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Abstract
PURPOSE OF REVIEW This article reviews the spectrum of neurologic disease associated with human herpesvirus infections. RECENT FINDINGS As more patients are becoming therapeutically immunosuppressed, human herpesvirus infections are increasingly common. Historically, infections with human herpesviruses were described as temporal lobe encephalitis caused by herpes simplex virus type 1 or type 2. More recently, however, additional pathogens, such as varicella-zoster virus, Epstein-Barr virus, cytomegalovirus, and human herpesvirus 6 have been identified to cause serious neurologic infections. As literature emerges, clinical presentations of herpesvirus infections have taken on many new forms, becoming heterogeneous and involving nearly every location along the neuraxis. Advanced diagnostic methods are now available for each specific pathogen in the herpesvirus family. As data emerge on viral resistance to conventional therapies, newer antiviral medications must be considered. SUMMARY Infections from the herpesvirus family can have devastating neurologic outcomes without prompt and appropriate treatment. Clinical recognition of symptoms and appropriate advanced testing are necessary to correctly identify the infectious etiology. Knowledge of secondary neurologic complications of disease is equally important to prevent additional morbidity and mortality. This article discusses infections of the central and peripheral nervous systems caused by herpes simplex virus type 1 and type 2, varicella-zoster virus, Epstein-Barr virus, cytomegalovirus, and human herpesvirus 6. The pathophysiology, epidemiology, clinical presentations of disease, diagnostic investigations, imaging characteristics, and treatment for each infectious etiology are discussed in detail.
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2
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Abstract
The epidemiology of spinal cord disease in human immunodeficiency virus (HIV) infection is largely unknown due to a paucity of data since combination antiretroviral therapy (cART). HIV mediates spinal cord injury indirectly, by immune modulation, degeneration, or associated infections and neoplasms. The pathologies vary and range from cytotoxic necrosis to demyelination and vasculitis. Control of HIV determines the differential for all neurologic presentations in infected individuals. Primary HIV-associated acute transverse myelitis, an acute inflammatory condition with pathologic similarities to HIV encephalitis, arises in early infection and at seroconversion. In contrast, HIV vacuolar myelopathy and opportunistic infections predominate in uncontrolled disease. There is systemic immune dysregulation as early as primary infection due to initial depletion of gut-associated lymphoid tissue CD4 cells and allowance of microbial translocation across the gut that never fully recovers throughout the course of HIV infection, regardless of how well controlled. The subsequent proinflammatory state may contribute to spinal cord diseases observed even after cART initiation. This chapter will highlight an array of spinal cord pathologies classified by stage of HIV infection and immune status.
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Affiliation(s)
- Seth N Levin
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Jennifer L Lyons
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
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3
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Renshaw AA, Gould EW. Predominance of neutrophils in the cerebrospinal fluid of patients treated with intravenous immunoglobulin. Diagn Cytopathol 2017; 46:271-272. [PMID: 28990325 DOI: 10.1002/dc.23833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 09/27/2017] [Indexed: 11/10/2022]
Abstract
Patients treated with intravenous immunoglobulin can present with numerous neutrophils in the cerebrospinal fluid.
