ORIGINAL INVESTIGATION. Brain Biopsy in Patients With Acquired Immunodeficiency Syndrome. Diagnostic Value, Clinical Performance, and Survival Time

Size: px
Start display at page:

Download "ORIGINAL INVESTIGATION. Brain Biopsy in Patients With Acquired Immunodeficiency Syndrome. Diagnostic Value, Clinical Performance, and Survival Time"

Transcription

1 ORIGINAL INVESTIGATION Brain Biopsy in Patients With Acquired Immunodeficiency Syndrome Diagnostic Value, Clinical Performance, and Survival Time Mathias W. Hornef, MD; Anne Iten, MD; Philippe Maeder, MD; Jean-Guy Villemure, MD; Luca Regli, MD Background: Despite extensive discussion in recent years, brain biopsy in patients positive for human immunodeficiency virus who manifest cerebral mass lesions remains an ill-defined step in management. Methods: Prebiopsy data of 26 human immunodeficiency virus positive patients with cerebral mass lesions who underwent computed tomography guided stereotactic brain biopsy (SBB) were reviewed by a specialist in infectious diseases and by a neuroradiologist to establish a clinical diagnosis and a treatment plan for each patient. The postbiopsy diagnosis was compared with the prebiopsy diagnosis. Long-term patient outcome after SBB was recorded by means of a clinical performance scale to estimate its impact on life expectancy and clinical performance. Results: The SBB was diagnostic in 25 patients (96%). Potentially treatable disease was diagnosed in 21 patients (81%), and specific therapy was initiated in 17 patients (65%); 10 patients (39%) were able to complete therapy. The SBB corroborated the clinical diagnosis in 13 (52%) of 25 patients. The group with identical clinical and biopsy-proved diagnoses showed significantly better response to therapy (P =.02), clinical performance (P =.04), and survival after biopsy (P =.01), as compared with the group with different clinical and biopsyproved diagnosis, although no significant difference was found for the degree of immunosuppression. Only completion of the treatment plan increased life expectancy significantly (P =.008). Conclusions: These data show that in human immunodeficiency virus positive patients with brain mass lesions, SBB has a high diagnostic yield. A subgroup of patients will benefit from specific therapy guided by the SBB result. The procedure should, however, be strictly limited to patients able to tolerate specific therapy. Arch Intern Med. 1999;159: From the Departments of Neurosurgery (Drs Hornef, Villemure, and Regli), Internal Medicine (Division of Infectious Diseases) (Dr Iten), and Radiology (Dr Maeder), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland. Dr Hornef is now with the Max von Pettenkofer-Institut, Ludwig-Maximilian Universität München, Munich, Germany. SYMPTOMS AND signs of cerebral involvement are known to occur in more than half of all patients with longstanding human immunodeficiency virus (HIV) infection, and at least 75% have abnormalities of the central nervous system at autopsy. About 10% of patients have a neurologic disorder as the primary manifestation of HIV infection. 1 Cerebral mass lesions are one of the prominent findings (about 10%) in this cohort, who are highly susceptible to opportunistic infections as well as primary neoplastic processes. 2,3 Until the mid-1980s, management of HIV-positive patients with cerebral mass lesions was similar to that of non HIVinfected patients, consisting of biopsy of the lesion and specific treatment. The diagnostic rate of biopsy was reported to be less than 50% in these patients. 4 Since toxoplasmosis is the most frequent cause of cerebral mass lesions during the progression of HIV infection (reported in 40%- 70%), Rosenblum et al 5 recommended starting empiric antitoxoplasmosis therapy in all patients who show a cerebral mass and positive results of serological testing for Toxoplasma and to consider biopsy only in patients who fail to respond to this treatment. 5 Empiric radiation therapy for nonresponders to antitoxoplasmosis therapy was later proposed and discussed to treat lymphoma, the second most frequent mass lesion in this patient population. 6-9 Cirillo and Rosenblum 1 proposed, in 1990, early biopsy of single cerebral mass lesions visualized on magnetic resonance images to differentiate between lymphoma and other treatable conditions. 1,10-12 Positron emission tomography has also been reported to be a useful tool for differentiating infectious from neoplastic processes, 3,11 but routine use of positron emission tomographic scanning is limited to specialized medical centers because of high costs. Con- 2590

