[Influence of age on the clinical manifestations of invasive pneumococcal disease and antibiotic resistance rates]

BACKGROUND AND OBJECTIVE

Invasive pneumococcal disease (IPD) shows different epidemiological characteristics depending on age and pneumococcus serotype. The aims of the work were to analyze the clinical manifestations and mortality associated with IPD, the serotype isolated and the antibiotic resistance rates in different age groups.

PATIENTS AND METHOD

Retrospectively, 141 patients with IPD diagnosed between 2002 and 2008 were studied. Patients were classified in 4 age groups: ≤ 2 year-old, 3-14 year-old, 15-64 year-old and ≥ 65 year-old.

RESULTS

Pneumonia was the most common manifestation in all age groups (71%). Pneumococcal meningitis was more prevalent in patients ≤ 2 year-old (28 vs. 9%, P=.054) and empyema was more frequent in those between 3-14 year-old (31 vs. 5%, P<.001). Mortality was associated with age ≥ 65 year-old (odds ratio [OR] 7, 95% confidence interval [95% CI] 1.9-28.9), primary bacteremia (OR 7, 95% CI 1.9-28.9) and orotracheal intubation (OR 9, 95% CI 1.9-41.1). The more prevalent serotypes among patients ≤ 2 year-old were 14, 19A and 19F. The serotype 1 was most common in patients between 3-14 year-old and serotype 3 in those ≥ 65 year-old. A higher rate of non-susceptible penicillin strains was observed in pediatric population (42 vs. 19%, P=.007).

CONCLUSIONS

Age was related to the clinical manifestations, mortality and antibiotic resistance rates. Primary bacteremia was one of the risk factors of mortality.

High prevalence of pulmonary hypertension in patients with hereditary hemorrhagic telangiectasia

OBJECTIVE

Hereditary hemorrhagic telangiectasia (HHT) is a vascular disorder causing mucocutaneous telangiectases and visceral arteriovenous malformations (AVMs). Pulmonary hypertension (PH) is considered an uncommon complication of HHT whose impact on the survival of these patients is currently unknown.

METHODS

From January 1995 to December 2008, 29 hospitalized patients with definite HHT were included and followed until January 2011. Data on demographics, clinical symptoms and survival were recorded. PH was classified according to echocardiographic probability.

RESULTS

A CT angiogram was performed in 24 of the 29 patients with HHT and AVMs were detected in 16 of them (67%): hepatic in 58%, pulmonary in 33% and spinal in 3%; 37% had both pulmonary and hepatic AVMs. Transthoracic Doppler echocardiography (TTE) was performed in 21 patients. PH was considered possible in 4 (14%) and probable in 9 (31%). The mean age at diagnosis was lower in patients with PH than in patients without PH (54±16.5 years vs 73±8.8 years, p=0.002). PH was more prevalent in patients with AVMs (56 vs. 23%, p=0.036). The mean follow-up of the entire cohort was 6±4.4 years (range: 2 months-17 years), during this time 18 patients died (62%; mean age 73±8.1 years). Patients with PH died at a younger age (68±8.4 vs. 79±2.7 years, p=0.015) than those without PH.

CONCLUSIONS

PH is a severe condition that significantly reduces survival on HHT patients. PH should be suspected in all HHT patients with dyspnea and hepatic AVMs.

Synovial fluid eosinophilia: a case series with a long follow-up and literature review

OBJECTIVES

To establish the frequency and describe the characteristics of a cohort of patients with SF eosinophilia (SFE) and a long clinical follow-up. A systematic review of the literature on this topic was performed.

METHODS

From November 2005 to May 2010, 982 consecutive arthrocentesis procedures performed at a tertiary care hospital were reviewed. Clinical and analytical data of patients with SFE at the time of diagnosis and during follow-up until 31 January 2012, were recorded. According to the percentage of eosinophils in SF, SFE was classified as minor (<10%) or major (>10%). Also, a literature search of all publications on eosinophilic synovitis found in MEDLINE, EMBASE and Web of Science without publication date restrictions was performed.

RESULTS

Eosinophils in SF were found in 10 of 982 (1.02%) patients: minor SFE was recorded in three patients, all of them with haemorrhagic fluid and without peripheral eosinophilia. Major SFE was found in seven patients, and only two of them had peripheral eosinophilia. In six patients, an underlying cause of the arthritis was found. Only one patient was classified as having idiopathic SFE. Most SFE promptly resolved with NSAIDs without relapses or new deformities. The literature search identified 56 patients with SFE; 49 of them (88%) had major SFE and 7 (12%) had minor SFE.