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Affiliation(s)
- Andrew A Renshaw
- Department of Pathology, Baptist Hospital and Miami Cancer Institute, Miami, Florida
| | - Edwin W Gould
- Department of Pathology, Baptist Hospital and Miami Cancer Institute, Miami, Florida
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Panos G, Watson DC, Karydis I, Velissaris D, Andreou M, Karamouzos V, Sargianou M, Masdrakis A, Chra P, Roussos L. Differential diagnosis and treatment of acute cauda equina syndrome in the human immunodeficiency virus positive patient: a case report and review of the literature. J Med Case Rep 2016; 10:165. [PMID: 27268102 PMCID: PMC4895963 DOI: 10.1186/s13256-016-0902-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 04/17/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Acute cauda equina syndrome is an uncommon but significant neurologic presentation due to a variety of underlying diseases. Anatomical compression of nerve roots, usually by a lumbar disk hernia is a common cause in the general population, while inflammatory, neoplastic, and ischemic causes have also been recognized. Among human immunodeficiency virus (HIV) infected patients with acquired immunodeficiency syndrome, infectious causes are encountered more frequently, the most prevalent of which are: cytomegalovirus, herpes simplex virus 1/2, varicella zoster virus, and Mycobacterium tuberculosis infections. Studies of cauda equina syndrome in well-controlled HIV infection are lacking. We describe such a case of cauda equina syndrome in a well-controlled HIV-infected patient, along with a brief review of the literature regarding the syndrome's diagnosis and treatment in individuals with HIV infection. CASE PRESENTATION A 36-year-old Greek male, HIV-positive patient presented with perineal and left hemiscrotal numbness, lumbar pain, left-sided sciatica, and urinary incontinence. Magnetic resonance imaging of the patient's lumbar spine revealed intrathecal migration of a fragment from an intervertebral lumbar disk exerting pressure on the cauda equina. A cerebrospinal fluid examination, brain computed tomography scan, spine magnetic resonance imaging, and serological test results were negative for central nervous system infections. Our patient underwent emergency neurosurgical spinal decompression, which resolved most symptoms, except for mild urinary incontinence. CONCLUSIONS Noninfectious etiologies may also cause cauda equina syndrome in HIV-infected individuals, especially in well-controlled disease under antiretroviral therapy. Prompt recognition and treatment of the underlying cause is important to minimize residual symptoms. Targeted antimicrobial chemotherapy is used to treat infectious causes, while prompt surgical decompression is favored for anatomical causes of cauda equina syndrome in the HIV-infected patient.
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Affiliation(s)
- George Panos
- Special Infections Unit, 2nd Internal Medicine Clinic, 1st Ι.Κ.Α. Penteli General Hospital, Melissia, Athens, Greece. .,Department of Infectious Diseases, Patras University General Hospital, 26504, Rion, Patras, Greece.
| | - Dionysios C Watson
- Department of Infectious Diseases, Patras University General Hospital, 26504, Rion, Patras, Greece
| | - Ioannis Karydis
- Special Infections Unit, 2nd Internal Medicine Clinic, 1st Ι.Κ.Α. Penteli General Hospital, Melissia, Athens, Greece
| | - Dimitrios Velissaris
- Internal Medicine Department, University Hospital of Patras, 26504, Rion, Patras, Greece
| | - Marina Andreou
- Internal Medicine Department, University Hospital of Patras, 26504, Rion, Patras, Greece
| | - Vasilis Karamouzos
- Internal Medicine Department, University Hospital of Patras, 26504, Rion, Patras, Greece
| | - Maria Sargianou
- Department of Infectious Diseases, Patras University General Hospital, 26504, Rion, Patras, Greece
| | - Antonios Masdrakis
- Special Infections Unit, 2nd Internal Medicine Clinic, 1st Ι.Κ.Α. Penteli General Hospital, Melissia, Athens, Greece
| | - Paraskevi Chra
- Department of Microbiology, Benakio-Korgialenio Hospital, 1 Erythrou Staurou Street, 11526, Athens, Greece
| | - Lavrentios Roussos
- Neurosurgery Clinic, Κ.Α.Τ. Hospital, 2 Nikis Street, 14561, Kifissia, Athens, Greece
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5
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Cytomegalovirus infections of the adult human nervous system. HANDBOOK OF CLINICAL NEUROLOGY 2014; 123:307-18. [DOI: 10.1016/b978-0-444-53488-0.00014-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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6
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Abstract
Among the human herpes viruses, three are neurotropic and capable of producing severe neurological abnormalities: herpes simplex virus type 1 and 2 (HSV-1 and HSV-2) and varicella-zoster virus (VZV). Both the acute, primary infection and the reactivation from the site of latent infection, the dorsal sensory ganglia, are associated with severe human morbidity and mortality. The peripheral nervous system is one of the major loci affected by these viruses. The present review details the virology and molecular biology underlying the human infection. This is followed by detailed description of the symtomatology, clinical presentation, diagnosis, course, therapy, and prognosis of disorders of the peripheral nervous system caused by these viruses.
