Acute myelopathy or cauda equina syndrome in HIV-positive adults in a tuberculosis endemic setting: MRI, clinical, and pathologic findings

BACKGROUND AND PURPOSE

Cape Town is the center of an HIV-tuberculosis coepidemic. This study's aim was to highlight the importance and to describe the MR imaging features of tuberculosis in acute myelopathy and cauda equina syndrome in HIV-positive adults. To accomplish this we retrospectively reviewed the MR imaging and clinico-pathologic findings of HIV-positive patients presenting to our hospital with recent onset paraplegia and sphincter dysfunction over a 4-year period, 2008-2011.

MATERIALS & METHODS

MR imaging, CD4 count, and CSF analysis and pathology were correlated in 216 cases.

RESULTS

Fifty-eight percent (127) of subjects were female. The mean age was 37 years. The median CD4 count was 185 cells/μL. Twenty-five percent (54) of patients were on antiretroviral therapy. MR imaging showed spondylitis in 30% (65). The median CD4 count in these patients was significantly higher than in the remainder. Disk destruction was common and 10% had synchronous spondylitis elsewhere in the spinal column. Thirty percent (64) had features of myelitis/arachnoiditis. Twenty-five percent (55) had no MR imaging abnormality. In 123 (57%) of cases with a definitive etiology on CSF culture or biopsy, 84 (68%) were attributable to tuberculosis including all spondylitis cases and 40% of nonspondylitis cases. Twelve (10%) were due to nontuberculous infection and 12 (10%) had HIV-associated tumors including 2 rare Epstein-Barr-related tumors.

CONCLUSIONS

In our setting, acute onset myelopathy/cauda equina syndrome in HIV-positive patients is largely attributable to tuberculosis with nonspondylitic forms being more common than spondylitis and associated with a lower CD4 count.

Neuroradiological features of the tuberculosis-associated immune reconstitution inflammatory syndrome

SETTING

Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is an important complication in human immunodeficiency virus type I (HIV-1) infected tuberculosis (TB) patients who start combination antiretroviral treatment (ART). Neurological manifestations occur in more than 10% of TB-IRIS cases. Apart from a few case reports, the radiological features of neurological TB-IRIS have not been described.

OBJECTIVE

To describe the neuroradiological findings of patients with paradoxical neurological TB-IRIS.

DESIGN

Computed tomography (CT; n = 13) and magnetic resonance imaging (n = 3) findings of 16 patients were reviewed.

RESULTS

IRIS manifestations included meningitis (n = 4), intracranial space occupying lesions (SOLs, presumed tuberculomas; n = 5), meningitis and SOLs (n = 5), radiculomyelitis (n = 1) and spondylitis (n = 1). In patients with tuberculoma IRIS, we observed a high prevalence of 1) low density lesions on non-contrast-enhanced CT (all lesions), 2) multiple lesions (in 5/10 patients) and 3) perilesional oedema (17/22 lesions). In patients with meningitis, meningeal enhancement (n = 2) and hydrocephalus (n = 1) were infrequently observed.

CONCLUSION

This is the first substantial series to describe the radiological features of paradoxical neurological TB-IRIS. Compared to published radiological findings of tuberculomas in HIV-1-infected patients (not receiving ART), an increased inflammatory response is suggested in tuberculoma IRIS. However, this was not observed in patients with TB meningitis IRIS.

Arterial dissection and subarachnoid haemorrhage in human immunodeficiency virus-infected patients. A report of three cases

SUMMARY

Cerebrovascular complications of AIDS have been reported as high as 34% in post mortem series. Most patients suffer from ischaemic strokes but there are a number of reports of patients presenting with subarachnoid haemorrhage (SAH) related specifically to aneurysm rupture. We present three patients with advanced HIV disease and low CD4 counts who present with SAH. In two of the patients the haemorrhage appeared to be caused by intracranial artery dissection which, to our knowledge, has not previously been described. Both patients were successfully treated endovascularly, one with segmental vessel trapping and the other with partial coil embolization of a false aneurysm. The pathological basis for HIV related arteriopathy is discussed in relation to these cases.