2 PATIENTS AND METHODS PATIENTS Twenty-six HIV-positive patients underwent SBB of a cerebral mass lesion in our institution between October 1, 1987, and May 31, Medical records, imaging studies, and follow-up data were reviewed for all patients. The median age at biopsy was 35 years (range, years); 19 patients were men and 7 were women (male-female ratio, 2.7:1). Risk groups for HIV infection were as follows: intravenous drug abuse, 10 (38%); homosexual, 8 (31%); and heterosexual contact with HIV-positive partner, 8 (31%). The median time between the first positive HIV test and biopsy was 33.3 months (range, months). The median CD4 + cell count in the peripheral blood at the time of presentation was /L (range, /L). Clinical categories according to the Centers for Disease Control and Prevention classification system were as follows 31 : A3, 2 patients (8%); B3, 7 (27%); C2, 2 (8%); and C3, 15 (58%). One patient had cerebral toxoplasmosis as the primary manifestation of HIV infection. The other patients reported previous disease manifestations before the current hospitalization. These disease manifestations were recorded according to the Swiss HIV Cohort Study. 32 Among these, the most often reported manifestations were Candida stomatitis (19 patients [73%]), Pneumocystis carinii pneumonia (10 [38%]), weight loss (9 [35%]), Candida esophagitis (7 [27%]), and herpes zoster episodes (5 [19%]). Computed tomography guided stereotactic biopsy was performed taking multiple biopsy specimens (average, 5.2) along a single trajectory through the lesion and its margins (Brown-Roberts-Wells Stereotactic System and the Cosman-Roberts-Wells Stereotactic System, Radionics, Burlington, Mass). INDICATIONS FOR SBB The following indications were found: no response to empiric antitoxoplasmosis therapy for 10 to 14 days (13 patients [50%]), development of symptoms under primary antitoxoplasmosis prophylaxis (8 [31%]), secondary antitoxoplasmosis prophylaxis (2 [8%]), mass lesion not suggestive of toxoplasmosis origin (7 [27%]), and negative Toxoplasma serostatus (3 [12%]). (Some patients had more than 1 indication for SBB.) PATHOLOGIC AND MICROBIOLOGICAL PROCESSING In addition to direct examination, samples were sent for histopathologic and microbiological examination. All samples were fixed and prepared for histological and immunocytochemical staining. Microbiological investigations were performed for viruses, aerobic and anaerobic bacteria, and mycobacteria as well as fungi. Techniques performed varied during the study period but represented the standard practice. PRELIMINARY DIAGNOSIS To establish the value of additional information from SBB, a specialist in infectious diseases (A.I.) and a neuroradiologist (P.M.) carefully reviewed all available prebiopsy clinical, laboratory, and imaging data in a blinded fashion and they defined a clinical (prebiopsy) diagnosis. The following information was known for all 26 patients: age, sex, risk group, duration of known HIV infection, CD4 + cell count, previous disease manifestations, development of current symptoms, previous and present therapy, laboratory results, and a prebiopsy contrast computed tomographic scan (in 9 patients magnetic resonance images and in 3 patients positron emission tomographic scans were available in addition). The prebiopsy diagnosis was then compared with the results of SBB. DEFINITIONS Toxoplasmosis, cerebral lymphoma, Kaposi sarcoma, metastasis, and viral encephalitis were regarded as potentially treatable lesions. No specific treatment was available for patients with PML during the study period. A modified Karnofsky performance scale (Clinical Performance Scale [CPS]) was used to determine clinical performance retrospectively at least twice every month after biopsy. To facilitate evaluation of the CPS grade, 3 criteria were analyzed: description of the clinical state, the degree of disability in daily activity, and examples of disease manifestations corresponding to this grade (in parentheses). This scale is divided into 7 grades as follows: 6: excellent clinical state, minor disease manifestation, patient lives independently (oral candidiasis); 5: good clinical state, moderate disease manifestation, patient lives largely independently, symptoms do not interfere with