CONCLUSIONS

Eosinophils are infrequently found in SF, and in most cases peripheral eosinophilia was not detected. Most patients with SFE had a benign course with prompt resolution and few relapses.

Autoimmune manifestations of Kikuchi disease

OBJECTIVES

Kikuchi's disease (KD) has been associated with the presence of autoantibodies, systemic lupus erythematosus (SLE), and other autoimmune diseases. The aim of this study was to assess the frequency of autoimmune manifestations in a KD cohort with a long follow-up.

METHODS

Twenty patients with histologically confirmed KD since January 1990 until December 2010 were studied; 12 of them were periodically followed up as outpatients. Another 7 patients were contacted by telephone to offer them a specific consultation and a complete autoimmunity study.

RESULTS

Thirteen of 20 patients were women (65%) with a mean age of 29 years (range, 15-79). The age at diagnosis was higher in men (44 vs 27 years, P < 0.05). Lymphopenia was present in 75% of the patients (15/20) and was the more frequent hematological abnormality. The mean follow-up of the 17 patients included in the autoimmunity study was 119 months (range, 15-252). Autoimmune diseases were detected in 9 women (53%): SLE was diagnosed in 4 patients (2 SLE before, 1 simultaneous, and 1 after KD), 2 patients developed primary Sjögren's syndrome after KD, 1 thyroiditis before KD, 1 SLE-like, and 1 antiphospholipid antibodies after KD. Leukocytoclastic vasculitis was found in 2 patients; 1 of them eventually developed SLE. Female sex, painful adenopathies, and cytopenias were significantly associated with autoimmune diseases.

CONCLUSIONS

Among patients with KD, only women developed autoimmune manifestations. Therefore, long-term follow-up and active surveillance of autoimmune diseases in patients with KD, especially women, are recommended.

Late infection of an embolized renal graft presented as buttock cellulitis

Graft intolerance syndrome (GIS) is a common complication developed in failed kidney allografts left in situ when the patients returned to hemodialysis. GIS usually develops within the first 6 months after immunosuppression has been withdrawn. When medical treatment has failed, transplantectomy is the conventional therapy. Nevertheless, in recent years, transvascular ethanol embolization has been reported as an effective, safe, and less invasive technique than transplantectomy for the management of patients with GIS. Although infrequent, the most severe complication is infection of the graft or surrounding tissues, which usually appears in the first weeks after the procedure. We present the first case of late infection of an embolized renal graft, more than 2 years after embolization.

[Complications related with cocaine abuse that required hospital admission]

INTRODUCTION

Although cocaine abuse is an increasingly important medical problem, many manifestations of its toxicity are not well understood. The aim of this study is to review the most serious clinical manifestations related to cocaine abuse.

PATIENTS AND METHOD

We reviewed the medical records of all patients over 16 years of age admitted to the hospital from January 1994 to December 2005 where cocaine abuse was recorded in their clinical history.

RESULTS

A total of 170 patients, with 188 episodes and 268 pathologic manifestations related to cocaine abuse were included. Thirty two out of the 170 patients (18.8%) were females. Mean age was 33 +/- 11 years, with no significant difference between males and females. A total of 88.8% were smokers, 70% had alcohol abuse and 67.3% had other illegal drug abuses. The more frequent reason for their hospitalization was: pulmonary infection (29.6%), bronchial hyperreactivity (14%), acute psychotic attack related to drugs (12%), ischemic heart disease (10%), infectious endocarditis (7.8%), cerebrovascular disease (8.6%), seizures (6.2%) and severe abdominal complications (2.3%). Eight patients died (6.25%). The association with cocaine was only suspected in 46% of the toxic manifestations.

CONCLUSIONS

Several clinical manifestations are associated to cocaine abuse and its consumption causes potentially fatal complications. The integral treatment of these patients could be improved if these complications are kept in mind.

Infección asociada a prótesis vascular: manejo exitoso sin retirada de prótesis

INTRODUCTION

Removal of graft with intravenous antibiotics is traditionally considered the most effective treatment of vascular graft-associated infections. However, an increasing number of reports suggests that this complication can be effectively treated without graft removal.

