Raised ICP in a child with cryptococcal meningitis: CT evidence of a distal CSF block

Raised intracranial pressure (ICP) often complicates the course of cryptococcal meningitis. The pathogenesis of the severely raised cerebrospinal fluid (CSF) pressure commonly associated with this condition is largely unexplained, because the majority of patients have normal cranial computed tomographic (CT) findings when diagnosed. We report a case of cryptococcal meningitis in a child who had severely raised CSF pressure on admission, and in whom repeated CT scanning showed progressive enlargement of the subarachnoid space and ventricular system during the course of treatment. The normalization of these spaces after ventriculoperitoneal (VP) shunting suggests a distal CSF block as the cause of the raised ICP in this patient. The CSF pressure was monitored and treatment with oral acetazolamide and furosemide resulted in a definite, but slow and incomplete lowering of ICP. Intrathecal therapy with hyaluronidase had no beneficial effect on either ICP or the degree of visual loss.     

Factors predicting the diameter of the popliteal artery in healthy humans

A prospective observational study was conducted over a 10-month period to determine the clinical and laboratory manifestations of cryptococcal meningitis in Zimbabwe, a country where antifungal agents are not widely available. Eighty-nine patients with cryptococcal meningitis (median age, 34 years; range, 11-63 years; 56 males) were identified from 406 patients for whom a clinical diagnosis of meningitis had been made. All patients tested were positive for antibody to human immunodeficiency virus. Cryptococcal meningitis was the first AIDS-defining illness in 88% of patients. Typical presentations were headache, mental impairment, and meningism (median duration, 14 days; range, 1-180 days). The median CD4+ cell count was 70/microL (range, 0-651/microL). The cumulative median survival from the time of diagnosis was 14 days (range, 0-233 days); 22% of patients survived for >30 days. Independent indicators of a good prognosis were not identified. This study provides a unique basis for the development of novel management strategies for patients with cryptococcal meningitis who reside in resource-poor countries.     

Arteritis and fatal subarachnoid hemorrhage complicating occult Candida meningitis: unusual presentation in pediatric acquired immunodeficiency syndrome

We report the case of an 11-month-old child with acquired immunodeficiency syndrome, who despite treatment for systemic candidiasis developed undetected Candida meningitis. This uncommon manifestation of candidiasis was accompanied by basilar granulomatous inflammation and fibrosis of meninges with arteritis, vascular invasion by fungi, and terminal subarachold hemorrhage. To our knowledge, this constellation of findings has not been reported previously in pediatric acquired immunodeficiency syndrome.     

False-negative cerebrospinal fluid cryptococcal latex agglutination tests for patients with culture-positive cryptococcal meningitis

Three cases of false-negative cerebrospinal fluid latex agglutination test results for patients with culture-positive cryptococcal meningitis are reported. False-negative results occurred in settings of low cryptococcal antigen concentrations in cerebrospinal fluid and were dependent on the latex agglutination test kit used. Investigation of each case revealed that prozone phenomena or interference from bound antibody or protein could not account for the false-negative results.     

Orthopaedic surgery in hemophilic patients with human immunodeficiency virus

Patients registered at the author's hemophilia center between 1982 and 1994 were studied to establish whether major orthopaedic surgical procedures accelerate the fall of CD4 lymphocyte counts of patients with hemophilia who are infected with the human immunodeficiency virus, and whether patients who had surgery had different rates of development of acquired immune deficiency syndrome or death when compared with patients who did not have surgery. The patients were divided into four groups: Group 1, 22 patients who were human immunodeficiency virus positive undergoing orthopaedic surgery; Group 2, 89 patients who were human immunodeficiency virus positive not undergoing orthopaedic surgery; Group 3, 18 patients who were human immunodeficiency virus negative undergoing orthopaedic surgery; and Group 4, 135 patients who were human immunodeficiency virus negative not undergoing orthopaedic surgery. There was no significant difference between the rates of decline of CD4 lymphocyte counts for patients who were human immunodeficiency virus positive who underwent surgery when compared with human immunodeficiency virus positive patients who did not undergo surgery, nor was there any significant difference between the two human immunodeficiency virus negative groups. There were no significant differences in the rate of development of acquired immune deficiency syndrome or mortality rates between patients who had surgery and those who did not.     

Staphylococcus aureus meningitis in a patient with acquired immunodeficiency syndrome

Meningitis due to Staphylococcus aureus is well described but uncommon. Most cases arise as a complication of neurosurgical interventions or head trauma, although some arise spontaneously. To our knowledge, no case of S. aureus meningitis has been previously reported in a person with the acquired immunodeficiency syndrome (AIDS). Herein we describe a case of S. aureus meningitis in a person with AIDS who had no history of a neurosurgical procedure, head trauma, or overwhelming bacteremia. Treatment of this infection was successful. S. aureus should be added to the list of potential pathogens that can cause spontaneous meningitis in people with AIDS.     

