Time Trends in Causes of Death in People with HIV: Insights from the Swiss HIV Cohort Study

BACKGROUND

Advancements in access to antiretroviral therapy (ART) and human immunodeficiency virus (HIV) care have led to a decline in acquired immunodeficiency syndrome (AIDS)-related deaths among people with HIV (PWH) in Switzerland. However, data on the ongoing changes in causes of death among PWH over the past 15 years is scarce.

METHODS

We investigated all reported deaths in the Swiss HIV Cohort Study between 2005-2022. Causes of death were categorized using the Coding Causes of Death in HIV protocol. The statistical analysis included demographic stratification to identify time trends and logistic regression models to determine associated factors for the underlying cause of death.

RESULTS

In total, 1630 deaths were reported, with 23.7% of individuals assigned female at birth. Out of these deaths, 147 (9.0%) were HIV/AIDS-related, 373 (22.9%) due to non-AIDS, non-hepatic (NANH) cancers, 166 (10.2%) liver-related, and 158 (9.7%) cardiovascular-related. The median age at death increased from 45.0 [40.0,53.0] years in 2005-2007 to 61.0 [56.0,69.5] years in 2020-2022. HIV/AIDS and liver-related causes of death decreased, whereas deaths from NANH cancers increased, and cardiovascular-related deaths remained relatively stable.

CONCLUSION

The proportionally decreasing HIV/AIDS and liver-related deaths showcase the effectiveness of ART, comprehensive HIV patient care, and interventions targeting hepatitis C virus co-infection. Future research should focus on managing cancer and cardiovascular-related conditions as the new leading causes of death among PWH. Comprehensive healthcare strategies focusing on non-AIDS-related comorbidities, cancer management, and sustaining liver and cardiovascular health are needed to bridge the ongoing health disparities between PWH and the general population.

External validation of the Dat'AIDS score: A risk score for predicting 5-year overall mortality in people living with HIV aged 60 years or older

OBJECTIVE

To perform an external validation of the Dat'AIDS score for predicting 5-year overall mortality among people with HIV (PWH) aged 60 years or older.

METHODS

This was a multi-centre prospective cohort study at all sites participating in the Swiss HIV Cohort Study (SHCS). We calculated the Dat'AIDS score in PWH aged 60 years or older at their first visit between 1 January 2015 and 1 January 2020. People living with HIV-2 and those whose Dat'AIDS score could not be calculated were excluded. Patients were followed until 1 January 2020. The primary endpoint was all-cause mortality. Vital status was collected throughout the study period. We obtained population and score descriptive statistics and assessed the score's discrimination and calibration.

RESULTS

We included 2205 participants (82% male) of median [interquartile range (IQR)] age 62.0 (60.3-67.0) years, mostly with viraemia <50 copies/mL (92.7%). Median follow-up time was 15.9 years and median (IQR) CD4 cell count at enrolment was 586 (420-782) cells/μL. In all, 152 deaths were recorded during a total follow-up period of 7147 patient-years. The median (IQR) observed Dat'AIDS score was 3 (0-8). Discriminative capacities were good as the C-statistic was 0.73 (95% CI: 0.69-0.77) and consistent across all subgroups. Comparison of observed and expected survival probabilities showed good calibration.

CONCLUSIONS

External validation of the Dat'AIDS score in patients aged 60 years or older showed that it could be a useful tool not only for research purposes, but also to identify older patients at a higher mortality risk and to tailor the most appropriate interventions.

Can we forecast poor outcome in herpes simplex and varicella zoster encephalitis? A narrative review

Herpes simplex virus (HSV) and varicella zoster virus (VZV) are among the most commonly diagnosed infectious causes of sporadic encephalitis worldwide. Despite treatment, mortality and morbidity rates remain high, especially for HSV encephalitis. This review is intended to provide an overview of the existing scientific literature on this topic from the perspective of a clinician who is confronted with serious decisions about continuation or withdrawal of therapeutic interventions. We performed a literature review searching two databases and included 55 studies in the review. These studies documented or investigated specifically outcome and predictive parameters of outcome of HSV and/or VZV encephalitis. Two reviewers independently screened and reviewed full-text articles meeting the inclusion criteria. Key data were extracted and presented as a narrative summary. Both, HSV and VZV encephalitis have mortality rates between 5 and 20% and complete recovery rates range from 14 to 43% for HSV and 33 to 49% for VZV encephalitis. Prognostic factors for both VZV and HSV encephalitis are older age and comorbidity, as well as severity of disease and extent of magnetic resonance imaging (MRI) lesions on admission, and delay in treatment initiation for HSV encephalitis. Although numerous studies are available, the main limiting factors are the inconsistent patient selection and case definitions as well as the non-standardised outcome measures, which hampers the comparability of the studies. Therefore, larger and standardised observational studies applying validated case definitions and outcome measures including quality of life assessment are required to provide solid evidence to answer the research question.