METHODS

A prospective study to evaluate the outcome of conservative management of vascular graft-associated infection seen in our center was performed. The diagnosis of graft-associated infection was based on microbiological tests, and imaging studies. In our study, patients were hemodynamically stable with functioning vascular graft as per clinical and imaging evaluations. Conservative management included antibiotic treatment and local debridement without removal of vascular graft.

RESULTS

Fourteen patients with vascular graft-associated infection were enrolled in our study. Eleven out of 14 patients (78.6%) responded successfully to conservative management. Treatment failure was reported in 3 patients, 2 of whom required graft removal. After a two-year follow-up, these 14 patients were clinically stable without recurrence of infection.

CONCLUSIONS

Our study has revealed that conservative management of vascular graft-associated infection seems to be effective and should be considered in hemodynamically stable patients with functioning vascular graft.

Abscesos del psoas. Una perspectiva actual

OBJECTIVE

To analyze the characteristics of abscesses of the psoas muscle and assess the differences between pyogenic and tuberculous abscesses.

METHODS

Retrospective descriptive study of all patients with psoas abscess in our hospital over the period 1994 to 2004.

RESULTS

Fourteen patients were studied (10 males), with a mean age of 42 years. Half of them had had an underlying disease. The most frequent clinical manifestations were abdominal pain (64%), fever (57%), and back pain (43%). All the abscesses were secondary. In 7 patients the origin was gastrointestinal, in 6 osteoarticular, and 1 was related with infection of an aortobifemoral bypass. Computed tomography was the diagnostic imaging method in all patients. Culture of drainage specimens was positive in 92% of patients undergoing this procedure. Causal microorganisms included Mycobacterium tuberculosis (5), Streptococcus intermedius (4), Staphylococcus aureus (3), Escherichia coli (3) and Bacteroides fragilis (2). Tuberculous abscesses originated in spondylitis and the clinical presentation was longer prior to diagnosis. Drainage was performed in 12 patients (8 percutaneous and 4 surgical). Mean duration of antimicrobial therapy was 4 weeks. The infection resolved in all patients.

CONCLUSIONS

Psoas abscess commonly had a gastrointestinal and osteoarticular origin. We underscore the high percentage of tuberculous etiology, which had a more insidious clinical and analytical presentation and was usually secondary to spondylitis. Prolonged antimicrobial treatment associated with drainage was effective therapy.

[Pulmonary hemorrhage and anti-phospholipid syndrome]

The presence of anti-phospholipid antibodies (anticardiolipin antibodies and lupus anticoagulant) associated to venous and/or arterial thrombotic phenomena and fetal losses define the anti-phospholipid syndrome. On rare occasions severe hypoprothrombinemia associated with this disease as a cause of hemorrhagic manifestations has been described. In addition very few cases of alveolar hemorrhage in anti-phospolipid syndrome (APS) have been described, being this complication usually related to microthrombosis and/or capillaritis of pulmonary vessels. We describe two patients without previous clinical manifestations of anti-phospholipid syndrome that showed pulmonary hemorrhage with anticardiolipin antibodies positivity. The first of them, a 33-year-old male, began his disease with low prothrombin time and the presence of antiprothrombin antibodies. In the biopsy by thoracoscopy the presence of pulmonary hemorrhage without capillaritis nor thrombotic phenomena was demonstrated, becoming evident certain clinical improvement and normalization of the prothrombin time after receiving immunosuppressive treatment but with persistence of the pulmonary hemorrhage 5 years later. The second case, a 89-year-old male, began his condition with bilateral lung infiltrates and hemoptysis, anticardiolipin antibodies positivity, and thrombopenia, with recurrence of the condition 1 year later. After other etiological possibilities were ruled out, and despite hemorrhagic trait in both patients, we consider that they should be in the clinical context of the anti-phospholipid syndrome, although at this time they did not meet the criteria recognized in order to diagnose this disease. Within the ampliable clinical spectrum of the anti-phospholipid syndrome we should take into account the pulmonary hemorrhage.

[Strongyloides stercoralis in the south of Galicia]

Strongyloides stercoralis is the only parasite which can produce a chronic illness in humans, being through autoinfection. This nematode can also provoke death when patient's immunologic state deteriorates producing a massive hyper infection. The first patient with strongyloidiasis who has always lived in the Galician South area is described. The clinical picture consisted of unspecific cutaneous lesions and abdominal pain with severe peripheral eosinophilia (> 20,000/ml. The diagnosis was carried out observing the larvae in the fecal examination and was confirmed with a culture. Treatment with albendazole failed and the healing was reached with ivermectin. We must consider the possibility of strongyloidiasis because misdiagnosing these patients as eosinophilic gastroenteritis there would be a higher risk of hyperinfection if they are treated with corticosteroids.

