQC, Gutierrez-Galhardo MC. Meningeal Sporotrichosis Due to Sporothrix brasiliensis: A 21-Year Cohort Study from a Brazilian Reference Center. J Fungi (Basel) 2022; 9:17. [PMID: 36675837 PMCID: PMC9863964 DOI: 10.3390/jof9010017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
Meningeal sporotrichosis is rare and occurs predominantly in immunosuppressed individuals. This retrospective study explored clinical and laboratory characteristics, treatment, and prognosis of patients with disseminated sporotrichosis who underwent lumbar puncture (LP) at a Brazilian reference center from 1999 to 2020. Kaplan-Meier and Cox regression models were used to estimate overall survival and hazard ratios. Among 57 enrolled patients, 17 had meningitis. Fifteen (88.2%) had HIV infection, and in 6 of them, neurological manifestations occurred because of the immune reconstitution inflammatory syndrome (IRIS). The most frequent symptom was headache (88.2%). Meningeal symptoms at first LP were absent in 7/17 (41.2%) patients. Sporothrix was diagnosed in cerebrospinal fluid either by culture or by polymerase chain reaction in seven and four patients, respectively. All but one patient received prolonged courses of amphotericin B formulations, and seven received posaconazole, but relapses were frequent. Lethality among patients with meningitis was 64.7%, with a higher chance of death compared to those without meningitis (HR = 3.87; IC95% = 1.23;12.17). Meningeal sporotrichosis occurs mostly in people with HIV and can be associated with IRIS. Screening LP is indicated in patients with disseminated disease despite the absence of neurological complaints. Meningitis is associated with poor prognosis, and better treatment strategies are needed.
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Affiliation(s)
- Marco A. Lima
- Evandro Chagas National Institute of Infectious Diseases (INI), FIOCRUZ, Brazilian Ministry of Health, Rio de Janeiro 21040-900, Brazil
- Neurology Section, Hospital Universitário Clementino Fraga Filho, The Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-617, Brazil
| | - Dayvison F. S. Freitas
- Evandro Chagas National Institute of Infectious Diseases (INI), FIOCRUZ, Brazilian Ministry of Health, Rio de Janeiro 21040-900, Brazil
| | - Raquel V. C. Oliveira
- Evandro Chagas National Institute of Infectious Diseases (INI), FIOCRUZ, Brazilian Ministry of Health, Rio de Janeiro 21040-900, Brazil
| | - Vivian Fichman
- Evandro Chagas National Institute of Infectious Diseases (INI), FIOCRUZ, Brazilian Ministry of Health, Rio de Janeiro 21040-900, Brazil
| | - Andréa G. Varon
- Evandro Chagas National Institute of Infectious Diseases (INI), FIOCRUZ, Brazilian Ministry of Health, Rio de Janeiro 21040-900, Brazil
| | - Andréa D. Freitas
- Evandro Chagas National Institute of Infectious Diseases (INI), FIOCRUZ, Brazilian Ministry of Health, Rio de Janeiro 21040-900, Brazil
| | - Cristiane C. Lamas
- Evandro Chagas National Institute of Infectious Diseases (INI), FIOCRUZ, Brazilian Ministry of Health, Rio de Janeiro 21040-900, Brazil
| | - Hugo B. Andrade
- Evandro Chagas National Institute of Infectious Diseases (INI), FIOCRUZ, Brazilian Ministry of Health, Rio de Janeiro 21040-900, Brazil
| | - Valdilea G. Veloso
- Evandro Chagas National Institute of Infectious Diseases (INI), FIOCRUZ, Brazilian Ministry of Health, Rio de Janeiro 21040-900, Brazil
| | - Rodrigo Almeida-Paes
- Evandro Chagas National Institute of Infectious Diseases (INI), FIOCRUZ, Brazilian Ministry of Health, Rio de Janeiro 21040-900, Brazil
| | - Fernando Almeida-Silva
- Evandro Chagas National Institute of Infectious Diseases (INI), FIOCRUZ, Brazilian Ministry of Health, Rio de Janeiro 21040-900, Brazil
| | - Rosely Maria Zancopé-Oliveira
- Evandro Chagas National Institute of Infectious Diseases (INI), FIOCRUZ, Brazilian Ministry of Health, Rio de Janeiro 21040-900, Brazil
| | - Priscila M. de Macedo
- Evandro Chagas National Institute of Infectious Diseases (INI), FIOCRUZ, Brazilian Ministry of Health, Rio de Janeiro 21040-900, Brazil
| | - Antonio C. F. Valle
- Evandro Chagas National Institute of Infectious Diseases (INI), FIOCRUZ, Brazilian Ministry of Health, Rio de Janeiro 21040-900, Brazil
| | - Marcus T. T. Silva
- Evandro Chagas National Institute of Infectious Diseases (INI), FIOCRUZ, Brazilian Ministry of Health, Rio de Janeiro 21040-900, Brazil
| | - Abelardo Q. C. Araújo
- Evandro Chagas National Institute of Infectious Diseases (INI), FIOCRUZ, Brazilian Ministry of Health, Rio de Janeiro 21040-900, Brazil
- Deolindo Couto Institute of Neurology (INDC), The Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 22290-140, Brazil
| | - Maria C. Gutierrez-Galhardo
- Evandro Chagas National Institute of Infectious Diseases (INI), FIOCRUZ, Brazilian Ministry of Health, Rio de Janeiro 21040-900, Brazil
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Fournier A, Fines M, Verdon R. Neurosifilide. Neurologia 2022. [DOI: 10.1016/s1634-7072(22)47092-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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Clinical features and incidence of visual improvement following systemic antibiotic treatment in patients with syphilitic uveitis. Sci Rep 2022; 12:12553. [PMID: 35869241 PMCID: PMC9307809 DOI: 10.1038/s41598-022-16780-5] [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: 03/01/2022] [Accepted: 07/15/2022] [Indexed: 11/15/2022] Open
Abstract
To describe the clinical features, longitudinal pattern, and incidence rate of improvement of visual acuity (VA) following antibiotic therapy in patients with syphilitic uveitis. A total of 36 patients were included in this retrospective study from 2009 to 2020. The longitudinal patterns of mean VA values during follow-up were analyzed using a linear mixed model. Most patients were men with HIV coinfection (81%) and presented with panuveitis (49%). The mean VA at baseline improved from 0.97 to 0.39 logMAR at 6 months and remained stable thereafter. The cumulative incidence of VA ≥ 20/25 achieved by 2 years was 70%. Receiving antibiotic therapy within four weeks of the onset of ocular symptoms (adjusted hazard ratio [aHR] 3.4, P = 0.012), absence of HIV coinfection (aHR 8.2, P < 0.001), absence of neurosyphilis (aHR 6.5, P = 0.037), better presenting VA (aHR 5.0, P = 0.003), and intermediate uveitis as opposed to panuveitis (aHR 11.5, P = 0.013) were predictive of achieving VA ≥ 20/25. Men with HIV coinfection represented the majority of our patients. Visual outcomes, in response to antibiotics, were favorable. Delayed treatment, poor presenting VA, presence of HIV coinfection, and concomitant neurosyphilis decreased the likelihood of VA restoration.
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Meyer AC, Njamnshi AK, Gisslen M, Price RW. Neuroimmunology of CNS HIV Infection: A Narrative Review. Front Neurol 2022; 13:843801. [PMID: 35775044 PMCID: PMC9237409 DOI: 10.3389/fneur.2022.843801] [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: 12/27/2021] [Accepted: 05/10/2022] [Indexed: 11/13/2022] Open
Abstract
This short review provides an overview of the interactions of human immunodeficiency virus type 1 (HIV), immune and inflammatory reactions, and CNS injury over the course of infection. Systemic infection is the overall driver of disease and serves as the “platform” for eventual CNS injury, setting the level of immune dysfunction and providing both the HIV seeding and immune-inflammatory responses to the CNS. These systemic processes determine the timing of and vulnerability to HIV-related neuronal injury which occurs in a separate “compartment” with features that parallel their systemic counterparts but also evolve independently. Direct CNS HIV infection, along with opportunistic infections, can have profound neurological consequences for the infected individual. HIV-related CNS morbidities are of worldwide importance but are enhanced by the particular epidemiological, socioeconomic and environmental factors that heighten the impact of HIV infection in Africa.