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Affiliation(s)
- Israel Steiner
- Department of Neurology, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel.
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7
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Sohal A, Riordan A, Mallewa M, Solomon T, Kneen R. Successful treatment of cytomegalovirus polyradiculopathy in a 9-year-old child with congenital human immunodeficiency virus infection. J Child Neurol 2009; 24:215-8. [PMID: 19182160 DOI: 10.1177/0883073808322671] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cytomegalovirus lumbosacral polyradiculopathy is a well-documented complication of human immunodeficiency virus in adults who have a CD4 count of less than 40/microL. Patients present with an acute ascending flaccid paralysis of the lower limbs with areflexia, paresthesia, and urinary and bowel symptoms. However, it appears to be rare in children with congenitally acquired immune deficiency syndrome. We report a 9-year-old child with congenital human immunodeficiency virus infection who presented with cytomegalovirus polyradiculopathy and made an excellent response to cytomegalovirus treatment.
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Affiliation(s)
- Aman Sohal
- Department of Neurology, Littlewoods Neuroscience Foundation, Royal Liverpool Children's NHS Trust, Alder Hey, Liverpool, United Kingdom
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8
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Acquired, induced and secondary malformations of the developing central nervous system. HANDBOOK OF CLINICAL NEUROLOGY 2008. [PMID: 18809034 DOI: 10.1016/s0072-9752(07)87020-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register]
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9
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Abstract
Intranuclear inclusions typical of cytomegalovirus infections were first noticed in 1881 by German scientists who thought they represented protozoa. After viruses were grown in cell cultures, Weller, Smith and Rowe independently isolated and grew CMV from man and mice in 1956-1957. Antibodies in 30-100% of normal adults indicate not only a past infection, but the presence of a present latent infection. The presence of CMV DNA in tissues and most organs surveyed indicates the ubiquity of latent infection. CMV disease requires the virus and some deficiency of immunity such as occurs in the immature fetus, in AIDS, and in transplant patients on immunosuppressive drugs. Antiviral agents can inhibit CMV replication but they cannot prevent or cure latent infections. A pharmacological approach using the many leads in understanding latency is needed.
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Affiliation(s)
- Monto Ho
- 618 Friendship Circle, Pittsburgh, PA 15241-3998, USA.
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10
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Abstract
UNLABELLED Because of the increase in patients with human immunodeficiency virus, practitioners are likely to see a concordant increase of infections. Spontaneous spinal infections can result from a variety of organisms. A common pathogen is Staphylococcus aureus, which is the most frequent cause of pyogenic spinal infection in patients who test positive for the human immunodeficiency virus. Human immunodeficiency virus has caused a resurgence of spinal tuberculosis and other infections. The pandemic of human immunodeficiency virus has caused a rise in extremely rare spinal infections caused by fungus, virus, and atypical bacteria that usually are nonpathogenic. As the number of elective and emergent spinal surgeries become more frequent, spinal practitioners also must become more familiar with the particularities of preoperative and perioperative decision making. Patients' CD4 cell counts are a useful preoperative parameter to stratify the risk for postoperative wound infection because counts less than 200/mm3 seem to be a critical threshold. A case of a patient with the human immunodeficiency virus is presented. The patient had a chronic, postoperative infection and posttraumatic post-laminectomy kyphosis; he was successfully treated with staged procedures including debridement, deformity correction, stabilization, and appropriate antibiotic therapy. LEVEL OF EVIDENCE Level V (expert opinion). Please see the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Christopher M Bono
- Department of Orthopaedic Surgery, Boston University Medical Center, Boston, Massachusetts 02118, USA.