[Cerebral abscesses of oral origin]

INTRODUCTION

It has been suggested that between 3% and 13% of the cerebral abscesses (CA) are presumably associated to oral infections or dental procedures.

AIM

Determine the prevalence of CA of oral origin, discussing their clinical and microbiological characteristics.

PATIENTS AND METHODS

Retrospectively, 54 cases of CA diagnosed in 3 hospitals of Galicia between 2001 and 2002 were reviewed.

RESULTS

A presumed oral portal of entry was recorded in 6 patients (11.1%); 4 cases were associated to oral infections and the remaining 2 had received dental treatment in the months prior to the onset of symptoms. Half of the patients showed irrelevant medical record, 2 had had previous extracranial abscesses and 1 presented a type A immunoglobulin deficiency. In 4 cases, the microbiological analysis was positive and typical oral bacteria (Streptococcus viridans and Peptostreptococcus spp.) were identified.

CONCLUSIONS

The results of this study suggest that a significant number of CA are probably of oral origin. In consequence, to maintain a good oral health status is important and specific prophylactic measures before any dental procedure should be applied, especially in patients with risk recognized factors.

Isoniazid hepatotoxicity among drug users: the role of hepatitis C

The incidence of and risk factors associated with hepatotoxicity in patients with chronic hepatitis have not been systematically studied. Therefore, we conducted a prospective study that included former drug users who were treated with isoniazid for latent tuberculosis infection. Of 415 patients, 20 (4.8%; 95% confidence interval [CI], 3-7.4) had hepatotoxicity diagnosed, and 6 (1.4%; 95% CI, 0.5-3.2) developed clinical hepatitis, none of whom had serious symptoms. The only 2 factors independently associated with isoniazid hepatotoxicity were excessive alcohol consumption (odds ratio [OR]; 4.2, 95% CI, 1.6-10.8; P=.002) and a high baseline alanine transaminase level (OR, 4.3; 95% CI, 1.6-11.4; P=.002). The presence of hepatitis C virus antibodies was associated with hepatotoxicity only on univariate analysis. Treatment with isoniazid in drug users appears to be safe and well tolerated, although frequent asymptomatic elevations in transaminase levels were observed.

[Lack of human herpesvirus type 6 DNA in CSF by nested PCR among patients with multiple sclerosis]

BACKGROUND

The etiology of multiple sclerosis (MS) is currently unknown. Different viruses have tentatively been involved as causative agents of MS that would trigger an autoimmune response leading to demyelination plaques. There is controversy regarding the role that the human herpesvirus 6 (HHV-6) might play in this condition, and high antibody titers have been detected to HHV-6. HHV-6 DNA has also been detected by PCR both in blood and cerebrospinal fluid by means of the Polymerase Chain Reaction (PCR). Immunohistochemistry studies were performed with histologic specimens from the white matters of patientes with MS. All this has led some authors to incriminate this virus as the triggering etiologic agent of this disease.

PATIENTS AND METHODS

CSF specimens from 23 patients with Relapsing-Remitting MS were studied. The CSF specimens from 23 patients undergoing rachianesthesia were used as controls, and none of them had neurologic disorders. A nested PCR was performed in the collected specimens to detect specific DNA sequences of HHV-6.

RESULTS

No DNA sequences of HHV-6, EBV, VZV, CMV and HSV were detected in the tested specimens.

CONCLUSIONS

No HHV-6 DNA sequences were detected from CSF specimens of patients with MS. Further investigations on the association between HHV-6 and MS should be performed to elucidate the role of HHV-6 in the pathogenesis of this disease.

[Mycotic pseudoaneurysm caused by Mycobacterium tuberculosis]

Mycobacterium tuberculosis can involve any organ of the body, including the arteries. Usually the mycobacteria infects the arterial wall spreading from a contiguous foci. We report a case of tuberculous pseudoaneurysm involving the iliac artery clinically manifested as fever of unknown origin. The diagnosis relied on abdominal CT-scanning. Tuberculous etiology was confirmed postoperatively by microbiologic and microscopic study. The antituberculous therapy was early started, but the patient died three months later as a consequence of a non-infectious abdominal aortic rupture. Clinicians should consider tuberculous etiology when the diagnosis of mycotic pseudoaneurysm is being entertained.