daily activity (chronic cough); 4: fair clinical state, major disease manifestation, patient under close follow-up/temporary hospitalization, limited daily activity (moderate hemisyndrome); 3: poor clinical state, major disability, patient mostly hospitalized, normal consciousness level (hemiplegia); 2: very poor clinical state, patient severely disabled, permanently hospitalized or in nursing home, contact possible (patient not oriented, bedfast); 1: patient stuporous or comatose; and 0: dead. Response to treatment was recorded in accordance with the definitions shown in Table 1. STATISTICAL ANALYSIS The Mann-Whitney U test and the Wilcoxon matchedpairs signed rank test were used for the statistical evaluation of subgroups; the Spearman rank test was used for analysis of correlations. comitantly, extensive efforts were made to improve the diagnostic rate of biopsy with the introduction of routine immunohistochemical analysis, electron microscopy, polymerase chain reaction, and even animal testing Progress has been made in the treatment of cerebral lymphoma New diagnostic and therapeutic strategies were developed for the treatment of progressive multifocal leukoencephalopathy (PML) Even though the number of guidelines regarding patient managment increased recently, little is known about the overall benefit of brain biopsy in HIV-positive patients. 14,23-28 Several studies have reported the diagnostic rate of computed tomography 2591

3 Table 1. Definition of Clinical Response to Specific Treatment Response Definition Excellent Disappearance of clinical symptoms or slight residual state not interfering with daily activity, increase in CPS* by at least 2 grades and lasting longer than 1 month, patient lives independently at home Good Marked improvement of symptoms, increase in CPS by at least 1 grade, lasting longer than 1 month, patients leaves hospital for some time Poor Some definite amelioration of clinical symptoms lasting longer than 1 month, no change in CPS, patient under close follow-up or permanently hospitalized None Stable or deteriorating clinical symptoms, CPS stable or decreasing, patient permanently hospitalized Transient Amelioration of clinical symptoms lasting less than 1 month, change in CPS (may be 1 or 2 grades) for less than 1 month *Clinical Performance Scale (see Definitions subsection of the Patients and Methods section). This category was introduced to define patients who showed only short-term clinical amelioration and whose condition deteriorated shortly afterward. Even marked clinical improvement lasting less than 1 month was not regarded to fulfill the definition of an excellent or good response. guided stereotactic brain biopsy (SBB) as well as the number of potentially treatable conditions found, but none of the studies addresses the overall benefit of SBB regarding treatment, life expectancy, and quality of life. 6,14 Introduction of combination treatments for HIV infection, such as highly active antiretroviral therapy (HAART), has steadily decreased the number of patients with severe clinical disease manifestation in industrialized nations. 29 However, since financial resources for medical care in the developing world are limited, and the emergence of multiple drug resistance was recently reported, this problem will probably remain of interest. 30 Moreover, a certain proportion of patients have central nervous system lesions as the initial manifestation of their HIV infection. The purpose of this study was to analyze the diagnostic value and impact of SBB for cerebral mass lesion on treatment, long-term outcome, and survival of HIV-positive patients. RESULTS BIOPSY RESULTS Nondiagnostic (n = 1, 4%) No Treatment Available (n = 4, 15%) No Specific Treatment Started (n = 4, 15%) No (n = 4, 15%) SBB (n = 26, 100%) Incomplete Treatment (n = 7, 27%) Poor or Transient (n = 3, 12%) Diagnostic Biopsy (n = 25, 96%) Treatment Available (n = 21, 81%) Specific Treatment (n = 17, 65%) No (n = 1, 4%) Completed Treatment (n = 10, 38%) Poor or Transient (n = 3, 12%) Excellent or Good (n = 6, 23%) Figure 1. Outcome of the 26 human immunodeficiency virus positive patients undergoing stereotactic brain biopsy (SBB). Asterisk indicates the patient responded well to anti-toxoplasma therapy prescribed on the basis of clinical data. Definitions of the grades of response to therapy (daggers) are given in Table 1. Stereotactic biopsy disclosed a definite diagnosis in 25 (96%) of 26 patients: high-grade B-cell lymphoma was found in 11 patients (42%); cerebral toxoplasmosis in 6 patients (23%); PML in 4 patients (15%); viral encephalitis in 2 patients (8%); and metastasis and Kaposi sarcoma in 1 patient each (4%). In both cases of viral encephalitis, the histological examination stated changes comparable with an acute viral encephalitis, but immunostaining and polymerase chain reaction did not result in a more specific diagnosis. Biopsy was nondiagnostic in 1 patient (4%); this patient s condition responded well to atovaquone and clindamycin hydrophosphate therapy for toxoplasmosis prescribed on the basis of clinical data despite unsuccessful previous antitoxoplasmosis therapy. There were 2 major postoperative complications (8%); both were intracerebral hemorrhages. One patient had cerebral lymphoma and died 2 days after biopsy. The other patient had PML and showed deterioration of his hemiparesis; he died 3 months later. MANAGEMENT AND RESPONSE TO TREATMENT Four patients had PML, and no specific treatment could be offered at the time of the study. In 1 patient, SBB was not diagnostic. In 21 patients (81%) a potentially treatable condition was diagnosed with SBB; 17 (65%) started specific therapy and 10 (38%) were able to complete specific therapy. Clinical deterioration (3 patients), death (2 patients), multiple drug allergy (1 patient), and depression (1 patient) led to interruption of treatment before completion in 7 patients (41% of all patients who started specific therapy). In 4 (19%) of 21 patients with a potentially treatable disease (all cerebral lymphoma), no specific therapy was initiated because of a marked deterioration after biopsy or a poor clinical state (CPS grade 4 and lower) at the time of the biopsy result. The condition of 1 of these 4 patients deteriorated after a major complication of SBB. Of 17 patients who started specific therapy based on the biopsy result, 6 showed an excellent or good response, 6 had a poor or transient response, and 5 did not respond to therapy. The overall response rate (excellent or good response), excluding the patient with a nondiagnostic biopsy, was therefore 23% (Figure 1). Five patients with toxoplasmosis completed therapy; 2 showed an excellent, 2 a good, and 1 a poor response. One patient died shortly after biopsy despite initiation of treatment. Four patients with cerebral lymphoma underwent a complete course of radiotherapy; of these, 1 each was in the excellent, good, transient, and noresponse groups. Three patients with lymphoma did not complete radiotherapy; 1 showed a poor, 1 a transient, and 1 no response. Four patients with cerebral lymphoma did not undergo irradiation because of a marked recent decrease in clinical performance (of these, 1 pa- 2592

4 Table 2. Comparison Between Clinical (Prebiopsy) Diagnosis and Result of Stereotactic Biopsy Clinical Diagnosis Biopsy Lymphoma Toxoplasmosis PML* Encephalitis Metastasis Kaposi Sarcoma Total Lymphoma Toxoplasmosis PML Encephalitis Metastasis Kaposi sarcoma Nondiagnostic Total *PML indicates progressive multifocal leukoencephalopathy. In 2 of these patients, autopsy was performed and confirmed the diagnosis in 1 patient (36 days after biopsy) but demonstrated multiple Toxoplasma abscesses, human immunodeficiency virus encephalitis, cytomegalovirus, and probable Cryptococcus meningitis in the other patient (5 months after biopsy). Autopsy performed 19 days after biopsy showed cerebral lymphoma and cytomegalovirus encephalitis. Autopsy in 1 of these patients confirmed PML (2 days after biopsy). Autopsy in 1 of these patients showed cerebral lymphoma (as suggested clinically) in addition to cytomegalovirus ventriculitis (52 days after biopsy). Autopsy 51 days after biopsy disclosed cerebral toxoplasmosis. tient after SBB-induced cerebral hemorrhage). Two patients with viral encephalitis received medical treatment (acyclovir and ganciclovir). In both, the histological diagnosis of acute viral encephalitis could not be further specified by immunostaining or polymerase chain reaction. One patient showed a transient good response to acyclovir; he died 52 days later, and autopsy disclosed cytomegalovirus ventriculitis. The other patient did not respond to antiviral drug therapy and died 3 months later. Radiotherapy was started in the patient with Kaposi sarcoma, but only a transient response was observed. The patient died 51 days later; the autopsy