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11
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Brew BJ. The peripheral nerve complications of human immunodeficiency virus (HIV) infection. Muscle Nerve 2003; 28:542-52. [PMID: 14571455 DOI: 10.1002/mus.10484] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Peripheral nerve complications occurring in patients with human immunodeficiency virus (HIV) infection are frequent and challenging. This review discusses these various complications according to the degree of advancement of HIV disease. Particular emphasis is placed upon emerging causes of neuropathy found in the context of HIV disease, such as infection with hepatitis C and human T-lymphotropic virus type I, as well as neuropathies related to antiretroviral medications.
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Affiliation(s)
- B J Brew
- Departments of Neurology and HIV Medicine, St Vincent's Hospital and National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Darlinghurst, Sydney 2010, Australia.
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12
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Fux CA, Pfister S, Nohl F, Zimmerli S. Cytomegalovirus-associated acute transverse myelitis in immunocompetent adults. Clin Microbiol Infect 2003; 9:1187-90. [PMID: 14686983 DOI: 10.1111/j.1469-0691.2003.00796.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We report a case of transverse myelitis as a complication of acute cytomegalovirus (CMV) infection in immunocompetent patients; and review the literature on the entity. Primary CMV infection was documented by CMV antigenemia and high serum titers of CMV IgM and IgG antibodies. Cerebrospinal fluid (CSF) pleocytosis indicated central nervous system inflammation; CSF polymerase chain reaction (PCR) for CMV, however, was negative. The results of magnetic resonance imaging of the myelon were normal. Although CMV-associated transverse myelitis has been well described in HIV-positive individuals, but is very rare in immunocompetent individuals. It remains unclear whether the neuronal damage is immune mediated or due to a cytotoxic effect of viral infection. The outcome is mainly favorable.
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Affiliation(s)
- C A Fux
- Institute for Infectious Diseases, University of Bern, Switzerland
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13
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Abstract
Cytomegalovirus (CMV) infection of the CNS occurs most commonly in patients with severe immunosuppression such as those with advanced HIV infection (i.e. AIDS) or those who have undergone bone marrow or solid organ transplantation. Immunocompetent patients are affected very rarely. The infection of the CNS may affect the brain (diffuse encephalitis, ventriculoencephalitis, cerebral mass lesions) or the spinal cord (transverse myelitis, polyradiculomyelitis). Diagnosis is very difficult and should be based on clinical presentation, results of imaging and virological markers. The most specific diagnostic tool is the detection of CMV DNA by polymerase chain reaction in the CSF. Treatment should be initiated promptly if CMV infection is suspected. Antiviral therapy consists of intravenous ganciclovir, intravenous foscarnet or a combination of both. Cidofovir is the treatment of second choice. Patients who experience clinical improvement or stabilisation during induction therapy should be given maintenance therapy. After immune reconstitution (in HIV-positive patients) or discontinuation of immunosuppressive therapy (in transplant recipients), maintenance therapy may be stopped. Despite therapy, the prognosis for long-term survival is very poor, especially in patients with AIDS.
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14
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Abstract
Suppression of the immune system by human immunodeficiency virus (HIV) infection or immunosuppressive therapy following transplantation increases susceptibility to CNS infection. Examination of the level and type of immunosuppression, in addition to the clinical and radiologic findings at the time of diagnosis can aid the clinician in determining the most likely etiology of infection. This article discusses how suppression of the host immune status modifies the presentation and diagnosis of selected CNS infections and the recommended treatment for these infections.
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Affiliation(s)
- Joseph R Zunt
- Department of Neurology, University of Washington School of Medicine, Seattle, Washington 98104, USA.