Hepatitis B Virus (HBV) Replication During Tenofovir Therapy Is Frequent in Human Immunodeficiency Virus/HBV Coinfection

In the Swiss HIV Cohort Study, 61 of 222 (27%) HIV-suppressed persons with chronic hepatitis B virus (HBV) infection had HBV replication after 2 years on tenofovir, of whom 77% were suppressed thereafter. Self-reported adherence to therapy and HBV viral load at tenofovir initiation were predictors of persistent replication.

Travel related histoplasmosis – a diagnostic challenge in a patient with tumor necrosis factor alpha (TNF-α) inhibitor therapy

Introduction

In a non-endemic setting, disseminated histoplasmosis is a rare travel-related health problem of immunosuppressed returnees from endemic regions.

Methods

We describe the case of a 68-year-old man with rheumatoid arthritis and tumor necrosis factor alpha (TNF-α) inhibitor treatment-related immunodeficiency, who suffered from disseminated histoplasmosis after traveling to Brazil. Based on this case, we discuss challenges and pitfalls associated with the diagnosis of disseminated histoplasmosis in a non-endemic setting.

Results

The disease mimicked a hemophagocytic lymphohistiocytosis (HLH) like syndrome. Histoplasma capsulatum was microscopically detected in bronchoalveolar fluid and bone marrow aspirate smears, but was initially misclassified as Leishmania spp., another class of pathogens, which may cause HLH like syndromes in immunocompromised individuals.

Discussion

Since the clinical symptoms of histoplasmosis are nonspecific and physicians in non-endemic regions might not be familiar with this disease pattern, there is a risk of delayed diagnosis of travel related cases. Taking a thorough travel history is key in unclear cases of illness in immunocompromised patients.

Emergence of letermovir resistance in solid organ transplant recipients with ganciclovir resistant cytomegalovirus infection: A case series and review of the literature

Ganciclovir (GCV)-resistant cytomegalovirus (CMV) infection is a common problem among solid organ transplant (SOT) recipients without prior CMV immunity (CMV D+/R-). GCV-resistant CMV represents a particular challenge for CMV management. Letermovir is a recently licensed antiviral agent for primary CMV prophylaxis in allogenic hematopoietic stem cell transplant (HSCT) recipients. Given the favorable safety profile and its oral bioavailability letermovir may be considered a valuable off-label option for secondary prophylaxis of GCV-resistant CMV in SOT recipients. Here, we describe our experience with letermovir as secondary prophylaxis for GCV-resistant CMV in two renal transplant recipients and review the literature in regard of previously published cases. Letermovir resistance emerged after a few months of secondary prophylaxis in the two renal transplant recipients. In both cases, the previously described UL56 C325Y letermovir resistance mutation was detected. In vitro studies of letermovir suggest a relatively low genetic barrier to resistance. Therefore, caution is warranted when using letermovir as secondary prophylaxis for GCV-resistant CMV infection.

Continuous pH monitoring in wounds using a composite indicator dressing - A feasibility study

PURPOSE

Modern burn care strives for new means to guarantee optimised wound healing. Several studies have shown a correlation between the pH value in a (burn) wound and successful wound healing. A multitude of devices to monitor pH is available, all requiring direct wound contact and removal of the dressing for pH monitoring. The aim of this feasibility study was to create a sterile and easy to handle method for pH monitoring while simultaneously using an advanced wound dressing.

MATERIALS AND METHODS

Dressing sheets of biotechnologically generated nanofibrillar cellulose (epicite^hydro) were chemically functionalised with the indicator dye GJM-534. pH-donors with increasing pH were subsequently applied to the created indicator dressing. To investigate temporal resolution and continuous monitoring we used circular pH-donors with different pH (7 and 10) and decreasing diameters that were placed on another dressing sheet. Clinically relevant spatial resolution was checked by a wound bed simulation with small areas (8 mm) of higher pH (10) on a field of lower pH (7) and vice versa.