[Pneumothorax in patients infected by the human immunodeficiency virus]

OBJECTIVE

Patients with HIV who develop pneumothorax have been previously described. Pneumocystis carinii pneumonia (PCN) is the leading cause of this complication, but infection by other pulmonary microorganism, inhaled pentamidine therapy and lung invasive manoeuvres have also been associated with pneumothorax in HIV infected patients.

METHOD

We review the most relevant clinical aspects of pneumothorax in HIV-infected persons, gathered in our hospital along eight years, before HAART therapy was started. During this time, 97 patients with PCN were diagnosed and 148 patients received prophylaxis with inhaled pentamidine. Only 14 episodes of pneumothorax in 13 patients, were recorded. In ten occasions pneumothorax was related to pulmonary invasive manoeuvres, pulmonary infections were found in three and was considered spontaneous in one. The pulmonary invasive manoeuvres were: subclavia vein catheterisation in six cases (one of them was diagnosed of proved PCN and the other has pneumococcal pneumonia); transbronchial biopsy in one patient (also with proved PCN), knife chest trauma in two cases and after fine needle aspiration of an axillary lymph node in one patient.

RESULTS

The pulmonary infections associated with pneumothorax in three patients were: proved PCN (this patient was the only one in the group with inhaled pentamidine prophylaxis who developed pneumothorax), active pulmonary infection by mycobacterium tuberculosis and Pseudomonas aeruginosa pneumonia. A drainage chest tube was placed in 12 patients with complete resolution in nine. In the other two patients pleurodesis was necessary and surgical repair was carried out in the other one (who had pulmonary tuberculosis). During the follow up six patients died (median time to death: 7 months). Among patients who died, five had pulmonary infections when the pneumothorax was diagnosed: PCN in three cases, pulmonary tuberculosis and pseudomonas pneumonia in the other two; all of them with less than 100 CD4 lymphocytes.

CONCLUSIONS

Pneumothorax is frequent in HIV-infected patients with PCN, but other lung infections and, above all pulmonary invasive manoeuvres, can cause this complication. In our experience, HIV-infected patients who develop pneumothorax have a bad prognosis.

[Prevalence of hereditary hemochromatosis among healthy workers. Diagnostic value of transferrin saturation assay]

AIM

Hereditary hemochromatosis is the most common inherited disorder in white population (2-8 cases per 1000 habitants). Hemochromatosis is characterized by increased intestinal absorption of iron leading to its deposition into multiple organs. An early diagnosis and proper management with frequent phlebotomies are known to improve life expectancy and quality of life. Diagnosis is suggested by an elevated Transferrin saturation (TS) (more than 60%).

METHOD

Prospective study of the level of TS among 1131 healthy workers, who came to the Security and Hygiene Official Centre for their annual revision had been undertaken.

RESULTS

Twenty-wo workers had high TS; in 10 of them the increase of TS was confirmed on repeated determinations. Liver biopsy was performed in six (and refused by the other four), eventually a diagnosis of hemochromatosis was confirmed in three (in-group prevalence of 2.6 per 1000 people).

CONCLUSIONS

In our experience, TS is the most appropriate initial screening test for detecting hereditary hemochromatosis in a normal population.

Response to standard syphilis treatment in patients infected with the human immunodeficiency virus

In a study designed to evaluate the efficacy of penicillin in HIV-infected patients with syphilis and to determine the clinical and laboratory responses after treatment, 13 patients with HIV infection and syphilis were assessed at enrollment and at the last follow-up examination (median time of 21 months). The Venereal Diseases Research Laboratory (VDRL) test, the Treponema pallidum hemaglutination test, and leukocyte counts in cerebrospinal fluid were evaluated both at enrollment and at the last follow-up visit, and the polymerase chain reaction for Treponema pallidum DNA and the rabbit infectivity test were performed on cerebrospinal fluid samples at the last follow-up visit. Primary syphilis was confirmed in four patients, latent syphilis in five, and neurosyphilis in four. After penicillin treatment, all patients were asymptomatic. The serum rapid plasma reagin test became negative in five patients, and titers declined in eight. The VDRL test, Treponema pallidum DNA, and the rabbit infectivity test were negative in all 13 patients. Except for one patient whose serological titer was slow to decline, all patients had good clinical and serological responses to penicillin. In certain settings, factors other than penicillin treatment failure should be considered in HIV-infected patients with suspected relapse of syphilis.