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15
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Anduze-Faris BM, Fillet AM, Gozlan J, Lancar R, Boukli N, Gasnault J, Caumes E, Livartowsky J, Matheron S, Leport C, Salmon D, Costagliola D, Katlama C. Induction and maintenance therapy of cytomegalovirus central nervous system infection in HIV-infected patients. AIDS 2000; 14:517-24. [PMID: 10780714 DOI: 10.1097/00002030-200003310-00007] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of the foscarnet-ganciclovir combination in induction therapy (IT) and maintenance therapy (MT) for cytomegalovirus (CMV) central neurological disorders in HIV-infected patients. DESIGN An open pilot non-comparative multicentre study. METHODS Thirty-one patients with acute CMV encephalitis (CMVe) (n = 17) or CMV myelitis (CMVm) (n = 14) during the era before highly active antiretroviral therapy (HAART) received intravenous IT with foscarnet 90 mg/kg plus ganciclovir 5 mg/kg twice a day followed by MT. The primary endpoint was clinical efficacy, assessed at the end of the induction phase. RESULTS The foscarnet-ganciclovir combination in IT resulted in a 74% (23 out of 31 patients) clinical improvement or stabilization. Eight patients did not respond clinically. Side-effects leading to drug discontinuation occurred in 10 patients during IT. Among the 23 patients who qualified for the maintenance phase, CMV disease progressed in 10, with a median time to the first relapse of 126 days (range 64-264 days). Overall, the median survival time was 3 months [95% confidence interval (CI), 2-4 months]. CONCLUSION The combination of foscarnet and ganciclovir can safely be used for CMV central nervous system (CNS) infection, with an improvement or stabilization in 74% of patients. Life-long MT with this combination is recommended as long as the immune system is profoundly impaired.
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Affiliation(s)
- B M Anduze-Faris
- Department of Maladies Infectieuses et Tropicales, Hôpital Pitié-Salpétrière, Paris, France
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16
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Hoy J. Management of CMV infections in HIV-infected patients. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 1999; 458:77-87. [PMID: 10549381 DOI: 10.1007/978-1-4615-4743-3_8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Affiliation(s)
- J Hoy
- Clinical Research Section, Alfred Hospital, Melbourne, Victoria, Australia
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17
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Alla P, de Jaureguiberry JP, Legier HP, Valance J, Jaubert D. [Cytomegalovirus myeloradiculitis in pregnancy]. Rev Med Interne 1999; 20:514-6. [PMID: 10422143 DOI: 10.1016/s0248-8663(99)80086-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Cytomegalovirus neurological complications are frequent in immunocompromised patients specially in HIV positive patient. In immunocompetent patient these complications are infrequent. EXEGESIS We describe a case of cytomegalovirus myeloradiculitis during pregnancy in a 25-year-old woman, HIV negative. The evolution was favorable with foscarnet therapy. CONCLUSION A spinal complication during cytomegalovirus infection in immunocompetent patient should lead to a therapy with a specific antiviral to reduce neurologic involvement.
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Affiliation(s)
- P Alla
- Service de neurologie, HIA Sainte-Anne, Toulon Naval, France
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18
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Affiliation(s)
- I G Williams
- Department of Sexually Transmitted Diseases, Royal Free and University College Medical School, University College London, UK.
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19
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Villanueva JL, Cordero E, Caballero-Granado FJ, Regordan C, Becerril B, Pachón J. Pneumocystis carinii meningoradiculitis in a patient with AIDS. Eur J Clin Microbiol Infect Dis 1997; 16:940-2. [PMID: 9495679 DOI: 10.1007/bf01700565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pneumocystis carinii is a common opportunistic pathogen in patients infected with the human immunodeficiency virus (HIV). Pneumocystis carinii pneumonia is common, while extrapulmonary infections with Pneumocystis carinii have been reported sparingly. The clinical features are frequently nonspecific. The detection of Pneumocystis carinii in cerebrospinal fluid (CSF) has not been reported thus far. In this report, an unusual case of Pneumocystis carinii meningoradiculitis in an HIV-infected patient who had previously received primary prophylaxis with trimethoprim-sulfamethoxazole is presented.