Candidal meningitis in HIV-infected patients: analysis of 14 cases

Five cases of candidal meningitis in human immunodeficiency virus (HIV)-infected patients have been diagnosed in our hospital. This article describes these cases and reviews another nine previously reported in the literature. Most patients (71%) had at least one well-known predisposing factor for candidiasis. Median CD4 cell count was 135/mm3. Headache and fever, in the absence of focal neurologic signs, were the predominant clinical features. The CSF analysis revealed mild pleocytosis and hypoglycorrachia, indistinguishable from those seen in tuberculous or cryptococcal meningitis. Twelve patients (92%) received amphotericin B for a median of 51 days, in combination with flucytosine in five cases. The overall mortality among treated patients was 31%. Although the risk of relapse of candidal meningitis is unknown, maintenance antifungal therapy was given to seven patients (63%), usually with fluconazole. Candida species must be kept in mind as a cause of chronic meningitis in HIV-infected patients who have a known predisposing factor.     

Clinical and laboratory profile of sixty patients with AIDS: a South Indian study

Sixty patients who fulfilled the WHO case definition of acquired immunodeficiency syndrome (AIDS) were admitted and treated between January 1993 and June 1995 in JIPMER Hospital, Pondicherry, South India. Their mean age was 30.3 +/- 6.4 years. Male: female ratio was 5 : 1. The heterosexual route was the major mode of transmission (96.7%). Fever was the commonest presentation (98.3%), followed by weight loss (85%) and cough (36.7%). The commonest opportunistic infection seen was tuberculosis (pulmonary, extrapulmonary - single or in combination) followed by esophageal candidiasis. Cryptococcal meningitis, intestinal crytosporidiosis, CNS toxoplasmosis, Pneumocystis pneumonia and group B Salmonella septicemia were the other infections encountered. Ten out of the 38 patients with tuberculosis were followed up on antituberculous treatment for 6 months. Seven out of 18 patients with esophageal candidiasis were treated with ketoconazole.     

Neurosyphilis. A comparative study of the effects of infection with human immunodeficiency virus

BACKGROUND: The course of neurosyphilis has been reported to be altered by human immunodeficiency virus (HIV) infection. Prior reports of neurosyphilis occurring in association with HIV infection have been largely anecdotal and have failed to compare neurosyphilis in patients with HIV infection with an uninfected control group. This study was performed to determine if the clinical presentation encountered is different in the presence of HIV infection. DESIGN: A retrospective, hospital-based, case series study based on chart review encompassing a 64-month period. SETTING: The study was performed in a large, university-affiliated, public health trust hospital in south Florida. PATIENTS: Forty-six hospitalized patients with neurosyphilis were identified; 13 patients fulfilled Centers for Disease Control and Prevention (Atlanta, Ga) criteria for acquired immunodeficiency syndrome (AIDS), 11 were HIV seropositive only, and 22 were HIV uninfected. Neurosyphilis was determined by a reactive cerebrospinal fluid VDRL slide test. RESULTS: The HIV-infected patients (both AIDS and HIV-seropositive groups) were younger and more frequently had features of secondary syphilis, such as rash, fever, adenopathy, headache, or meningismus. Significant differences were observed in cerebrospinal fluid measurements when the HIV-infected group was compared with the HIV-uninfected group, including a higher mean white blood cell count in patients with AIDS and a higher mean protein level and a lower mean glucose level in the HIV-infected group. Syphilitic meningitis was more common in HIV-seropositive patients, although the HIV-uninfected patients presented with a greater variety of types of neurosyphilis. Ophthalmic syphilis was observed more frequently in the HIV-infected group. CONCLUSIONS: Significant differences exist between neurosyphilis occurring in the presence and absence of HIV infection.     

Kala-azar comes to New York

Visceral leishmaniasis (kala-azar) is a disseminated protozoal infection that occurs in areas of the world other than North America. In endemic regions, kala-azar is also an opportunistic infection associated with the acquired immunodeficiency syndrome. We report a case of acquired immunodeficiency syndrome-associated kala-azar acquired abroad that was first expressed in New York City. Human immunodeficiency virus-infected patients who have lived or traveled abroad may present in this country with unusual infections.     