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Affiliation(s)
- Ana-Claire Meyer
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Alfred Kongnyu Njamnshi
- Neuroscience Laboratory, Faculty of Medicine and Biomedical Sciences, The University of Yaoundé I, Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon
| | - Magnus Gisslen
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Infectious Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Richard W. Price
- Department of Neurology, University of California San Francisco (UCSF), San Francisco, CA, United States
- *Correspondence: Richard W. Price
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Martínez-Ayala P, Quiñonez-Flores A, González-Hernández LA, Ruíz-Herrera VV, Zúñiga-Quiñones S, Alanis-Sánchez GA, Cabrera-Silva RI, Amador-Lara F, Sánchez-Reyes K, Álvarez-Zavala M, Vázquez-Limón JC, Sánchez-Navarro JP, Andrade-Villanueva JF. Clinical features associated with neurosyphilis in people living with HIV and late latent syphilis. Int J STD AIDS 2022; 33:330-336. [PMID: 34978502 PMCID: PMC8958567 DOI: 10.1177/09564624211063091] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background The diagnosis of neurosyphilis is a challenge, and the criteria for deciding when to perform a lumbar puncture are still controversial, especially in people living with HIV with a late latent syphilis diagnosis. Methods Retrospective analysis of demographic, clinical, and laboratory data of people with HIV and documented late latent syphilis or syphilis of unknown duration with a cerebrospinal fluid VDRL test. Results 122 patients were evaluated, of whom 52 had the diagnosis of neurosyphilis. Patients with and without neurosyphilis presented a similar viral load and lymphocyte CD4+ T-cell count. Neurological symptoms (OR 6.4, 95% CI 2.1–22.4; p < 0.01), serum VDRL titers of 1:32 (p<0.01), 1:64 (p = 0.055), and ≥1:128 (p < 0.001) were associated with neurosyphilis. Furthermore, serum VDRL ≥1:32 were associated with (OR 24.9, 95% CI 5.45–154.9; p < 0.001) or without (OR 6.5, 95% CI 2.0–29.2; p = 0.004) neurological symptoms with neurosyphilis; however, VDRL ≤1:16 with neurological symptoms can be associated with neurosyphilis (OR 7.6, 95% CI 1.03–64.3; p = 0.046). Conclusion Neurological symptoms, particularly headache, were predictors of neurosyphilis in people with HIV irrespective of their viral load and lymphocyte CD4+ T-cell count in late latent syphilis. A serum VDRL ≥1:32 increased the risk of neurosyphilis in patients with or without any symptoms.
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Affiliation(s)
- Pedro Martínez-Ayala
- HIV Unit, 103531Hospital Civil of Guadalajara "Fray Antonio Alcalde", Guadalajara, Mexico
| | | | - Luz Alicia González-Hernández
- HIV Unit, 103531Hospital Civil of Guadalajara "Fray Antonio Alcalde", Guadalajara, Mexico.,HIV and Immunodeficiencies Research Institute, 42571University of Guadalajara, Guadalajara, Mexico
| | | | - Sergio Zúñiga-Quiñones
- HIV Unit, 103531Hospital Civil of Guadalajara "Fray Antonio Alcalde", Guadalajara, Mexico
| | | | | | - Fernando Amador-Lara
- HIV Unit, 103531Hospital Civil of Guadalajara "Fray Antonio Alcalde", Guadalajara, Mexico
| | - Karina Sánchez-Reyes
- HIV and Immunodeficiencies Research Institute, 42571University of Guadalajara, Guadalajara, Mexico
| | - Monserrat Álvarez-Zavala
- HIV and Immunodeficiencies Research Institute, 42571University of Guadalajara, Guadalajara, Mexico
| | | | | | - Jaime Federico Andrade-Villanueva
- HIV Unit, 103531Hospital Civil of Guadalajara "Fray Antonio Alcalde", Guadalajara, Mexico.,HIV and Immunodeficiencies Research Institute, 42571University of Guadalajara, Guadalajara, Mexico
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Abstract
PURPOSE OF REVIEW This article focuses on the epidemiology, clinical presentation, diagnosis, and management of neurosyphilis, with an emphasis on clinically relevant issues faced by the practicing neurologist. RECENT FINDINGS The incidence of primary and secondary syphilis, the sexually transmissible stages of infection, has been on the rise for the past 2 decades. A concerning recent trend is the surge in cases of syphilis in women and of congenital syphilis. Neurosyphilis remains a relatively common complication that can occur at any stage of syphilis. Along with meningitis, meningovascular syphilis, which has been historically described as a late presentation of neurosyphilis, now frequently occurs as a manifestation of early infection. Late forms of neurosyphilis, including tabes dorsalis and general paresis, are less prevalent in the era of widespread penicillin use. As more laboratories adopt the reverse-sequence algorithm for syphilis testing, patients with serodiscordant results (ie, a reactive serum treponemal test with a nonreactive nontreponemal test) may present an increasingly encountered diagnostic challenge for neurologists. Although the CSF Venereal Disease Research Laboratory (VDRL) remains a mainstay of diagnostic testing for neurosyphilis, using a higher titer cutoff (greater than 1:320) for the Treponema pallidum particle agglutination assay (TPPA) from the CSF may improve the utility of the TPPA as a supporting criterion for the diagnosis of neurosyphilis. Penicillin G is the treatment of choice for neurosyphilis, although ceftriaxone may be a reasonable alternative therapy. SUMMARY A high index of suspicion and awareness of the variable clinical presentations of neurosyphilis are essential to the approach to this treatable infection. Neurologists should be mindful of the limitations of serologic testing in the diagnosis of neurosyphilis and exercise clinical judgment to determine the likelihood of the diagnosis.
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Ladzinski AT, George NB, Jagger BW. Bilateral peripheral facial paralysis during pregnancy: a presentation of acute HIV seroconversion. BMJ Case Rep 2021; 14:14/5/e242150. [PMID: 34035026 DOI: 10.1136/bcr-2021-242150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A G7P5A1 woman in her 40s presented to the emergency department at 37 weeks 3 days' estimated gestational age (EGA) with headache, lip tingling and several days of difficulty speaking. Physical examination demonstrated bilateral facial weakness in a peripheral distribution, as well as decreased corneal reflexes and cervical lymphadenopathy. Routine fourth generation HIV screening had previously been negative at 14 and 28 weeks' EGA. Brain MRI was unremarkable, and lumbar puncture disclosed a low-grade, mononuclear cerebrospinal fluid pleocytosis; the patient was treated supportively. She returned for induction of labour at 39 weeks, at which time HIV infection was unexpectedly diagnosed. While unilateral idiopathic peripheral facial paralysis is associated with the third trimester of pregnancy and the early postpartum period, bilateral facial paralysis is rare and should prompt work-up for an underlying systemic cause, such as HIV infection.
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Affiliation(s)
- Adam T Ladzinski
- Department of Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - Nicholas B George
- Departments of Medicine and Pediatric & Adolescent Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - Brett W Jagger
- Department of Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
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13
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Abstract
PURPOSE OF REVIEW In the context of a resurgence of syphilis worldwide, it can be anticipated that a rise in cases of ocular, otic, and neurosyphilis will also be seen. This article reviews the current epidemiology, manifestations, and approach to management and treatment. RECENT FINDINGS Although studies continue investigating alternate approaches and new diagnostic tests for ocular and neurosyphilis, few data exist to change current diagnostic algorithms and approaches to diagnosis, management, or follow up. SUMMARY The diagnosis of neurologic and eye/ear involvement with syphilis may be delayed because of a lack of specificity of findings, low suspicion for syphilis, fluctuation in symptoms, and/or similarities in presentation to other diseases. A high index of suspicion for syphilis and re-education about the protean manifestations of syphilis by all clinicians is required provide timely diagnosis and management of ocular, otic, and neurosyphilis.
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Dunaway SB, Maxwell CL, Tantalo LC, Sahi SK, Marra CM. Neurosyphilis Treatment Outcomes After Intravenous Penicillin G Versus Intramuscular Procaine Penicillin Plus Oral Probenecid. Clin Infect Dis 2021; 71:267-273. [PMID: 31504293 DOI: 10.1093/cid/ciz795] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 08/19/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Data comparing neurosyphilis treatment regimens are limited. METHODS Participants were enrolled in a study of cerebrospinal fluid (CSF) abnormalities in syphilis that was conducted at the University of Washington between April 2003 to May 2014. They were diagnosed with syphilis and referred by their providers due to concerns for neurosyphilis. We evaluated 150 people with CSF abnormalities who were treated with either intravenous aqueous penicillin G (PenG) or intramuscular aqueous procaine penicillin G plus oral probenecid (APPG-P). An abnormal CSF diagnosis was defined as a white blood cell (WBC) count >20/µL, a CSF protein reading >50 mg/dL, or a reactive CSF-Venereal Disease Research Laboratory test (VDRL). Hazard ratios for normalization of CSF or serum measures were determined using Cox regression. RESULTS In individuals treated with either PenG or APPG-P, CSF WBCs and CSF-VDRL reactivity normalized within 12 months after treatment, while protein normalized more slowly and less completely. There was no relationship between treatment regimen or human immunodeficiency virus (HIV) status and likelihood of normalization of any measure. Among those living with HIV, CSF WBC counts and CSF-VDRL reactivity were more likely to normalize in those treated with antiretrovirals. Unexpectedly, CSF WBCs were more likely to normalize in those with low CD4+ T cell counts. When neurosyphilis was more stringently defined as a reactive CSF-VDRL, the relationship with the CD4+ T cell count remained unchanged. CONCLUSIONS In the current antiretroviral treatment era, neurosyphilis treatment outcomes are not different for PenG and APPG-P, regardless of HIV status. The relationship between the normalization of CSF WBC counts and CD4+ T cell counts may indicate continued imprecision in neurosyphilis diagnostic criteria, due to HIV-related CSF pleocytosis.