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Affiliation(s)
- J L Villanueva
- Infectious Disease Unit and Service of Microbiology, Hospital Universitario Virgen del Rocío, Seville, Spain
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20
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Cohen BA. NEUROLOGIC COMPLICATIONS OF HIV INFECTION. Prim Care 1997. [DOI: 10.1016/s0095-4543(22)00105-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lüttmann S, Husstedt IW, Lügering N, Heese C, Stoll R, Domschke W, Evers S, Kuchelmeister K, Gullotta F. Cytomegalovirus encephalomyelomeningoradiculitis in acquired immunodeficiency syndrome (AIDS). J Infect 1997; 35:78-81. [PMID: 9279730 DOI: 10.1016/s0163-4453(97)91121-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Acute inflammatory polyradiculitis represents an uncommon peripheral nerve complication during HIV infection. The case of an HIV-seropositive patient who was admitted to hospital for a cauda equina syndrome is reported. Despite early application of anticytomegalic medication, a cytomegalovrirus (CMV) infection spread out to the central nervous system (CNS), causing the patient's death. A post-mortem examination confirmed the diagnosis of CMV-encephalomyelomeningoradiculitis. To the authors' knowledge, such a progress of a CMV-related polyradiculitis to an encephalomyelomeningoradiculitis has not yet been described. The clinical features of this case will aid in the recognition of CMV-related neurological complications, and may permit earlier and perhaps more successful treatment.
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Affiliation(s)
- S Lüttmann
- Department of Neurology, University of Münster, Germany
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22
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Cinque P, Scarpellini P, Vago L, Linde A, Lazzarin A. Diagnosis of central nervous system complications in HIV-infected patients: cerebrospinal fluid analysis by the polymerase chain reaction. AIDS 1997; 11:1-17. [PMID: 9110070 DOI: 10.1097/00002030-199701000-00003] [Citation(s) in RCA: 173] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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23
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Miller RF, Fox JD, Thomas P, Waite JC, Sharvell Y, Gazzard BG, Harrison MJ, Brink NS. Acute lumbosacral polyradiculopathy due to cytomegalovirus in advanced HIV disease: CSF findings in 17 patients. J Neurol Neurosurg Psychiatry 1996; 61:456-60. [PMID: 8937337 PMCID: PMC1074040 DOI: 10.1136/jnnp.61.5.456] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To describe the abnormalities in CSF from HIV infected patients with acute lumbosacral polyradiculopathy (ALP) caused by cytomegalovirus (CMV) infection. METHODS Retrospective case notes and laboratory records were reviewed for 17 consecutive patients with CMV associated ALP admitted to specialist HIV/AIDS units at UCL Hospitals and Chelsea and Westminster Hospital. RESULTS Infection with CMV was confirmed by detection of CMV DNA by polymerase chain reaction amplification in 15 patients (all of whom were negative by culture), by culture in one patient, and by objective clinical response to anti-CMV treatment in one patient. Only nine patients had a CSF pleocytosis 28-1142 (median 150) cells/mm3; in seven there was a polymorphonuclear (PMN) leucocyte preponderance. Protein concentrations in CSF were moderately or considerably raised in 13 patients; CSF: plasma glucose ratios were < or = 50% in five patients. Two patients had no pleocytosis, normal CSF: plasma glucose, and normal or near normal protein values. CONCLUSIONS Abnormalities in CSF in CMV associated ALP are varied: only 50% of patients have a "typical" PMN preponderant pleocytosis. The diagnosis of this condition should not rely on demonstration of a PMN preponderant pleocytosis, but on identification of CMV DNA in CSF and the exclusion of other opportunistic infections and lymphoma in order that specific anti-CMV treatment may be instituted.