RESULTS

The indicator dressing showed a gradual colouring from yellow to dark orange with increasing pH in steps of 0.3. After conversion of digital pictures to greyscale values, a sigmoidal distribution with a pK_a-value of 8.4 was obtained. A ring-like pattern with alternating colour change corresponding to the pH was observed in the continuous monitoring experiment and the wound bed simulation delivered excellent local resolution.

CONCLUSION

Since the pH of a (burn) wound can have a significant influence on wound healing, a pH indicator was successfully linked to an advanced, temporary, alloplastic wound dressing material. We were able to show the possibility of pH monitoring by the dressing itself. Additional testing, including studies with large case numbers for optimisation are necessary before clinical implementation.

Chalcogenide substitution in the [2Fe] cluster of [FeFe]-hydrogenases conserves high enzymatic activity

[FeFe]-Hydrogenases efficiently catalyze the uptake and evolution of H₂ due to the presence of an inorganic [6Fe-6S]-cofactor (H-cluster). This cofactor is comprised of a [4Fe-4S] cluster coupled to a unique [2Fe] cluster where the catalytic turnover of H₂/H⁺ takes place. We herein report on the synthesis of a selenium substituted [2Fe] cluster [Fe₂{μ(SeCH₂)₂NH}(CO)₄(CN)₂]^2- (ADSe) and its successful in vitro integration into the native protein scaffold of [FeFe]-hydrogenases HydA1 from Chlamydomonas reinhardtii and CpI from Clostridium pasteurianum yielding fully active enzymes (HydA1-ADSe and CpI-ADSe). FT-IR spectroscopy and X-ray structure analysis confirmed the presence of structurally intact ADSe at the active site. Electrochemical assays reveal that the selenium containing enzymes are more biased towards hydrogen production than their native counterparts. In contrast to previous chalcogenide exchange studies, the S to Se exchange herein is not based on a simple reconstitution approach using ionic cluster constituents but on the in vitro maturation with a pre-synthesized selenium-containing [2Fe] mimic. The combination of biological and chemical methods allowed for the creation of a novel [FeFe]-hydrogenase with a [2Fe2Se]-active site which confers individual catalytic features.

Veränderungen an Vulva und Vestibulum bei Mutterkühen und Färsen in den letzten sieben Tagen vor der Geburt

Gegenstand und Ziel: Ziel dieser Untersuchung war zu überprüfen, inwiefern die Ödematisierung der Vulva, Austritt von Sekret aus der Rima vulvae unddie Veränderung der Schleimhautfarbe im Vestibulum dazu geeignet sind, bei Mutterkühen den genauen Geburtszeitpunktzu bestimmen. Weiterhin sollte die Frage beantwortetwerden,ob ein Rasse- und ein Paritätseinfluss auf diese Parameter bestehen. Material und Methoden: An 105 Tieren (10 Färsen; 95 Kühe, davon 68 Fleckvieh-Kühe und 27 Kreuzungstiere Fleckvieh x Limousin) wurden während der letzten 168 Stunden ante partum alle acht Stunden folgende Merkmale untersucht: Grad der Vulvaödematisierung, Schleimaustritt aus der Rima vulvae und Farbe der Vestibu- larschleimhaut. Ergebnisse: Alle Tiere zeigten eine ÖdematisierteVulva. DerAnteilvon Tieren mit hochgradiger Ödematisierung nahm mit nahender Geburt zu (p <0,001). Zwischen Kühen und Färsen sowie den Rassen ließ sich kein Unterschied nachweisen. Mit zeitlicher Annäherung an den Partus erhöhte sich derAn- teil der Tiere mit Schleimaustritt aus der Rima vulvae nicht (p >0,05). Die Intensitätdes Schleimaustritts war bei Kühen stärker alsbei Färsen (p < 0,05). Rasseunterschiede bestanden nicht. Statistisch signifikante Veränderungen der Schleimhautfarbe des Vestibulums konnten nicht festgestellt werden. Zwischen Kühen und Färsen und zwischen den Rassen fanden sich keine Unterschiede. Schlussfolgerung und klinische Relevanz: Der Grad der Vulvaödematisierung zeigt eine starke zeitliche Bindung zum Abkalbetermin. Sie ist jedoch nicht dazu geeignet,den Zeitpunktdes Partus genauer zu terminieren. Keine zeitliche Bindung besteht zwischen der Veränderung der Vestibularschleimhautfarbe sowie dem Austritt vonSchleimaus der Rima vulvae in der letzten Woche ante partum und dem Geburtszeitpunkt.