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Affiliation(s)
- Shelia B Dunaway
- Department of Medicine, Division of Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Clare L Maxwell
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Lauren C Tantalo
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Sharon K Sahi
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Christina M Marra
- Department of Neurology, University of Washington, Seattle, Washington, USA
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15
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Abstract
PURPOSE OF REVIEW Neurosyphilis (NS) and Lyme neuroborreliosis (LNB) are spirochetal diseases with distinct clinical manifestations. The diagnosis of NS remains challenging due to imperfect diagnostic criteria and testing modalities. With LNB, misconceptions about diagnosis and treatment lead to considerable morbidity and drug related adverse effects. RECENT FINDINGS Although studies continue investigating alternate approaches and new diagnostic tests for NS, few data exist to change current approaches to diagnosis, management or follow up. In the diagnosis of LNB, the chemokine CXCL13 shows promising diagnostic accuracy. A systematic review discourages the use of cell-based assays when investigating Lyme disease. Clinical studies show no benefit from extended antibiotic treatment for patients with unspecific symptoms labelled as having Lyme disease. SUMMARY The diagnosis of NS may be delayed due to a lack of specificity of findings, low suspicion for syphilis, and/or similarities in presentation to other diseases. A high index of suspicion for syphilis is required provide timely diagnosis and management of NS. Fortunately, penicillin remains the treatment of choice. Overdiagnosis and overtreatment in patients labelled as having Lyme disease can be avoided by an evidence-based approach towards diagnosis and treatment.
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16
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Luo Y, Xie Y, Xiao Y. Laboratory Diagnostic Tools for Syphilis: Current Status and Future Prospects. Front Cell Infect Microbiol 2021; 10:574806. [PMID: 33628742 PMCID: PMC7897658 DOI: 10.3389/fcimb.2020.574806] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 12/14/2020] [Indexed: 12/29/2022] Open
Abstract
With the increasing number of patients infected with syphilis in the past 20 years, early diagnosis and early treatment are essential to decline syphilis prevalence. Owing to its diverse manifestations, which may occur in other infections, the disease often makes clinicians confused. Therefore, a sensitive method for detecting T. pallidum is fundamental for the prompt diagnosis of syphilis. Morphological observation, immunohistochemical assay, rabbit infectivity test, serologic tests, and nucleic acid amplification assays have been applied to the diagnosis of syphilis. Morphological observation, including dark-field microscopy, silver-staining, and direct fluorescent antibody staining for T. pallidum, can be used as a direct detection method for chancre specimens in primary syphilis. Immunohistochemistry is a highly sensitive and specific assay, especially in the lesion biopsies from secondary syphilis. Rabbit infectivity test is considered as a sensitive and reliable method for detecting T. pallidum in clinical samples and used as a historical standard for the diagnosis of syphilis. Serologic tests for syphilis are widely adopted using non-treponemal or treponemal tests by either the traditional or reverse algorithm and remain the gold standard in the diagnosis of syphilis patients. In addition, nucleic acid amplification assay is capable of detecting T. pallidum DNA in the samples from patients with syphilis. Notably, PCR is probably a promising method but remains to be further improved. All of the methods mentioned above play important roles in various stages of syphilis. This review aims to provide a summary of the performance characteristics of detection methods for syphilis.
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Affiliation(s)
- Yuting Luo
- Department of Clinical Laboratory, The Second Affiliated Hospital of University of South China, Hengyang, China
| | - Yafeng Xie
- Department of Clinical Laboratory, The Second Affiliated Hospital of University of South China, Hengyang, China
| | - Yongjian Xiao
- Department of Clinical Laboratory, The Second Affiliated Hospital of University of South China, Hengyang, China
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17
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Davis AP, Stern J, Tantalo L, Sahi S, Holte S, Dunaway S, Marra CM. How Well Do Neurologic Symptoms Identify Individuals With Neurosyphilis? Clin Infect Dis 2019; 66:363-367. [PMID: 29020214 DOI: 10.1093/cid/cix799] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 09/07/2017] [Indexed: 11/12/2022] Open
Abstract
Background Current guidelines recommend lumbar puncture (LP) in patients with syphilis who have neurologic symptoms. Methods A total of 81 human immunodeficiency virus (HIV)-uninfected individuals and 385 HIV-infected individuals enrolled in a study of cerebrospinal fluid (CSF) abnormalities in syphilis underwent LP and a structured symptom history, including assessment of headache; stiff neck; photophobia; ocular inflammation; vision, hearing, or sensory loss; or gait incoordination. Neurosyphilis was defined as a reactive CSF-Venereal Disease Research Laboratory (VDRL) test. Association between categorical variables was assessed using χ2, Fisher exact test, or logistic regression. Association between continuous and categorical variables was assessed using Mann-Whitney U test. Results CSF-VDRL was reactive in 20 (24.7%) HIV-uninfected and 68 (17.7%) HIV-infected (P = .14) individuals. No symptom was more common in HIV-uninfected individuals with neurosyphilis. Among the HIV-infected, the odds of a reactive CSF-VDRL were higher in those with mild or greater severity photophobia (2.0 [95% confidence interval [CI], 1.1-3.8]; P = .03), vision loss (2.3 [1.3-4.1]; P = .003), or gait incoordination (2.4 [1.3-4.4]; P = .006); or moderate or greater severity hearing loss (3.1 [1.3-7.5]; P = .01). Diagnostic specificity of these 4 symptoms for neurosyphilis was high when limited to moderate or greater severity (91.6%-100%); however, the diagnostic sensitivity was low (1.5%-38.1%). Conclusions Among HIV-infected patients with syphilis, 4 specific neurologic symptoms are more common in those with a reactive CSF-VDRL. Lack of symptoms does not guarantee that the CSF-VDRL is nonreactive, regardless of HIV status.
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Affiliation(s)
| | - Joshua Stern
- Department of Global Health, University of Washington, Seattle
| | - Lauren Tantalo
- Department of Neurology, University of Washington, Seattle
| | - Sharon Sahi
- Department of Neurology, University of Washington, Seattle
| | - Sarah Holte
- Department of Global Health, University of Washington, Seattle.,Department of Biostatistics, University of Washington, Seattle
| | - Shelia Dunaway
- Department of Medicine, University of Washington, Seattle
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18
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19
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Livelli A, Vaida F, Ellis RJ, Ma Q, Ferrara M, Clifford DB, Collier AC, Gelman BB, Marra CM, McArthur JC, McCutchan JA, Morgello S, Sacktor N, Simpson DM, Grant I, Letendre SL. Correlates of HIV RNA concentrations in cerebrospinal fluid during antiretroviral therapy: a longitudinal cohort study. Lancet HIV 2019; 6:e456-e462. [PMID: 31208949 DOI: 10.1016/s2352-3018(19)30143-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 11/26/2018] [Accepted: 04/03/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Few large projects have evaluated the factors that influence the HIV RNA concentrations (viral load) in cerebrospinal fluid (CSF) during antiretroviral therapy (ART) over time. We aimed to determine the correlates of HIV RNA in CSF in a large cohort. METHODS We analysed longitudinal data from adults living with HIV in the US CHARTER cohort. Participants in the CHARTER study were recruited from six US academic medical centres-in Baltimore (MD), Galveston (TX), New York (NY), St Louis (MO), San Diego (C92A), and Seattle (WA). Participants in this study had been assessed at least three times between Sept 4, 2003, and Sept 14, 2010, and were taking ART and underwent venous and lumbar puncture with measurement of HIV RNA concentration at all assessments. The lower limit of quantification of the HIV RNA assays was 50 copies per mL. Data were analysed with longitudinal mixed effects logistic regression to identify correlates of HIV RNA concentration (as a binary [detectable or not] and as a continuous variable) in CSF over time. We tested demographic characteristics, plasma HIV RNA, nadir and current CD4 cell count in blood, current CD8 cell count in blood, estimated duration of HIV infection, AIDS diagnosis, duration of ART, adherence to ART, ART characteristics, and CSF characteristics as potential correlates. FINDINGS At the time of analysis, 2207 assessments from 401 participants met the criteria for inclusion in this study. Mean duration of observation was 33·7 months (range 12-84). HIV RNA concentrations in 710 (32·2%) plasma specimens and in 255 (11·6%) CSF specimens were greater than the lower limit of quantification. The best multivariate model of HIV RNA concentration in CSF greater than the lower limit of quantification over time included increased plasma HIV RNA concentration (odds ratio 18·0 per 1 log10 copy per mL, 95% CI 11·3 to 28·8; p<0·0001), increased CSF leucocyte count (2·01 per 5 cells per μL, 1·61 to 2·39; p<0·0001), decreased CD4 cell count (0·53 per 5 square-root cells per μL, 0·35 to 0·79; p=0·0025), decreased CNS penetration-effectiveness value (0·71 per unit, 0·56 to 0·92; p=0·0078), increased CD8 cell count (1·51 per 5 square-root cells, 1·11 to 2·06; p=0·0089), and protease inhibitor use (3·26, 1·04 to 10·23; p=0·039; model R2=0·22, p<0·0001). Analyses of continuous HIV RNA concentration in CSF that accounted for censoring below the lower limit of quantification had similar findings, although increased HIV RNA concentrations in CSF were also associated with black ethnicity (change in log10 HIV RNA concentration in CSF 0·205, 0·0367 to 0·3733; p=0·017), increased total protein in CSF (0·0025, -0·0002 to 0·0052; p=0·069), and the presence of addictive-drug metabolites in urine (0·103, -0·013 to 0·219; p=0·081). INTERPRETATION The identified correlates of HIV RNA concentration in CSF during ART could strengthen clinical prediction of risk for failure to achieve or maintain HIV RNA suppression in CSF. Because most participants in this analysis were ART-experienced and were taking a three-drug regimen that did not include an integrase inhibitor, future research should focus on participants who are taking their first ART regimens or regimens that include integrase inhibitors or two drugs. FUNDING The work was supported by the National Institute of Mental Health and the National Institute of Neurological Disorders and Stroke.