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Affiliation(s)
- R F Miller
- Department of Sexually Transmitted Diseases, UCLMS, Camden, London, UK
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Engelter S, Lyrer P, Radu EW, Steck AJ. Acute infectious disorders of the spinal cord and its roots with gadolinium-DTPA enhancement in magnetic resonance imaging. J Neurol 1996; 243:191-5. [PMID: 8750559 DOI: 10.1007/bf02444013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We studied three patients with myelomeningoradiculitis caused by Borrelia burgdorferi, herpes zoster virus or cytomegalovirus infection. All patients underwent MRI of the spinal cord with gadolinium-DTPA and showed enhancing lesions of the spinal cord or nerve roots that correlated with clinical signs. Gadolinium-DTPA enhancement may visualize lesions that suggest an inflammation associated with blood-brain-barrier alteration and indicate the diagnosis before serological results are available.
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Affiliation(s)
- S Engelter
- Department of Neurology, University Hospital, Basle, Switzerland
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25
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Abstract
Cytomegalovirus polyradiculopathy, a late complication of HIV infection, is characterized by lower extremity weakness, urinary retention, and sacral dysesthesias. We describe four patients (mean CD4 T-cell count = 25 cells/mm3) who developed this "infectious cauda equina syndrome." The characteristic cerebrospinal fluid (CSF) findings, notably atypical for a viral infection, included polymorphonuclear leukocytosis (mean white blood cell count = 1512 cells/mm3, 72% polymorphonuclear leukocytes), elevated protein level (mean = 370 mg/dl), and hypoglycorrhacia (mean = 28 mg/dl). Physicians who treat patients with HIV should be familiar with this syndrome because early intervention, prior to microbiologic confirmation, provides the best hope for improving neurologic function.
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Affiliation(s)
- P A Meier
- Department of Infectious Diseases, Wilford Hall Medical Center, Lackland Air Force Base, TX 78236-5300, USA
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26
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So YT, Olney RK. Acute lumbosacral polyradiculopathy in acquired immunodeficiency syndrome: experience in 23 patients. Ann Neurol 1994; 35:53-8. [PMID: 8285593 DOI: 10.1002/ana.410350109] [Citation(s) in RCA: 81] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
We reviewed our experience in 23 patients with acquired immunodeficiency syndrome (AIDS) who had acute lumbosacral polyradiculopathy. The patients developed a distinctive syndrome of rapidly progressive flaccid paraparesis and areflexia that was frequently associated with sphincter disturbances. Persuasive laboratory evidence of a cytomegalovirus polyradiculopathy (polymorphonuclear pleocytosis or confirmatory cerebrospinal fluid culture) was found in 15 of the 23 patients. Treatment with ganciclovir in these patients led to clinical stabilization, although worsening during the first 2 weeks of treatment was common. Most patients with cytomegalovirus polyradiculopathy had severe residual deficits. Metastasis from systemic lymphoma accounted for the polyradiculopathy in 2 other patients. A more benign syndrome was identified in the remaining 6 patients. They generally had slower clinical progression and less severe neurological deficits at their nadir than did patients with cytomegalovirus polyradiculopathy. Unlike patients with cytomegalovirus infection, their cerebrospinal fluid showed a predominantly mononuclear pleocytosis. Moreover, spontaneous improvement without treatment was common. Our experience together with the published experience of others suggests that the acute lumbosacral polyradiculopathy in AIDS is a clinical syndrome with different etiologies and variable clinical outcome. Recognition of this heterogeneity is necessary for the management of individual patients, as well as the interpretation of treatment results.
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Affiliation(s)
- Y T So
- Department of Neurology, University of California at San Francisco 94143-0870
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Strategies for the treatment and prevention of cytomegalovirus infections. Int J Antimicrob Agents 1993; 3:187-204. [DOI: 10.1016/0924-8579(93)90012-t] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/1993] [Indexed: 11/19/2022]
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