Sucralfate and methylprednisolone enemas in active ulcerative colitis: a prospective, single-blind study

In order to investigate the role of sucralfate in active ulcerative colitis, 60 patients were randomized to receive either sucralfate enemas (20 g/100 ml) or methylprednisolone enemas (20 mg/100 ml). The enemas were administered twice daily for one week, and then once daily for three weeks. Clinical evaluation was documented at entry and at two weeks and four weeks. The sigmoidoscopic appearance of the rectal mucosa was scored, and rectal biopsies taken at entry and at four weeks. Results indicated similar reduction in diarrhea and rectal bleeding at two weeks and at four weeks. Sigmoidoscopy demonstrated similar significant improvement in the macroscopic appearance of the rectal mucosa in both groups (8.28 to 6.20 in sucralfate group, P < 0.02; and 8.72 to 6.36 in the methylprednisolone treated group, P < 0.04). Histologic assessment, likewise, showed similar improvements in the two groups. This study indicates that sucralfate enemas may be useful in the treatment of ulcerative proctosigmoiditis.

The value of an elimination diet in the management of patients with ulcerative colitis

Debate exists about the role of diet in both the aetiology and the management of ulcerative colitis. To examine the latter, a group of patients with documented ulcerative colitis was studied at the Groote Schuur Hospital Gastro-intestinal Clinic. A total of 18 subjects, 9 female and 9 male, were randomised into active or control groups and followed up weekly for 6 weeks. Subjects in the control group were asked to document but not alter their intake of food and drink. Those in the experimental group had their diets systematically manipulated to exclude foods that appeared to provoke symptoms. The symptoms, sigmoidoscopy and biopsy findings of all subjects were compared before and after. 'Remission' was defined as the passage of normal stools with absence of rectal bleeding. 'Improvement' was defined as a decrease in the number of diarrhoeal stools and/or a diminution of rectal bleeding. At the end of the trial the diet group displayed significantly fewer symptoms than did the controls (P = 0.009; Fisher's exact test). Sigmoidoscopic findings improved in 8 subjects in the diet group compared with 2 of the controls. Histological findings improved in 3 of the diet group as well as in 3 of the controls. There were no foods that provoked symptoms in all patients, though spiced and curried foods and fruits, especially grapes, melon and the citruses, commonly caused diarrhoea. In only 2 patients were symptoms reproduced consistently on reintroduction of a particular food, pork in 1 case and yellow cheese in another.

A controlled double blind study of azathioprine in the management of Crohn's disease

While immunosuppressive agents are used widely in the management of Crohn's disease, their efficacy has not been well established in randomised controlled trials. This study was designed to examine whether azathioprine increases remission rate when used in conjunction with a diminishing dose regimen of prednisolone over a period of 12 weeks. It further examined whether azathioprine offers any therapeutic advantage over placebo in the maintenance of remission in Crohn's disease over a period of 15 months. Sixty three patients with active Crohn's disease were treated with a 12 weeks diminishing dose of prednisolone and at the same time entered into a randomised, double blind 15 month trial of either azathioprine (2.5 mg/kg) or placebo. Remission rates between the two groups were compared at 12 weeks and at 15 months. There was no significant difference in the proportion of patients who had achieved and maintained remission by week 12 but at 15 months there was a highly significant difference in the proportion of patients in remission (42% receiving azathioprine v 7% receiving placebo), p = 0.001. Using life tables this beneficial effect was reflected as the difference in the median number of days on the trial (p = 0.02). There were significantly greater decreases over the trial period in the median erythrocyte sedimentation rate, C reactive protein, and leucocyte count in the azathioprine group. There were no cases of severe bone marrow suppression or clinical pancreatitis. In conclusion, azathioprine offers a therapeutic advantage over placebo in the maintenance of remission in Crohn's disease.

Oral hyperalimentation in the nutritional management of burned patients

Total daily protein and energy requirements for burned adult patients were adapted from Sutherland's formulae and implemented in the Burn Unit at Tygerberg Hospital. Patients were given a high-protein ward diet and oral hyperalimentation, and weekly recording of body mass was used for monitoring. It was found that the high protein and energy intake minimized body mass loss during the period after thermal injury.