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Affiliation(s)
- Alessandro Livelli
- Department of Psychology, Università degli Studi di Torino, Torino, Italy
| | - Florin Vaida
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - Ronald J Ellis
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA; Department of Neurosciences, University of California San Diego, San Diego, CA, USA
| | - Qing Ma
- Department of Pharmacy Practice, University at Buffalo, Buffalo, NY, USA
| | - Micol Ferrara
- Department of Medical Sciences, Università degli Studi di Torino, Torino, Italy
| | - David B Clifford
- Department of Neurology, Washington University, St Louis, MO, USA
| | - Ann C Collier
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Benjamin B Gelman
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
| | | | - Justin C McArthur
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - J Allen McCutchan
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Susan Morgello
- Department of Neurology, Mount Sinai School of Medicine, New York, NY, USA; Department of Pathology, and Department of Neuroscience, Mount Sinai School of Medicine, New York, NY, USA
| | - Ned Sacktor
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - David M Simpson
- Department of Neurology, Mount Sinai School of Medicine, New York, NY, USA
| | - Igor Grant
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - Scott L Letendre
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA; Department of Medicine, University of California San Diego, San Diego, CA, USA.
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20
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Abstract
Human immunodeficiency virus (HIV)-associated neurocognitive disorders (HAND) remain a common end-organ manifestation of viral infection. Subclinical and mild symptoms lead to neurocognitive and behavioral abnormalities. These are associated, in part, with viral penetrance and persistence in the central nervous system. Infections of peripheral blood monocytes, macrophages, and microglia are the primary drivers of neuroinflammation and neuronal impairments. While current antiretroviral therapy (ART) has reduced the incidence of HIV-associated dementia, milder forms of HAND continue. Depression, comorbid conditions such as infectious liver disease, drugs of abuse, antiretroviral drugs themselves, age-related neurodegenerative diseases, gastrointestinal maladies, and concurrent social and economic issues can make accurate diagnosis of HAND challenging. Increased life expectancy as a result of ART clearly creates this variety of comorbid conditions that often blur the link between the virus and disease. With the discovery of novel biomarkers, neuropsychologic testing, and imaging techniques to better diagnose HAND, the emergence of brain-penetrant ART, adjunctive therapies, longer life expectancy, and better understanding of disease pathogenesis, disease elimination is perhaps a realistic possibility. This review focuses on HIV-associated disease pathobiology with an eye towards changing trends in the face of widespread availability of ART.
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21
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Hobbs E, Vera JH, Marks M, Barritt AW, Ridha BH, Lawrence D. Neurosyphilis in patients with HIV. Pract Neurol 2018; 18:211-218. [PMID: 29478035 DOI: 10.1136/practneurol-2017-001754] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2018] [Indexed: 01/26/2023]
Abstract
Syphilis is a resurgent sexually transmitted infection in the UK that is disproportionately diagnosed in patients living with HIV, particularly in men who have sex with men. Syphilis appears to present differently in patients with HIV, particularly in those with severe immunosuppression. Progression to neurosyphilis is more common in HIV coinfection and can be asymptomatic, often for several years. The presentations of neurosyphilis vary but can include meningitis, meningovascular disease, general paresis and tabes dorsalis. There is debate about the circumstances in which to perform a lumbar puncture, and the current gold standard diagnostics have inadequate sensitivity. We recommend a pragmatic approach to lumbar punctures, interpreting investigations and deciding when to consider treatment with a neuropenetrative antibiotic regimen.
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Affiliation(s)
- Emily Hobbs
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Jaime H Vera
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK.,Lawson Unit, Royal Sussex County Hospital, Brighton, UK
| | - Michael Marks
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Andrew William Barritt
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK.,Hurstwood Park Neurological Centre, Haywards Heath, UK
| | - Basil H Ridha
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK.,Hurstwood Park Neurological Centre, Haywards Heath, UK
| | - David Lawrence
- Lawson Unit, Royal Sussex County Hospital, Brighton, UK.,Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
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22
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Marra CM. Other central nervous system infections: cytomegalovirus, Mycobacterium tuberculosis, and Treponema pallidum. HANDBOOK OF CLINICAL NEUROLOGY 2018; 152:151-166. [PMID: 29604973 DOI: 10.1016/b978-0-444-63849-6.00012-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Human immunodeficiency virus (HIV)-infected individuals are particularly susceptible to several central nervous system infections: human cytomegalovirus, which may cause encephalitis, ventriculitis, polyradiculitis, or polyradiculomyelitis; Mycobacterium tuberculosis, which can cause meningitis or space-occupying lesions; and Treponema pallidum subspecies pallidum (T. pallidum), which affects the meninges, cerebrospinal fluid, cranial nerves, and vasculature in early neurosyphilis, and additionally the brain and spinal cord parenchyma in late neurosyphilis. Central nervous system cytomegalovirus infection is seen in HIV-infected individuals with very advanced immunosuppression. Its prognosis is poor and optimal therapy has not been determined. Tuberculous meningitis has a high mortality in those also infected with HIV, especially in the developing world, and better therapies are urgently needed. As the rates of syphilis increase in the developed world, neurosyphilis and in particular ocular syphilis are increasingly reported. The likelihood of all three of these central nervous system infections is decreased in individuals who receive potent antiretroviral therapy.
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Affiliation(s)
- Christina M Marra
- Departments of Neurology and Medicine, University of Washington School of Medicine, Seattle, WA, United States.
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23
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Eggers C, Arendt G, Hahn K, Husstedt IW, Maschke M, Neuen-Jacob E, Obermann M, Rosenkranz T, Schielke E, Straube E. HIV-1-associated neurocognitive disorder: epidemiology, pathogenesis, diagnosis, and treatment. J Neurol 2017; 264:1715-1727. [PMID: 28567537 PMCID: PMC5533849 DOI: 10.1007/s00415-017-8503-2] [Citation(s) in RCA: 193] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/30/2017] [Accepted: 05/02/2017] [Indexed: 01/05/2023]
Abstract
The modern antiretroviral treatment of human immunodeficiency virus (HIV-1) infection has considerably lowered the incidence of opportunistic infections. With the exception of the most severe dementia manifestations, the incidence and prevalence of HIV-associated neurocognitive disorders (HAND) have not decreased, and HAND continues to be relevant in daily clinical practice. Now, HAND occurs in earlier stages of HIV infection, and the clinical course differs from that before the widespread use of combination antiretroviral treatment (cART). The predominant clinical feature is a subcortical dementia with deficits in the domains concentration, attention, and memory. Motor signs such as gait disturbance and impaired manual dexterity have become less prominent. Prior to the advent of cART, the cerebral dysfunction could at least partially be explained by the viral load and by virus-associated histopathological findings. In subjects where cART has led to undetectable or at least very low viral load, the pathogenic virus-brain interaction is less direct, and an array of poorly understood immunological and probably toxic phenomena are discussed. This paper gives an overview of the current concepts in the field of HAND and provides suggestions for the diagnostic and therapeutic management.
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Affiliation(s)
- Christian Eggers
- Department of Neurology, Krankenhaus Barmherzige Brüder, Seilerstätte 2, 4021, Linz, Austria.
| | - Gabriele Arendt
- Neurologische Klinik, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Katrin Hahn
- Neurologische Klinik, Charité, Berlin, Germany
| | - Ingo W Husstedt
- Klinik für Neurologie, Universitätsklinikum Münster, Münster, Germany
| | - Matthias Maschke
- Neurologische Abteilung, Brüderkrankenhaus Trier, Trier, Germany
| | - Eva Neuen-Jacob
- Institut für Neuropathologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Mark Obermann
- Direktor des Zentrums für Neurologie, Asklepios Kliniken Schildautal, Seesen, Germany
| | - Thorsten Rosenkranz
- Neurologische Abteilung, Asklepios-Klinik Hamburg-St. Georg, Hamburg, Germany
| | - Eva Schielke
- Praxis für Neurologie Berlin-Mitte, 10117, Berlin, Germany
| | - Elmar Straube
- HIV-Schwerpunktpraxis, 30890, Barsinghausen, Germany
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24
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Mehta SR, Pérez-Santiago J, Hulgan T, Day TRC, Barnholtz-Sloan J, Gittleman H, Letendre S, Ellis R, Heaton R, Patton S, Suben JD, Franklin D, Rosario D, Clifford DB, Collier AC, Marra CM, Gelman BB, McArthur J, McCutchan A, Morgello S, Simpson D, Connor J, Grant I, Kallianpur A. Cerebrospinal fluid cell-free mitochondrial DNA is associated with HIV replication, iron transport, and mild HIV-associated neurocognitive impairment. J Neuroinflammation 2017; 14:72. [PMID: 28359324 PMCID: PMC5374652 DOI: 10.1186/s12974-017-0848-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 03/21/2017] [Indexed: 12/19/2022] Open
Abstract
Background Mitochondria are abundant organelles critical for energy metabolism and brain function. Mitochondrial DNA (mtDNA), released during cellular injury and as part of the innate immune response to viral pathogens, contains CpG motifs that act as TLR-9 ligands. We investigated relationships between cerebrospinal fluid (CSF) cell-free mtDNA levels and HIV viral load (VL), biomarkers of inflammation and iron transport, and neurocognitive (NC) function in the CNS HIV Antiretroviral Therapy Effects Research (CHARTER) cohort. Methods We quantified cell-free mtDNA in CSF by droplet digital PCR in 332 CHARTER participants who underwent comprehensive neuropsychiatric evaluation. NC performance was assessed using the global deficit score (GDS) as either a continuous or a binary measure (GDS ≥ 0.5, impaired vs. GDS < 0.5, unimpaired). CSF, clinical, and biomarker data from the earliest available time point were analyzed. Cell-free mtDNA associations with CSF inflammation and iron-related biomarkers [CXCL10, IL-6, IL-8, TNF-a, transferrin (TF), ceruloplasmin (CP), and vascular endothelial growth factor (VEGF)], VL, and GDS were evaluated by multivariable regression. Results CSF cell-free mtDNA levels were significantly lower in participants with undetectable (vs. detectable) VL in either plasma (p < 0.001) or CSF (p < 0.001) and in those on antiretroviral therapy (ART; p < 0.001). Participants on ART with undetectable VL in both CSF and plasma had lower mtDNA levels than those with detectable VL in both compartments (p = 0.001). Higher mtDNA levels were observed in participants in the highest vs. lowest tertile (T3 vs. T1) of CSF CXCL10 (T3 vs. T1, p < 0.001) and TNF-a (T3 vs. T1, p < 0.05) in unadjusted analyses. MtDNA levels also correlated with CSF leukocyte count. After adjusting for CSF leukocyte count and VL, mtDNA levels were also associated with other inflammation- and iron-related biomarkers in CSF, including TF (T3 vs. T1, p < 0.05) and CP (T3 vs. T1, p < 0.05). With additional correction for ART use, mtDNA was also negatively associated with CSF VEGF (p < 0.05) and IL-6 (p = 0.05). We observed no associations of CSF mtDNA levels with age or GDS-defined NC impairment. Conclusions CSF cell-free mtDNA levels were associated with HIV RNA and ART status, as well as with biomarkers of iron transport and VEGF, a growth factor with known effects on mitochondrial integrity and autophagy. CSF mtDNA may be a biomarker of iron dysregulation and/or neuroinflammation during HIV infection. Electronic supplementary material The online version of this article (doi:10.1186/s12974-017-0848-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sanjay R Mehta
- Department of Medicine, University of California-San Diego, San Diego, CA, USA. .,Department of Medicine, San Diego Veterans Affairs Medical Center, San Diego, CA, USA.