Cutaneous Cryptococcus infection and AIDS. Report of 12 cases and review of the literature

BACKGROUND: Cryptococcal infections occur in 6% to 13% of patients with acquired immunodeficiency syndrome (AIDS), most commonly infecting the central nervous system. Cutaneous lesions have been described morphologically as umbilicated papules, nodules, and violaceous plaques and can mimic molluscum contagiosum and Kaposi's sarcoma. Cutaneous lesions can present months prior to other signs of systemic infection. OBSERVATIONS: Cases of infection with cutaneous Cryptococcus and AIDS were reviewed and compared with cases reported in the literature. Among patients with Cryptococcus infection and AIDS seen at our institutions, 5.9% had skin lesions. All patients with cutaneous lesions had systemic involvement. Women were less commonly infected than men. There was no apparent predisposition associated with age, race, or human immunodeficiency virus infection risk factors. The median CD4 helper T-cell count was 0.024 X 10(9)/L (24/microL), and 44% (16/36) of the patients had previous opportunistic infections. Lesions were most commonly seen on the head and neck (78% [36/46]) and often mimicked molluscum contagiosum (54% [25/46]). The median serum and cerebrospinal fluid cryptococcal antigen titers were 1:32,768 and 1:512, respectively. Patients in our group did well with therapy (one death at 6 weeks, compared with 38% [13/34] mortality in the literature). There was no correlation between onset of lesions, number of lesions, CD4 helper T-cell count, or histopathologic characteristics. CONCLUSIONS: Disseminated Cryptococcus infection in AIDS presents with cutaneous lesions in up to 6% of cases. Clinicians need to be aware of the varied morphologic characteristics, since cutaneous lesions may present well in advance of other signs of systemic infection.     

Perforation of the right ventricle: a complication of blind placement of a chest tube into the postpneumonectomy space

Coinfection of the nervous system by two distinct nonviral organisms is uncommon and often undiagnosed. Medical teaching emphasizes that a single pathologic process should be sought; however, in the presence of severe immunocompromise this approach may not hold true. We describe seven HIV-1 seropositive patients with cryptococcal meningitis, three of whom had a proven nervous system infection with a second organism: concurrent tuberculous meningitis, a tuberculoma, and the first documented case of cryptococcal meningitis and neurosyphilis.     

An autopsy study of the prostate in acquired immunodeficiency syndrome: evidence for excessive apoptosis and intracytoplasmic epithelial inclusions

We describe a combination of epithelial cell apoptosis and intracytoplasmic inclusions in prostatic epithelium in 6 patients who died from the acquired immunodeficiency syndrome. Two different types of apoptosis were detected: simple cell shrinkage and exploding glandular cells. No intracellular or extracellular viral particles were detected, either ultrastructurally or immunohistochemically. Intracytoplasmic inclusions are apoptotic bodies in a state of degradation and in close association with lipofuscin. The cell degeneration we observed confirms the theory that increased apoptotic cell depletion is responsible for weight loss in the acquired immunodeficiency syndrome. In the prostate itself, the combination of excessive apoptosis and active phagosomal digestion of apoptotic bodies presents a "human model" of postcastration rat ventral prostate, under the conditions of severe immune deficiency.     

Kaposi's sarcoma of the head and neck in patients with acquired immunodeficiency syndrome

Kaposi's sarcoma is the most common neoplastic process in patients infected with the human immunodeficiency virus. Moreover, the occurrence of Kaposi's sarcoma in human immunodeficiency virus-infected patients advances their classification to having the acquired immunodeficiency syndrome. We reviewed the medical records of 48 patients with human immunodeficiency virus infection who had Kaposi's sarcoma documented on their initial visit to the hospital. The onset of Kaposi's sarcoma occurred independent of the Centers for Disease Control and Prevention classification of human immunodeficiency virus infection (modified to exclude Kaposi's sarcoma). This neoplasm developed more frequently in patients who acquired human immunodeficiency virus infection by sexual contact (75% of cases), but manifestations were not significantly different in any of the risk populations for human immunodeficiency virus infection. Kaposi's sarcoma lesions were unpredictable and either showed progression, remained static, or occasionally, regressed spontaneously. Moreover, the lesions were usually multifocal at presentation, with the head and neck (62.5% of cases) as the primary site of involvement. In this region cutaneous lesions predominated (66.7%), followed by mucosal (56.7%) and deep structure (13.3%) involvement. The majority of patients with acquired immunodeficiency syndrome Kaposi's sarcoma involving head and neck structures were asymptomatic (80% of cases). Mucosal lesions were associated with symptoms in 29.3% of cases, whereas cutaneous lesions had symptoms in 5% of cases.     

The feasibility of smoking bans on psychiatric units

Cryptococcal meningitis has a high mortality rate of central nervous infection. The patients usually die of the disease itself, or complications from increased intracranial pressure. Early diagnosis and treatment, including surgical drainage, will improve the results. In this series, twenty-one patients with high intracranial pressure (ICP > 300 mmH2 O) are presented. Fourteen received implantation of Ommaya reservoir to aspirate cerebrospinal fluid (CSF) for relief of symptoms of ICP. Meanwhile 4 of these 14 patients also received intraventricular injection of amphotericin B because of poor response to systemic drugs. Another seven patient received systemic drug therapy only. Survival during therapy occurred in 11 of 14 patients in the surgical group, compared with only 1 of 7 patients treated by drug therapy alone (P = 0.019). In the 14 patients who received implantation of an Ommaya reservoir, there was one complication of CSF leakage when the reservoir ruptured because of repeated aspiration. For patients with cryptococcal meningitis with high ICP, early implantation of an Ommaya reservoir will improve the survival rate.     