report described multiple Toxoplasma abscesses but did not mention histological alterations seen in cases with Kaposi sarcoma. No response to radiotherapy was seen in a patient with metastasis of a lung cancer. SURVIVAL AFTER BIOPSY Median survival (mean ± SD; range) after biopsy was 61 days (222.1 ± 394.3; ) and was inversely correlated with the time interval between first HIV-positive test and SBB (P =.02). No significant correlation was found for age, risk group, CD4 + cell count, number of previous disease manifestations, or CPS grade at the time of biopsy. Median survival in patients with cerebral Toxoplasma infection was found to be 147 days (517.8 ± 654.9; ); in patients with cerebral lymphoma, 61 days (136.9 ± 175.8; 2-580); and in patients with PML, 24 days (33.7 ± 36.5; 3-92). Median survival of patients without specific therapy was 24 days (50.7 ± 49.0; 2-137), whereas patients receiving an incomplete therapy course lived for 36 days (50.3 ± 56.4; 3-171). Completion of treatment increased life expectancy significantly to a median of 161 days (400.2 ± 501.2; ; P =.008). COMPARISON OF PRELIMINARY AND BIOPSY DIAGNOSES Thirteen (52%) of 25 clinical (prebiopsy) diagnoses established by the specialist of infectious diseases and the neuroradiologist on the basis of clinical and imaging data were confirmed by SBB. Twelve clinical diagnoses (48%) differed from the biopsy result and would have resulted in a different therapy in 8 patients (31%). In 4 patients (15%), biopsy diagnosis was PML and therefore did not result in specific therapy. A detailed analysis of concordant or different diagnosis based on clinical vs biopsy data is given in Table 2. Comparison between the group with correct clinical diagnosis vs patients with a different biopsy diagnosis showed a significantly better response to specific therapy (P =.02), clinical performance (P =.04), and survival after biopsy (P =.01) in the group with concordant diagnosis. No significant difference was found for age, risk group, CD4 + T cells, number of previous disease manifestations, or CPS grade at time of biopsy. However, patients with a discordant diagnosis showed a tendency to more previous disease manifestations. All patients with excellent or good response to therapy (n = 6) were found in the group correctly diagnosed on the basis of prebiopsy data. In contrast, clinical improvement was found in only 3 (25%) of 12 patients with differing diagnosis (poor and transient response only). Median survival (mean ± SD; range) after biopsy was 137 days (267.2 ± 441.4; ) in patients with concordant diagnosis vs 52 days (61.1 ± 51.3; 2-171) in patients with differing diagnoses (P =.01) (Table 3). AUTOPSY RESULTS Autopsy was performed in only 6 patients (23%) 51 days (median) after the biopsy procedure. It confirmed the SBB result in 4 patients (3 patients with lymphoma and 1 with PML) but disclosed additional cerebral abnormalities in 2 of those patients with lymphoma. Autopsy reports showed cytomegalovirus encephalitis in 1 patient (19 days after biopsy) and cytomegalovirus ventriculitis in another (52 days after biopsy) in addition to lymphoma. An autopsy diagnosis that differed from the SBB diagnosis was seen in 2 cases. In 1 patient, the SBB diagnosis was cerebral Kaposi sarcoma, but autopsy disclosed multiple Toxoplasma abscesses. This 2593

5 Table 3. Comparison of Patients With Identical vs Different Clinical and Biopsy-Based Diagnosis Clinical Diagnosis Compared With Biopsy Result Identical Diagnosis (n = 13) Different Diagnosis (n = 12) P No. of previous disease manifestations, median (mean ± SD) 3 (3.1 ± 2.1) 4 (4.2 ± 1.9).29 CD4 + cell count, median (mean ± SD), 10 6 /L 36 (46.1 ± 46.8) 38 (69.6 ± 134.1).62 No. of patients with response to therapy (excellent, good, poor, or transient)* No. of patients with good or excellent response to therapy* No. of patients with no response to therapy* Survival after biopsy, median (mean ± SD), d* 137 (267 ± 441) 52 (61 ± 51).01 *The 2 patients with complications of stereotactic brain biopsy were excluded. Definitions of the grades of response to therapy are given in Table 1. HIV-Seropositive Patient With Cerebral Mass Lesion(s) Typical Clinical and Radiological Appearance Unclear Clinical and/or Radiological Picture Response patient showed a transient good response to radiotherapy, but clinical deterioration and death occurred 52 days after biopsy. The other patient had an SBB diagnosis