Candida albicans endophthalmitis in brown heroin addicts: response to early vitrectomy preceded and followed by antifungal therapy

The management of Candida albicans endophthalmitis in intravenous drug abusers (IVDAs) has yet to be established. Early vitrectomy was previously reported as a promising treatment for C. albicans endophthalmitis. In our series, C. albicans endophthalmitis was diagnosed for 15 IVDAs. Funduscopic examinations confirmed severe vitritis in 12 patients and chorioretinitis in three. Blood and vitreal cultures were positive for C. albicans for seven and eight patients, respectively. Patients with vitritis received antifungal therapy before and after vitrectomy. Amphotericin B or fluconazole therapy was given according to the physician's preference. Vitrectomy was defined as early if it was performed within 1 week after the diagnosis of vitritis. All seven patients who underwent early vitrectomy had a favorable response without complications. Two of three patients who underwent late vitrectomy developed blindness or scotoma. Blindness was also described in two patients with vitritis who did not undergo vitrectomy. Early vitrectomy preceded and followed by antifungal therapy seems to be appropriate management of vitritis in IVDAs.

Histiocytic necrotizing lymphadenitis, Kikuchi-Fujimoto's disease, associated with systemic lupus erythemotosus

Histiocytic necrotizing lymphadenitis, Kikuchi-Fujimoto's Disease (KFD), is a condition rarely associated with systemic lupus erythematosus (SLE). The diagnosis of KFD can precede, postdate or coincide with the diagnosis of SLE. Lymphadenopathy is a common clinical presentation of KFD and SLE, and is histologically indistinguishable in both conditions. We describe two cases of KFD associated with SLE. The diagnosis of KFD in one case was made several years before the diagnosis of SLE, and the other was simultaneous. Both showed large lymphadenopathy, but neither fever nor neutropenia. Lymph-node biopsy showed necrosis, with proliferation of histiocytes and immunoblasts, paucity of neutrophils and absence of hemathoxilin bodies. Both patients responded favourably to steroid treatment. Patients with KFD should be assessed for SLE and have long-term follow-up checking for development of SLE. KFD should be ruled out in SLE flare-up accompanied by lymphadenopathy.

Serum angiotensin converting enzyme and C4 protein of complement as a combined diagnostic index in alcoholic liver disease

Diagnosis of liver cirrhosis relies on hepatic biopsy. So far, attempts have failed to achieve a serologic test that differentiates cirrhosis from other hepatic conditions. The aim of this work was to assess the diagnostic value of the ratio of serum angiotensin converting enzyme activity (SACE) and the levels of protein C4 of serum complement (SACE/C4) in differentiating cirrhotic from noncirrhotic alcoholic liver diseases. In this study, 68 active alcoholic patients (17 with fatty liver or minimal changes, 11 with acute alcoholic hepatitis and 40 with cirrhosis) were included. Twenty healthy subjects were studied as a control group. Liver biopsy was performed in all patients. SACE levels were significantly higher in the group with cirrhosis when compared with the group of patients without cirrhosis and the control. On the other hand, serum C4 level decreased as liver damage progressed. SACE values above 25 IU/l had a sensitivity of 92.5 percent (95 percent confidence interval, 87.5 to 97.5) and a specificity of 79 percent (95% percent confidence interval, 70.5 to 87.5), in detecting those patients with liver cirrhosis. The sensitivity further increased to 95 percent (95 percent confidence interval, 90.5 to 99.5) and the specificity to 100 percent when the SACE/C4 ratio was used and a cutoff point of 145 was chosen. To conclude, in alcoholics SACE is specifically elevated in patients with cirrhosis, and the SACE/C4 ratio is a excellent biochemical index for the diagnosis of cirrhosis in alcoholic patients.

Parkinsonism in an HIV-infected patient with hypodense cerebral lesion

A 49-year-old man presented with fever and parkinsonism. Examination of cerebrospinal fluid confirmed tuberculous meningitis. Cerebral computerized tomography scan revealed hypodense lesions and human immunodeficiency virus tests were positive. The patient's clinical picture and parkinsonism were improved with tuberculosis treatment.