Educational Level, Anticoagulation Quality, and Clinical Outcomes in Elderly Patients with Acute Venous Thromboembolism: A Prospective Cohort Study

Whether the level of education is associated with anticoagulation quality and clinical outcomes in patients with acute venous thromboembolism (VTE) is uncertain. We thus aimed to investigate the association between educational level and anticoagulation quality and clinical outcomes in elderly patients with acute VTE. We studied 817 patients aged ≥65 years with acute VTE from a Swiss prospective multicenter cohort study (09/2009-12/2013). We defined three educational levels: 1) less than high school, 2) high school, and 3) post-secondary degree. The primary outcome was the anticoagulation quality, expressed as the percentage of time spent in the therapeutic INR range (TTR). Secondary outcomes were the time to a first recurrent VTE and major bleeding. We adjusted for potential confounders and periods of anticoagulation. Overall, 56% of patients had less than high school, 25% a high school degree, and 18% a post-secondary degree. The mean percentage of TTR was similar across educational levels (less than high school, 61%; high school, 64%; and post-secondary, 63%; P = 0.36). Within three years of follow-up, patients with less than high school, high school, and a post-secondary degree had a cumulative incidence of recurrent VTE of 14.2%, 12.9%, and 16.4%, and a cumulative incidence of major bleeding of 13.3%, 15.1%, and 15.4%, respectively. After adjustment, educational level was neither associated with anticoagulation quality nor with recurrent VTE or major bleeding. In elderly patients with VTE, we did not find an association between educational level and anticoagulation quality or clinical outcomes.

Artifacts in orthodontic bracket systems in cone-beam computed tomography and multislice computed tomography

OBJECTIVES

The purpose of this study was to quantify artifacts caused by different bracket systems in cone-beam computed tomography (CBCT) and multislice computed tomography (MSCT) scans.

METHODS

Orthodontic brackets of four different systems were consecutively bonded to the surface of a residual molar on a human cadaveric mandible. One MSCT system and three CBCT units were used to scan each of the four bonded brackets, in addition to obtaining a blank reference scan of the tooth surface. All datasets were registered to the reference dataset using visualization software (Analyze 11.0® by AnalyzeDirect). Artifact-related reductions in image quality were expressed in percent of theoretical maximum standard deviations (SD) obtained for the gray values of the adjacent voxels, with higher percentages correlating more pronounced artifacts.

RESULTS

Both the SD percentages for three defined line profiles and their mean values were almost invariably higher with the MSCT system than with the CBCT units. Looking into the individual SD percentages, two of the CBCT units (Pax Zenith 3D® and Picasso Trio®; both Vatech) produced higher values than the MSCT system (SOMATOM Definition AS+®; Siemens) in some line profiles. The titanium bracket, in particular, was associated with marked differences between the two scanner technologies, as the mean artifact intensities from this bracket were particularly high with the MSCT unit and relatively low with the CBCT units. The artifact intensities observed with the other three bracket systems varied widely depending on which scanner was used.

CONCLUSION

Different artifact intensities were noted depending on the composition of the bracket system and on the scanner technology (MSCT/CBCT). While the artifacts manifested themselves differently with different scanners, their adverse effects were comparable. However, given the variable severity of the artifacts observed depending on the materials scanned and the scanners used, a blanket recommendation for or against MSCT or CBCT units cannot be given on the basis of this study.

A structural view of synthetic cofactor integration into [FeFe]-hydrogenases

Crystal structures of semisynthetic [FeFe]-hydrogenases with variations in the [2Fe] cluster show little structural differences despite strong effects on activity.

[FeFe]-hydrogenases are nature's fastest catalysts for the evolution or oxidation of hydrogen. Numerous synthetic model complexes for the [2Fe] subcluster (2Fe_H) of their active site are known, but so far none of these could compete with the enzymes. The complex Fe₂[μ-(SCH₂)₂X](CN)₂(CO)₄^2– with X = NH was shown to integrate into the apo-form of [FeFe]-hydrogenases to yield a fully active enzyme. Here we report the first crystal structures of the apo-form of the bacterial [FeFe]-hydrogenase CpI from Clostridium pasteurianum at 1.60 Å and the active semisynthetic enzyme, CpI^ADT, at 1.63 Å. The structures illustrate the significant changes in ligand coordination upon integration and activation of the [2Fe] complex. These changes are induced by a rigid 2Fe_H cavity as revealed by the structure of apoCpI, which is remarkably similar to CpI^ADT. Additionally we present the high resolution crystal structures of the semisynthetic bacterial [FeFe]-hydrogenases CpI^PDT (X = CH₂), CpI^ODT (X = O) and CpI^SDT (X = S) with changes in the headgroup of the dithiolate bridge in the 2Fe_H cofactor. The structures of these inactive enzymes demonstrate that the 2Fe_H-subcluster and its protein environment remain largely unchanged when compared to the active enzyme CpI^ADT. As the active site shows an open coordination site in all structures, the absence of catalytic activity is probably not caused by steric obstruction. This demonstrates that the chemical properties of the dithiolate bridge are essential for enzyme activity.