| | | | - Todd Hulgan
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University, Nashville, TN, USA
| | - Tyler R C Day
- Division of Biostatistics, Washington University, St. Louis, MO, USA
| | - Jill Barnholtz-Sloan
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Haley Gittleman
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Scott Letendre
- Department of Medicine, University of California-San Diego, San Diego, CA, USA
| | - Ronald Ellis
- Department of Neurology, University of California-San Diego, San Diego, CA, USA
| | - Robert Heaton
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Stephanie Patton
- Department of Neurosurgery, Pennsylvania State/Hershey College of Medicine, Hershey, PA, USA
| | - Jesse D Suben
- Department of Medicine, University of California-San Diego, San Diego, CA, USA
| | - Donald Franklin
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Debralee Rosario
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - David B Clifford
- Department of Neurology, Washington University, St. Louis, MO, USA
| | - Ann C Collier
- Department of Medicine, University of Washington, Seattle, WA, USA
| | | | - Benjamin B Gelman
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
| | - Justin McArthur
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Allen McCutchan
- Department of Medicine, University of California-San Diego, San Diego, CA, USA
| | - Susan Morgello
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David Simpson
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James Connor
- Department of Neurosurgery, Pennsylvania State/Hershey College of Medicine, Hershey, PA, USA
| | - Igor Grant
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Asha Kallianpur
- Genomic Medicine Institute/Lerner Research Institute Cleveland Clinic, Cleveland, OH, USA.,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
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25
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Salamano R, Ballesté R, Perna A, Rodriguez N, Lombardo D, García N, López P, Cappuccio P. Cerebrospinal fluid examination may be useful in diagnosing neurosyphilis in asymptomatic HIV+ patients with syphilis. ARQUIVOS DE NEURO-PSIQUIATRIA 2016; 74:128-32. [PMID: 26982990 DOI: 10.1590/0004-282x20160016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 11/03/2015] [Indexed: 11/21/2022]
Abstract
Lumbar puncture in neurologically asymptomatic HIV+ patients is still under debate. There are different criteria for detecting neurosyphilis through cerebrospinal fluid (CSF), especially in cases that are negative through the Venereal Disease Research Laboratory (VDRL), regarding cellularity and protein content. However, a diagnosis of neurosyphilis can still exist despite negative VDRL. Treponema pallidum hemagglutination assay (TPHA) titers and application of the TPHA index in albumin and IgG improve the sensitivity, with a high degree of specificity. Thirty-two patients were selected for this study. VDRL was positive in five of them. The number of diagnoses reached 14 when the other techniques were added. It was not determined whether cellularity and increased protein levels were auxiliary tools in the diagnosis. According to our investigation, CSF analysis using the abovementioned techniques may be useful in diagnosing neurosyphilis in these patients.
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Affiliation(s)
- Ronald Salamano
- Sección Neuroinfectología, Instituto de Neurología, Hospital de Clínicas, Montevideo, Uruguay
| | - Raquel Ballesté
- Sección Inmunología, Departamento de Laboratorio Clínico, Hospital de Clínicas, Montevideo, Uruguay
| | - Abayubá Perna
- Sección Neuroinfectología, Instituto de Neurología, Hospital de Clínicas, Montevideo, Uruguay
| | - Natalia Rodriguez
- Sección Inmunología, Departamento de Laboratorio Clínico, Hospital de Clínicas, Montevideo, Uruguay
| | - Diego Lombardo
- Sección Neuroinfectología, Instituto de Neurología, Hospital de Clínicas, Montevideo, Uruguay
| | - Natalia García
- Sección Inmunología, Departamento de Laboratorio Clínico, Hospital de Clínicas, Montevideo, Uruguay
| | - Pablo López
- Sección Inmunología, Departamento de Laboratorio Clínico, Hospital de Clínicas, Montevideo, Uruguay
| | - Pablo Cappuccio
- Servicio de Enfermedades Infecto-Contagiosas, Hospital Pasteur, Montevideo, Uruguay
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26
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Tipirneni A, Koch S, Romano JG, Malik AM. A 27-Year-Old Man With Right-Sided Hemiparesis and Dysarthria. Neurohospitalist 2016; 6:174-180. [PMID: 27695601 DOI: 10.1177/1941874416648197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Anita Tipirneni
- Cerebrovascular Division, Department of Neurology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL, USA
| | - Sebastian Koch
- Cerebrovascular Division, Department of Neurology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL, USA
| | - Jose G Romano
- Cerebrovascular Division, Department of Neurology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL, USA
| | - Amer M Malik
- Cerebrovascular Division, Department of Neurology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL, USA
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27
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Tuddenham S, Ghanem KG. Ocular syphilis: opportunities to address important unanswered questions. Sex Transm Infect 2016; 92:563-565. [PMID: 27116973 DOI: 10.1136/sextrans-2016-052570] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 03/24/2016] [Accepted: 04/02/2016] [Indexed: 11/04/2022] Open
Affiliation(s)
- Susan Tuddenham
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Khalil G Ghanem
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Kingston M, French P, Higgins S, McQuillan O, Sukthankar A, Stott C, McBrien B, Tipple C, Turner A, Sullivan AK, Radcliffe K, Cousins D, FitzGerald M, Fisher M, Grover D, Higgins S, Kingston M, Rayment M, Sullivan A. UK national guidelines on the management of syphilis 2015. Int J STD AIDS 2015; 27:421-46. [PMID: 26721608 DOI: 10.1177/0956462415624059] [Citation(s) in RCA: 146] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 12/02/2015] [Indexed: 12/12/2022]
Abstract
These guidelines are an update for 2015 of the 2008 UK guidelines for the management of syphilis. The writing group have piloted the new BASHH guideline methodology, notably using the GRADE system for assessing evidence and making recommendations. We have made significant changes to the recommendations for screening infants born to mothers with positive syphilis serology and to facilitate accurate and timely communication between the teams caring for mother and baby we have developed a birth plan. Procaine penicillin is now an alternative, not preferred treatment, for all stages of syphilis except neurosyphilis, but the length of treatment for this is shortened. Other changes are summarised at the start of the guideline.