Etiology of lymphadenopathy in patients with AIDS in Taiwan

From 1986 to 1995, we retrospectively reviewed the records of 40 of 125 patients (32.0%) with acquired immunodeficiency syndrome (AIDS) who presented with extrainguinal lymphadenopathy. Most of the patients had an advanced stage of HIV infection with a mean CD4 lymphocyte count of 44/mm3. AIDS-defining opportunistic infections and malignancies were present in most patients and the neck region was the most common site of involvement. The etiology of lymphadenopathy was established in 26 patients. Tuberculous lymphadenitis was the most common cause, followed by lymphadenopathic Kaposi's sarcoma, benign reactive hyperplasia, cryptococcal lymphadenitis and disseminated Mycobacterium avium complex infection. Characteristic histopathologic findings were detected in 19 patients and 7 had presumptive tuberculous infections. The remaining 14 patients had no definitive etiology for their lymphadenopathy. As the causes are variable and the number of HIV/AIDS cases is increasing in Taiwan, more patients with lymphadenopathy, especially in the early stages of HIV infection will be encountered. Therefore, it is essential that diagnostic histopathologic and microbiologic studies be performed for appropriate and timely treatment.     

Cryptococcal meningitis: our experience in 24 black patients

The records of 24 patients with cryptococcal meningitis, admitted to King Edward VIII Hospital in Durban, were reviewed. There were 21 adults and 3 children over periods of 10 and 18 years, respectively. Slightly more males were affected. The age distribution was fairly even. The common clinical presentations were headache, neck stiffness, mental changes, cranial nerve palsies and papilloedema. The diagnosis was proved by the presense of Cryptococcus neoformans in the cerebrospinal fluid (CSF) in 21 of the patients, and in pathological tissue in the remaining 3 patients. A significant percentage of patients presented with an initial polymorphonuclear leucocyte predominance in the CSF. The other CSF findings were elevated protein and low sugar levels. Tuberculosis was the common coexisting disease. We found the mortality rate of 58% to be very high and a significant number of patients died even after adequate treatment with amphotericin B either singly or in combination with 5-fluorocytosine.     

Echinococcus granulosus: cloning of a thioredoxin peroxidase

Disseminated histoplasmosis has been recognized as a serious opportunistic infection in patients with acquired immunodeficiency syndrome (AIDS). However, cases reported in the literature have been predominantly in adult patients. Here we report an infant with AIDS who presented with fever, cough, rhinorrhea, hepatosplenomegaly, pancytopenia and coagulopathy, and died of respiratory failure. Autopsy revealed disseminated histoplasmosis involving multiple organs including lungs, intestines, liver, spleen, bone marrow, lymph nodes, kidneys, and meninges. The diagnosis was established based on histomorphology and confirmed by blood culture.     

Critical values: ASCP practice parameter. American Society of Clinical Pathologists

During the past year progress has been made in our understanding of the pathogenesis of the dementia associated with the acquired immunodeficiency syndrome. As many as one-third of acquired immunodeficiency syndrome patients eventually develop this condition, and at present it remains only poorly or transiently treated by existing antiretroviral therapies which do not penetrate well into the central nervous system. The past year has witnessed further characterization of microglial/macrophage neurotoxins, increasing evidence for neuronal death by apoptosis, and a more quantitative search for viral products, surrogate markers, or magnetic resonance spectroscopic parameters of brain or cerebrospinal fluid, or both. An increased understanding that the mediation of neuronal injury is not by direct infection of neurons, but rather via a complex network of cytokines, excitotoxins, and free radical mechanisms triggered by human immunodeficiency virus-infected or immune-stimulated brain macrophages and astrocytes has led to the development of therapies that are administered adjunctively with antiretroviral drugs. Some of these potential new treatments have now entered clinical trials.     

Maintenance therapy with itraconazole after treatment of cryptococcal meningitis in the acquired immunodeficiency syndrome

We conducted a prospective, open trial to establish the efficacy of itraconazole 400 mg/d as maintenance treatment for cryptococcal meningitis in AIDS patients. Between February 1996 and May 1997, 50 patients were included for analysis. After a mean follow-up of 326 days, 2 of 38 patients (5.3 per cent) had relapses of symptomatic cryptococcal meningitis. Hepatotoxicity occurred in 2 cases. In conclusion, maintenance therapy with itraconazole 400 mg/d is effective in preventing recurrent cryptococcal meningitis.