Imaging the Parasinus Region with a Third-Generation Dual-Source CT and the Effect of Tin Filtration on Image Quality and Radiation Dose

BACKGROUND AND PURPOSE

CT is the imaging technique of choice in the evaluation of midface trauma or inflammatory disease. We performed a systematic evaluation of scan protocols to optimize image quality and radiation exposure on third-generation dual-source CT.

MATERIALS AND METHODS

CT protocols with different tube voltage (70-150 kV), current (25-300 reference mAs), prefiltration, pitch value, and rotation time were systematically evaluated. All images were reconstructed with iterative reconstruction (Advanced Modeled Iterative Reconstruction, level 2). To individually compare results with otherwise identical factors, we obtained all scans on a frozen human head. Conebeam CT was performed for image quality and dose comparison with multidetector row CT. Delineation of important anatomic structures and incidental pathologic conditions in the cadaver head was evaluated.

RESULTS

One hundred kilovolts with tin prefiltration demonstrated the best compromise between dose and image quality. The most dose-effective combination for trauma imaging was Sn100 kV/250 mAs (volume CT dose index, 2.02 mGy), and for preoperative sinus surgery planning, Sn100 kV/150 mAs (volume CT dose index, 1.22 mGy). "Sn" indicates an additional prefiltration of the x-ray beam with a tin filter to constrict the energy spectrum. Exclusion of sinonasal disease was possible with even a lower dose by using Sn100 kV/25 mAs (volume CT dose index, 0.2 mGy).

CONCLUSIONS

High image quality at very low dose levels can be achieved by using a Sn100-kV protocol with iterative reconstruction. The effective dose is comparable with that of conventional radiography, and the high image quality at even lower radiation exposure favors multidetector row CT over conebeam CT.

Cone beam computed tomography and low-dose multislice computed tomography in orthodontics and dentistry: a comparative evaluation on image quality and radiation exposure

OBJECTIVES

The goal of the present work was to assess various computed tomography (CT) systems in term of image quality and organ doses, namely five cone-beam CT (CBCT) scanners operated at standard settings and three multislice CT (MSCT) scanners operated at greatly dose-reduced settings.

MATERIALS AND METHODS

Radiographic volume scans were taken on a complete human cadaveric head specimen and the image quality of each was rated by four experienced examiners according to specific skeletal structures and bone-soft tissue interfaces. Radiation doses were captured by a head-and-neck phantom (Rando; Alderson Research Laboratories). Standard protocols were used for the CBCT scans. For the MSCT scans, tube voltage and current were adjusted to minimize radiation without compromising image quality.

RESULTS

Interobserver agreement was close to perfect, with iota coefficients of 0.931 (95% CI 0.807-0.978) between groups 1 and 2 and 0.959 (95% CI 0.869-1.000) between groups 1 and 3. Ratings of image quality in terms of skeletal-structure representation were slightly better for the CBCT than the MSCT scanners, although these differences were not statistically significant. The two groups of scanners applied considerably different organ doses: the lowest dose (0.03 mSv) was measured on the bone surface with a CBCT unit (Picasso Trio® from Vatech) and the highest dose (8.30 mSv) in the vicinity of the eye lens with another CBCT unit (3D Accuitomo 170® from J. Morita).

CONCLUSION

The various systems tested offer similar imaging quality but demonstrated distinct differences in organ dose levels. The decision on which approach to take is not between CBCT and MSCT but rather between specific models and parameter settings. If these are optimized, MSCT images providing useful clinical information can be obtained at much reduced levels of radiation. Depending on the model and setting used, MSCT radiation levels may even be lower than during CBCT scans.