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Affiliation(s)
- M Kingston
- Manchester Centre for Sexual Health, Manchester, UK
| | - P French
- Mortimer Market Centre, London, UK
| | - S Higgins
- North Manchester General Hospital, Manchester, UK
| | - O McQuillan
- Manchester Centre for Sexual Health, Manchester, UK
| | - A Sukthankar
- Manchester Centre for Sexual Health, Manchester, UK
| | - C Stott
- Manchester Centre for Sexual Health, Manchester, UK
| | - B McBrien
- Manchester Centre for Sexual Health, Manchester, UK
| | - C Tipple
- Jefferiss Wing Centre for Sexual Health, Imperial College Health Care NHS Trust, London, UK
| | - A Turner
- The Public Health England/Clinical Virology Laboratory, Manchester Royal Infirmary, Manchester, UK
| | | | | | - Keith Radcliffe
- Clinical Effectiveness Group, British Association for Sexual Health and HIV, Macclesfield, UK
| | - Darren Cousins
- Clinical Effectiveness Group, British Association for Sexual Health and HIV, Macclesfield, UK
| | - Mark FitzGerald
- Clinical Effectiveness Group, British Association for Sexual Health and HIV, Macclesfield, UK
| | - Martin Fisher
- Clinical Effectiveness Group, British Association for Sexual Health and HIV, Macclesfield, UK
| | - Deepa Grover
- Clinical Effectiveness Group, British Association for Sexual Health and HIV, Macclesfield, UK
| | - Stephen Higgins
- Clinical Effectiveness Group, British Association for Sexual Health and HIV, Macclesfield, UK
| | - Margaret Kingston
- Clinical Effectiveness Group, British Association for Sexual Health and HIV, Macclesfield, UK
| | - Michael Rayment
- Clinical Effectiveness Group, British Association for Sexual Health and HIV, Macclesfield, UK
| | - Ann Sullivan
- Clinical Effectiveness Group, British Association for Sexual Health and HIV, Macclesfield, UK
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Firlag-Burkacka E, Swiecki P, Cielniak I, Siwak E, Gizinska J, Bakowska E, Kubicka J, Pulik P, Kowalski J, Podlasin R, Horban A. High frequency of neurosyphilis in HIV-positive patients diagnosed with early syphilis. HIV Med 2015; 17:323-6. [PMID: 27089861 DOI: 10.1111/hiv.12307] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Syphilis is an infection frequently seen with HIV, and European guidelines on the management of syphilis suggest that HIV-infected patients may have an increased risk of early neurological involvement, sometimes asymptomatic. Recent study shows a relationship between neurosyphilis and cerebrospinal fluid (CSF) HIV viral load (VL), which in turn may be associated with subsequent neurocognitive decline. OBJECTIVES AND METHODS The aim of the study was estimation of the frequency of neurosyphilis among HIV-positive patients with early syphilis. The study included all patients diagnosed with early syphilis who had lumbar puncture performed in the years 2008-2012. Analysis included CSF parameters (serology, mononuclear cells, protein, glucose, chloride and lactate levels), CD4 count, serum VL and highly active antiretroviral therapy (HAART). Diagnosis of neurosyphilis was confirmed by CSF serology [positive fluorescent treponemal antibody and/or Venereal Disease Research Laboratory (VDRL) test(s)] and increased number of mononuclear cells. Statistical analysis included χ(2) tests with an accepted significance level of P < 0.05. RESULTS Lumbar puncture was performed in 72 patients, all men, with median age 33 (interquartile range 11) years. Neurosyphilis was confirmed in 65 (90.28%) of the patients. No statistically significant association between CSF parameters and CD4 count was found. However, statistically significant associations were found only between pleocytosis and serum VL > 1000 HIV-1 RNA copies/mL (P = 0.0451), as well as HAART treatment (P = 0.0328). The proportion of confirmed neurosyphilis cases, also in patients with low serum VDRL titres, was very high. CONCLUSIONS Considering the high proportion of patients who objected to having LP performed in the absence of neurological symptoms and the risk associated with this procedure, it may be preferable to use treatments with good CNS penetration in all HIV-positive patients with early syphilis.
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Affiliation(s)
| | - P Swiecki
- Hospital of Infectious Diseases, Warsaw, Poland
| | - I Cielniak
- Hospital of Infectious Diseases, Warsaw, Poland
| | - E Siwak
- Hospital of Infectious Diseases, Warsaw, Poland
| | - J Gizinska
- Hospital of Infectious Diseases, Warsaw, Poland
| | - E Bakowska
- Hospital of Infectious Diseases, Warsaw, Poland
| | - J Kubicka
- Hospital of Infectious Diseases, Warsaw, Poland
| | - P Pulik
- Hospital of Infectious Diseases, Warsaw, Poland
| | - J Kowalski
- Hospital of Infectious Diseases, Warsaw, Poland
| | - R Podlasin
- Hospital of Infectious Diseases, Warsaw, Poland
| | - A Horban
- Warsaw Medical University, Warsaw, Poland
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30
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Tuddenham S, Ghanem KG. Emerging trends and persistent challenges in the management of adult syphilis. BMC Infect Dis 2015; 15:351. [PMID: 26286439 PMCID: PMC4545322 DOI: 10.1186/s12879-015-1028-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 07/15/2015] [Indexed: 01/13/2023] Open
Abstract
There are an estimated 10.6 million incident cases of syphilis worldwide each year. We highlight some persistent challenges and emerging trends in the clinical management of syphilis with a particular focus on therapy, serology, diagnostics, and prevention. Decades after the introduction of penicillin, the optimal management of early syphilis continues to be a controversial topic, particularly in the setting of HIV co-infection. Similarly, the need for routine lumbar puncture in HIV co-infected asymptomatic persons is an unanswered question. Despite advances in both automation and point-of-care diagnostics, we continue to rely on indirect measures of disease activity to manage this infection. As syphilis rates in some populations continue to rise, novel and effective prevention strategies are needed.
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Affiliation(s)
- Susan Tuddenham
- Johns Hopkins University School of Medicine, 5200 Eastern Ave, MFL Center Tower #378, Baltimore, MD, 21224, USA. .,Division of Infectious Diseases, 1830 E. Monument Street, Room 442, Baltimore, MD, 21287, USA.
| | - Khalil G Ghanem
- Johns Hopkins University School of Medicine, 5200 Eastern Ave, MFL Center Tower #378, Baltimore, MD, 21224, USA. .,Division of Infectious Diseases, 1830 E. Monument Street, Room 442, Baltimore, MD, 21287, USA.
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31
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[HIV 1-associated neurocognitive disorder: current epidemiology, pathogenesis, diagnosis and management]. DER NERVENARZT 2015; 85:1280-90. [PMID: 25292163 DOI: 10.1007/s00115-014-4082-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
By restoring the immunological function the modern antiretroviral treatment of human immunodeficiency virus (HIV-1) infection has considerably lowered the incidence of opportunistic infections. As opposed to the classical manifestations of HIV-induced immunosuppression the incidence and prevalence of HIV-associated neurocognitive disorders (HAND) has not noticeably decreased and HAND continues to be relevant in daily clinical practice. At present, HAND occurs in earlier stages of HIV infection, and the clinical course differs from that before the introduction of combination antiretroviral treatment (cART). The predominant clinical manifestation is a subcortical dementia with deficits in the domains attention, concentration and memory. Signs of central motor pathway lesions have become less frequent and less prominent. Prior to the advent of cART the cerebral dysfunction could at least partially be explained by the viral load and by virus-associated histopathological findings. In patients with at least partially successfully treated infections, this relationship no longer exists, but a plethora of poorly understood immunological and probably toxic phenomena are under discussion.This consensus paper summarizes the progress made in the last 12 years in the field of HAND and provides suggestions for the diagnostic and therapeutic management.
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Abstract
A review article is addressed the issue of the diagnosis and treatment of neurosyphilis that is developing against the background of HIV-infection. HIV-infected patients are at higher risk of neurologic, ocular and auricular manifestation of syphilis as well as treatment failures and relapses. Diagnosis of neurosyphilis in HIV-positive patients is complicated because both infections cause similar changes in the cerebrospinal fluid (CSF). The effectiveness of neurosyphilis treatment in patients with HIV co-infection is difficult to estimate, since the normalization of their CSF goes slower comparing to HIV-negatives. The increase in incidence of syphilis and HIV co-infection is anticipated in the coming years. This necessitates a comprehensive study of the problem and requires the development of new approaches to neurosyphilis diagnosis and treatment in co-infected patients.
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33
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Ho EL, Spudich SS. Neurosyphilis and the impact of HIV infection. Sex Health 2015; 12:148-54. [DOI: 10.1071/sh14195] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 01/18/2015] [Indexed: 11/23/2022]
Abstract
Neurosyphilis is a complication of systemic syphilis. This review of the clinical presentation, diagnostic laboratory findings, treatment and management of neurosyphilis discusses the impact of HIV and the specific challenges it brings, focusing on areas of controversy, and highlighting important questions that remain to be answered.
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34
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Ragin AB, Wu Y, Gao Y, Keating S, Du H, Sammet C, Kettering CS, Epstein LG. Brain alterations within the first 100 days of HIV infection. Ann Clin Transl Neurol 2014; 2:12-21. [PMID: 25642430 PMCID: PMC4301670 DOI: 10.1002/acn3.136] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 09/27/2014] [Accepted: 09/29/2014] [Indexed: 01/12/2023] Open
Abstract
Objective Brain involvement is a serious complication of HIV infection. The earliest changes in the brain, which represents an anatomic site for viral persistence, are largely unknown. Methods This investigation used quantitative Magnetic Resonance methodologies, including high resolution and diffusion tensor (DTI) imaging, to evaluate the brain in 15 HIV and 20 seronegative subjects. All HIV subjects were antibody nonreactive with assay-estimated infection duration of less than 100 days. Results Brain volumetric analysis revealed reduced parenchyma with enlargement of the third ventricle and brainstem. DTI quantified loss of white matter integrity in the corpus callosum and diffusion alterations in caudate. Cognitive differences were indicated in psychomotor speed and visual recall. There were no differences between antiretroviral-initiated and naïve HIV subgroups. Interpretation These findings, quantified within 100 days of infection, shed light on the earliest brain changes in HIV infection. Onset of neural injury may date to initial viral invasion and the transient early period of unchecked viremia and marked immunosuppression of the seroconversion period.
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Affiliation(s)
- Ann B Ragin
- Department of Radiology, Feinberg School of Medicine, Northwestern University Chicago, Illinois
| | - Ying Wu
- Center for Advanced Imaging, NorthShore University Hospital Evanston, Illinois
| | - Yi Gao
- Department of Statistics, Northwestern University Evanston, Illinois
| | - Sheila Keating
- Blood Systems Research Institute San Francisco, California
| | - Hongyan Du
- Clinical & Research Informatics, NorthShore University Hospital Evanston, Illinois
| | - Christina Sammet
- Department of Radiology, Feinberg School of Medicine, Northwestern University Chicago, Illinois ; Department of Medical Imaging, Ann and Robert H. Lurie Children's Hospital of Chicago Chicago, Illinois
| | - Casey S Kettering
- Department of Radiology, Feinberg School of Medicine, Northwestern University Chicago, Illinois
| | - Leon G Epstein
- Department of Neurology, Ann and Robert H. Lurie Children's Hospital of Chicago Chicago, Illinois ; Department of Pediatrics & Neurology, Feinberg School of Medicine, Northwestern University Chicago, Illinois
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35
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Libbey JE, Fujinami RS. Adaptive immune response to viral infections in the central nervous system. HANDBOOK OF CLINICAL NEUROLOGY 2014. [PMID: 25015488 DOI: 10.1016/b978-0-444-0.00010-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Jane E Libbey
- Department of Pathology, University of Utah, Salt Lake City, UT, USA
| | - Robert S Fujinami
- Department of Pathology, University of Utah, Salt Lake City, UT, USA.
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36
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Libbey JE, Fujinami RS. Adaptive immune response to viral infections in the central nervous system. HANDBOOK OF CLINICAL NEUROLOGY 2014; 123:225-47. [PMID: 25015488 DOI: 10.1016/b978-0-444-53488-0.00010-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jane E Libbey
- Department of Pathology, University of Utah, Salt Lake City, UT, USA
| | - Robert S Fujinami
- Department of Pathology, University of Utah, Salt Lake City, UT, USA.
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37
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Katchanov J, von Kleist M, Arastéh K, Stocker H. 'Time-to-amphotericin B' in cryptococcal meningitis in a European low-prevalence setting: analysis of diagnostic delays. QJM 2014; 107:799-803. [PMID: 24722846 DOI: 10.1093/qjmed/hcu077] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cryptococcal meningitis is a rare disease in Europe, resulting in delayed recognition and slower initiation of specific treatment. AIM To analyse the time-to-treatment and the factors that delay the diagnosis and treatment in the low-prevalence setting of a European centre. DESIGN Retrospective review METHODS We reviewed full medical records of all adult patients with cryptococcal meningitis referred to an HIV centre in Berlin, Germany in 10-year period between 1st of October 2003 and 31st of September 2013. Multivariant statistics with bootstrap-resampling were performed. RESULTS We identified 19 patients with a diagnosis of HIV-related cryptococcal meningitis (0.55% of all consecutive HIV-infected patients). In almost half of our patients the diagnosis was not considered initially on admission to the secondary care centre and the first diagnostic clue being an accidental positive blood, cerebrospinal fluid or bronchoalveolar lavage culture growing Cryptococcus neoformans. The median time-to-treatment was 5 days (range: 1-16). Known positive HIV status accelerated the time-to-diagnosis (p < 0.05) by a median of 1.89 days, whereas the CSF cell count ≤ 10/µl delayed diagnosis by a median time of 1.93 days (p < 0.1). CONCLUSIONS Diagnostic delays could be avoided by encouraging practising physicians (i) to consider cryptococcal meningitis in immunosuppressed HIV-infected patients irrespective of neurological symptoms; (ii) to test for India ink, cryptococcal antigen and fungal cultures in immunosuppressed HIV-infected patients with normal CSF; (iii) to consider a possibility of underlying HIV infection in patients with unknown HIV status presenting with meningitis; and (iv) to consider early targeted HIV testing in persons at risk according to locally validated criteria.
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Affiliation(s)
- J Katchanov
- From the Department of Infectious Diseases, Vivantes Auguste-Viktoria Klinikum, Berlin and Department of Mathematics and Computer Science, Freie Universität Berlin, Germany
| | - M von Kleist
- From the Department of Infectious Diseases, Vivantes Auguste-Viktoria Klinikum, Berlin and Department of Mathematics and Computer Science, Freie Universität Berlin, Germany
| | - K Arastéh
- From the Department of Infectious Diseases, Vivantes Auguste-Viktoria Klinikum, Berlin and Department of Mathematics and Computer Science, Freie Universität Berlin, Germany
| | - H Stocker
- From the Department of Infectious Diseases, Vivantes Auguste-Viktoria Klinikum, Berlin and Department of Mathematics and Computer Science, Freie Universität Berlin, Germany
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Evering TH, Kamau E, St Bernard L, Farmer CB, Kong XP, Markowitz M. Single genome analysis reveals genetic characteristics of Neuroadaptation across HIV-1 envelope. Retrovirology 2014; 11:65. [PMID: 25125210 PMCID: PMC4145222 DOI: 10.1186/s12977-014-0065-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 07/24/2014] [Indexed: 01/25/2023] Open
Abstract
Background The widespread use of highly effective, combination antiretroviral therapy (cART) has led to a significant reduction in the incidence of HIV-associated dementia (HAD). Despite these advances, the prevalence of HIV-1 associated neurocognitive disorders (HANDs) has been estimated at approximately 40%-50%. In the cART era, the majority of this disease burden is represented by asymptomatic neurocognitive impairment and mild neurocognitive disorder (ANI and MND respectively). Although less severe than HAD, these diagnoses carry with them substantial morbidity. Results In this cross-sectional study, single genome amplification (SGA) was used to sequence 717 full-length HIV-1 envelope (env) clade B variants from the paired cerebrospinal fluid (CSF) and blood plasma samples of fifteen chronically infected HIV-positive individuals with normal neurocognitive performance (NCN), ANI and MND. Various degrees of compartmentalization were found across disease states and history of cART utilization. In individuals with compartmentalized virus, mean HIV-1 env population diversity was lower in the CSF than plasma-derived variants. Overall, mean V1V2 loop length was shorter in CSF-derived quasispecies when compared to contemporaneous plasma populations, and this was found to correlate with a lower mean number of N-linked glycosylation sites in this region. A number of discrete amino acid positions that correlate strongly with compartmentalization in the CSF were identified in both variable and constant regions of gp120 as well as in gp41. Correlated mutation analyses further identified that a subset of amino acid residues in these compartmentalization “hot spot” positions were strongly correlated with one another, suggesting they may play an important, definable role in the adaptation of viral variants to the CSF. Analysis of these hot spots in the context of a well-supported crystal structure of HIV-1 gp120 suggests mechanisms through which amino acid differences at the identified residues might contribute to viral compartmentalization in the CSF. Conclusions The detailed analyses of SGA-derived full length HIV-1 env from subjects with both normal neurocognitive performance and the most common HAND diagnoses in the cART era allow us to identify novel and confirm previously described HIV-1 env genetic determinants of neuroadaptation and relate potential motifs to HIV-1 env structure and function. Electronic supplementary material The online version of this article (doi:10.1186/s12977-014-0065-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Teresa H Evering
- Aaron Diamond AIDS Research Center, an affiliate of the Rockefeller University, New York, USA.
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39
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Marra CM. Headache in HIV-Infected Patients: Much to Consider. Headache 2014; 54:951. [DOI: 10.1111/head.12355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Christina M. Marra
- Departments of Neurology; Medicine (Infectious Diseases); University of Washington School of Medicine; Seattle WA USA
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40
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Abstract
Syphilis is a sexually transmitted infection caused by Treponema pallidum. A total of 13,106 cases of primary and secondary syphilis were reported in the United States in 2011 and the rate of infection has increased in subgroups, particularly men who have sex with men. The disease is mainly diagnosed through clinical findings and serologic testing. However, no single serologic test of syphilis is sufficient. Hence, the serologic diagnosis of syphilis requires the detection of 2 types of antibodies (nontreponemal antibodies and treponemal antibodies). The paradigm in syphilis testing has recently shifted in many centers to screen with a treponemal antibody test, reflexing to a nontreponemal test if the treponemal antibody test is positive. This reverse of the traditional algorithm may not be widely recognized among clinicians.
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Affiliation(s)
| | - Steven C Johnson
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora
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41
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Abstract
With the widespread use of combination antiretroviral therapy (cART), the incidence of central nervous system (CNS) opportunistic infections and coinfections has significantly decreased. This review focuses on the clinical presentation, diagnostic laboratory and radiologic findings, as well as the treatment of neurosyphilis, progressive multifocal leukoencephalopathy, primary CNS lymphoma, and toxoplasmosis, which are CNS opportunistic infections and coinfections that are most relevant to clinicians in North America.
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Affiliation(s)
- Emily L. Ho
- Department of Neurology, Harborview Medical Center, Seattle, Washington
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42
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Affiliation(s)
- Marie F Grill
- Department of Neurology, Division of Hospital Neurology, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Richard W Price
- Department of Neurology, School of Medicine, University of California San Francisco, San Francisco, CA, USA.