Metric precision via soft-tissue landmarks in three-dimensional structured-light scans of human faces

OBJECTIVES

The goal of the current work was to investigate the suitability of ten facial soft-tissue landmarks (trichion, glabella, nasion, left and right orbital, subnasal, left and right porion, pogonion, gnathion) as reference points for metric facial analysis by analyzing their intra- and interserial precision in all three dimensions.

METHODS

The faces of 32 volunteers were scanned using a standardized protocol with a structured-light scanner (FaceSCAN(3D) Scientific Photolab 60 Hz; 3D Shape, Erlangen, Germany). Three examiners placed the landmarks twice within a 2-week interval. Image processing (Onyx Ceph(3); Image Instruments; Chemnitz, Germany) and statistical (SAS 9.2; SAS Institute, Cary, NC, USA) software was used for analysis. All measurements were corrected for mean values per patient and analyzed for intraserial and interserial error by model II ANOVA for a simple classification with random effects.

RESULTS

Median intraserial precision was 0.40 mm (range 0.05-1.01 mm) overall, including 0.40 mm (0.33-0.85 mm) on the x-axis, 0.64 mm (0.36-0.87 mm) on the y-axis, and 0.27 mm (0.05-1.01 mm) on the z-axis. Interserial precision was substantially lower at a median of 0.05 mm (0-0.22 mm), often not statistically assessable with intraserial precision. We observed no landmark-associated differences; in particular, the medians of the bilateral landmarks orbital (intraserial: 0.40 mm; interserial: 0.02 mm) and porion (intraserial: 0.36 mm; interserial: small and not assessable) were in the middle of the range of our results. Trichion (intraserial: 0.73 mm; interserial: 0.05 mm) and gnathion (intraserial: 0.87 mm; interserial: 0.20 mm) revealed the highest degrees of intraserial measurement imprecision. Outliers were identified in 1.2% (64 of 5400) of measurements.

CONCLUSION

All selected landmarks offer suitably high levels of intra- and interserial precision for the three-dimensional (3D) metric assessment of facial soft-tissue parameters. No difference between (bi)lateral and facial midline landmarks was noted.

[Cerebral venous thrombosis and subdural haematoma: complications of spontaneous intracranial hypotension]

We report on the case of a spontaneous intracranial hypotension with subdural hygroma, as well as cerebral venous thrombosis (CVT), both known complications of intracranial hypotension. The 45-year-old patient was subsequently treated - according to current guidelines for CVT - with anticoagulation, but developed subdural haematoma (SDH), which required neurosurgical treatment. Our case highlights the complex pathophysiological sequelae of intracranial hypotension, as well as the occasionally difficult treatment decisions. Subdural hygroma probably predisposes patients to SDH during anticoagulation. Thus, the potential benefit of anticoagulation needs to be weighed against the risk of SDH on an individual basis.

Three-year follow-up of a patient with early-onset Alzheimer's disease with presenilin-2 N141I mutation - case report and review of the literature

Autosomal dominant early-onset Alzheimer disease (EOAD) is a heterogeneous condition that has been associated with mutations in 3 different genes: the amyloid precursor protein (APP), presenilin 1 (PSEN1), and presenilin 2 (PSEN2) genes. Most cases are due to mutations in the PSEN1 gene, whereas mutations in the APP and PSEN2 genes are rare. Mutation analysis of the APP, PSEN1 and PSEN2 genes was performed. We herein report the case of a German EOAD patient with a family history of dementia and a missense mutation at codon 141 (N141I) of the PSEN2 gene. To our knowledge, this is the first German EOAD patient without a Volga-German ancestry and a positive family history for dementia carries the mutation PSEN-2 N141I. The patient came to our clinic for the first time when she was 47 years old. During the following 3 years, her Mini-Mental State Examination (MMSE) score dropped from 28 to 0. Mild cognitive impairment (MCI) was an early symptom that was already present during the first consultation. The concentration in cerebrospinal fluid (CSF) of tau-protein (1151 pg/ml) was increased, whereas the concentration of beta-amyloid protein (Abeta1-42) was decreased (335 pg/ml). Magnetic resonance imaging (MRI) revealed only slight changes in the early stage of the disease and positron emission tomography with (18F) fluoro-2-deoxy-D-glucose (18F-FDG PET) demonstrated glucose reduction left parietal and in the precuneus region. Follow-up MRI and 18F-FDG PET studies showed progression of atrophy of the left entorhinal cortex with relative sparing of the hippocampus and progressive hypometabolism of both temporoparietal lobes and left frontal lobe.