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Dumaresq J, Langevin S, Gagnon S, Serhir B, Deligne B, Tremblay C, Tsang RSW, Fortin C, Coutlée F, Roger M. Clinical prediction and diagnosis of neurosyphilis in HIV-infected patients with early Syphilis. J Clin Microbiol 2013; 51:4060-6. [PMID: 24088852 PMCID: PMC3838065 DOI: 10.1128/jcm.01989-13] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Accepted: 09/24/2013] [Indexed: 11/20/2022] Open
Abstract
The diagnosis of neurosyphilis (NS) is a challenge, especially in HIV-infected patients, and the criteria for deciding when to perform a lumbar puncture (LP) in HIV-infected patients with syphilis are controversial. We retrospectively reviewed demographic, clinical, and laboratory data from 122 cases of HIV-infected patients with documented early syphilis who underwent an LP to rule out NS, and we evaluated 3 laboratory-developed validated real-time PCR assays, the Treponema pallidum particle agglutination (TPPA) assay, the fluorescent treponemal antibody absorption (FTA-ABS) assay, and the line immunoassay INNO-LIA Syphilis, for the diagnosis of NS from cerebrospinal fluid (CSF) samples of these patients. NS was defined by a reactive CSF-VDRL test result and/or a CSF white blood cell (WBC) count of >20 cells/μl. Thirty of the 122 patients (24.6%) had early NS. Headache, visual symptoms, a CD4 cell count of <500 cells/μl, and viremia, as defined by an HIV-1 RNA count of ≥50 copies/ml, were associated with NS in multivariate analysis (P = <0.001 for each factor). Blood serum rapid plasma reagin (RPR) titers were not associated with early NS (P = 0.575). For the diagnosis of NS, the PCR, FTA-ABS, TPPA, and INNO-LIA assays had sensitivities of 58%, 100%, 68%, and 100%, specificities of 67%, 12%, 49%, and 13%, and negative predictive values of 85%, 100%, 84%, and 100%, respectively. Visual disturbances, headache, uncontrolled HIV-1 viremia, and a CD4 cell count of <500 cells/μl were predictors of NS in HIV-infected patients with early syphilis, while blood serum RPR titers were not; therefore, RPR titers should not be used as the sole criterion for deciding whether to perform an LP in early syphilis. When applied to CSF samples, the INNO-LIA Syphilis assay easily helped rule out NS.
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Affiliation(s)
- Jeannot Dumaresq
- Département de Microbiologie et d'Infectiologie, Centre Hospitalier Affilié Universitaire Hôtel-Dieu de Lévis, Lévis, Québec, Canada
| | - Stéphanie Langevin
- Département de Microbiologie et d'Infectiologie, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Simon Gagnon
- Département de Microbiologie et d'Infectiologie, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Bouchra Serhir
- Laboratoire de Santé Publique du Québec, Sainte-Anne-de-Bellevue, Québec, Canada
| | - Benoît Deligne
- Département de Médecine Interne et Vasculaire, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Cécile Tremblay
- Département de Microbiologie et d'Infectiologie, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
- Laboratoire de Santé Publique du Québec, Sainte-Anne-de-Bellevue, Québec, Canada
| | - Raymond S. W. Tsang
- Division of Syphilis Diagnostics and Vaccine Preventable Bacterial Diseases, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Claude Fortin
- Département de Microbiologie et d'Infectiologie, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
- Département de Microbiologie et d'Immunologie de l'Université de Montréal, Montréal, Québec, Canada
| | - François Coutlée
- Département de Microbiologie et d'Infectiologie, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
- Département de Microbiologie et d'Immunologie de l'Université de Montréal, Montréal, Québec, Canada
| | - Michel Roger
- Département de Microbiologie et d'Infectiologie, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
- Département de Microbiologie et d'Immunologie de l'Université de Montréal, Montréal, Québec, Canada
- Laboratoire d'Immunogénétique, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
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44
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Abstract
Bacterial CNS infections comprise a wide spectrum of diseases, which may be acquired outside or inside the hospital, affect immunocompetent or immunocompromised patients, and be associated with trauma or procedures, as well as other exposures.
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Affiliation(s)
- Katharina M Busl
- Department of Neurological Sciences, Section of Neurocritical Care, Rush University Medical Center, 1725 West Harrison Street, POB Suite 1121, Chicago, IL, 60612, USA,
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45
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Dahiya S, Irish BP, Nonnemacher MR, Wigdahl B. Genetic variation and HIV-associated neurologic disease. Adv Virus Res 2013; 87:183-240. [PMID: 23809924 DOI: 10.1016/b978-0-12-407698-3.00006-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
HIV-associated neurologic disease continues to be a significant complication in the era of highly active antiretroviral therapy. A substantial subset of the HIV-infected population shows impaired neuropsychological performance as a result of HIV-mediated neuroinflammation and eventual central nervous system (CNS) injury. CNS compartmentalization of HIV, coupled with the evolution of genetically isolated populations in the CNS, is responsible for poor prognosis in patients with AIDS, warranting further investigation and possible additions to the current therapeutic strategy. This chapter reviews key advances in the field of neuropathogenesis and studies that have highlighted how molecular diversity within the HIV genome may impact HIV-associated neurologic disease. We also discuss the possible functional implications of genetic variation within the viral promoter and possibly other regions of the viral genome, especially in the cells of monocyte-macrophage lineage, which are arguably key cellular players in HIV-associated CNS disease.
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Affiliation(s)
- Satinder Dahiya
- Department of Microbiology and Immunology, Center for Molecular Virology and Translational Neuroscience, Institute for Molecular Medicine and Infectious Disease, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Bryan P Irish
- Department of Microbiology and Immunology, Center for Molecular Virology and Translational Neuroscience, Institute for Molecular Medicine and Infectious Disease, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Michael R Nonnemacher
- Department of Microbiology and Immunology, Center for Molecular Virology and Translational Neuroscience, Institute for Molecular Medicine and Infectious Disease, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Brian Wigdahl
- Department of Microbiology and Immunology, Center for Molecular Virology and Translational Neuroscience, Institute for Molecular Medicine and Infectious Disease, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
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Machado LDR, Livramento JA, Vianna LS. Cerebrospinal fluid analysis in infectious diseases of the nervous system: when to ask, what to ask, what to expect. ARQUIVOS DE NEURO-PSIQUIATRIA 2013; 71:693-8. [DOI: 10.1590/0004-282x20130153] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cerebrospinal fluid (CSF) analysis very frequently makes the difference to the diagnosis, not only in relation to infections but also in other diseases of the nervous system such as inflammatory, demyelinating, neoplastic and degenerative diseases. The authors review some practical and important features of CSF analysis in infectious diseases of the nervous system, with regard to acute bacterial meningitis, herpetic meningoencephalitis, neurotuberculosis, neurocryptococcosis, neurocysticercosis and neurosyphilis.
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Spudich S, González-Scarano F. HIV-1-related central nervous system disease: current issues in pathogenesis, diagnosis, and treatment. Cold Spring Harb Perspect Med 2012; 2:a007120. [PMID: 22675662 PMCID: PMC3367536 DOI: 10.1101/cshperspect.a007120] [Citation(s) in RCA: 144] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
HIV-associated central nervous system (CNS) injury continues to be clinically significant in the modern era of HIV infection and therapy. A substantial proportion of patients with suppressed HIV infection on optimal antiretroviral therapy have impaired performance on neuropsychological testing, suggesting persistence of neurological abnormalities despite treatment and projected long-term survival. In the underresourced setting, limited accessibility to antiretroviral medications means that CNS complications of later-stage HIV infection continue to be a major concern. This article reviews key recent advances in our understanding of the neuropathogenesis of HIV, focusing on basic and clinical studies that reveal viral and host features associated with viral neuroinvasion, persistence, and immunopathogenesis in the CNS, as well as issues related to monitoring and treatment of HIV-associated CNS injury in the current era.
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Affiliation(s)
- Serena Spudich
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
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Spudich S, Gisslen M, Hagberg L, Lee E, Liegler T, Brew B, Fuchs D, Tambussi G, Cinque P, Hecht FM, Price RW. Central nervous system immune activation characterizes primary human immunodeficiency virus 1 infection even in participants with minimal cerebrospinal fluid viral burden. J Infect Dis 2011; 204:753-60. [PMID: 21844301 DOI: 10.1093/infdis/jir387] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Central nervous system (CNS) human immunodeficiency virus (HIV) infection and immune activation lead to brain injury and neurological impairment. Although HIV enters the nervous system soon after transmission, the magnitude of infection and immunoactivation within the CNS during primary HIV infection (PHI) has not been characterized. METHODS This cross-sectional study analyzed cerebrospinal fluid (CSF) and blood from 96 participants with PHI and compared them with samples from neuroasymptomatic participants with chronic infection and ≥ 200 or < 200 blood CD4 T cells/μL, and with samples from HIV-seronegative participants with respect to CSF and plasma HIV RNA, CSF to serum albumin ratio, and CSF white blood cell counts (WBC), neopterin levels, and concentrations of chemokines CXCL10 and CCL2. RESULTS The PHI participants (median 77 days post transmission) had CSF HIV RNA, WBC, neopterin, and CXCL10 concentrations similar to the chronic infection participants but uniquely high albumin ratios. 18 participants had ≤ 100 copies/mL CSF HIV RNA, which was associated with low CSF to plasma HIV ratios and levels of CSF inflammation lower than in other PHI participants but higher than in HIV-seronegative controls. CONCLUSIONS Prominent CNS infection and immune activation is evident during the first months after HIV transmission, though a proportion of PHI patients demonstrate relatively reduced CSF HIV RNA and inflammation during this early period.
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Affiliation(s)
- Serena Spudich
- Department of Neurology, University of California San Francisco, USA.
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