of cerebral lymphoma, whereas autopsy 5 months later showed multiple Toxoplasma abscesses, HIV encephalopathy, cytomegalovirus ventriculitis, and Cryptococcus meningitis. This patient had not received specific treatment. COMMENT No Response Initiation of Specific Therapy Patient Not Regarded Able to Support Full Therapy Regimen Patient Regarded Able to Support Full Therapy Regimen Patient Able to Support Full Therapy Regimen Patient Not Able to Support Full Therapy Regimen Supportive Care Only Therapy Trial (?) Stereotactic Brain Biopsy Figure 2. Decision analysis for the management of human immunodeficiency virus (HIV) positive patients with cerebral mass lesions. Involvement of the central nervous system is one of the prominent findings in patients with acquired immunodeficiency syndrome, and rapid and precise diagnosis is essential for optimal patient managment. Although important progress was seen in imaging and molecular biology techniques during the last decade, cerebral stereotactic biopsy is the only reliable method of obtaining histological diagnosis. Stereotactic brain biopsy is highly sensitive (96%) in diagnosing cerebral mass lesions in HIV-positive patients, but it carries a significant risk of major complications (8%), emphasizing the importance of defining indications for this invasive procedure in this group of patients. 33 No specific therapy was given in 31% of all patients after diagnosis for 1 of 2 reasons. First, the patient s clinical state may have been so poor or markedly decreasing at the time of definite diagnosis that initiation of specific therapy seemed unreasonable. Second, no proved specific treatment could be offered to patients with PML at the time of the study. However, a recent study showed significant benefit of highly active antiretroviral therapy (HAART) in patients with HIV-associated PML. Therapy and prognosis therefore may change in the near future. 21,22,34 Specific therapy was started in two thirds of patients; nearly half of them, however, did not complete treatment. Interestingly, patients who completed the therapy protocol showed a significantly longer survival time and a significant increase in clinical performance. Incomplete treatment did not increase life expectancy, even though a transient response to therapy was seen in most patients. The large number of patients who received no treatment or an incomplete course of therapy (58%) after SBB emphasizes that indication for cerebral biopsy should be strictly limited to patients able to support a specific and complete course of therapy. 33 According to the CPS used in this study, this corresponds to grade 3 or greater. Figure 2 shows a decision analysis that summarizes the conclusions of our study for the management of HIV-positive patients with cerebral mass lesions. Survival and clinical performance after stereotactic biopsy correlated well with the clinical response to specific therapy, but no correlation was found between survival time and other factors such as age, sex, risk group, CD4 + count, time since first positive HIV testing, or CPS grade at the time of biopsy. This seems to indicate the critical role of cerebral disease on life expectancy in patients with acquired immunodeficiency syndrome. Since brain biopsy is the only method for tissue diagnosis of cerebral mass lesions, case-control pairs could not be obtained. Medical records from the treating physicians in most cases did not reflect a definite prebiopsy diagnosis. To overcome this, all prebiopsy data were reviewed in a blinded fashion as to SBB result by a specialist in infectious diseases and a neuroradiologist to establish diagnosis and treatment plan for each individual patient. The comparison of prebiopsy and postbiopsy diagnosis and treatment plan, as well as autopsy report, if available, and scoring of long-term outcome allowed us to extrapolate the value of SBB in this group of patients. Clinical diagnosis based on prebiopsy data showed a correct diagnosis compared with the biopsy result in 2594

6 about half of all patients. Similar results were found in a recent study by Everall et al 34 comparing magnetic resonance imaging and neuropathology data in patients with acquired immunodeficiency syndrome. 34 No significant difference between groups of patients with concordant vs discordant biopsy and clinical diagnosis was found for age, sex, time after first HIV-positive testing, and CD4 + count. Interestingly, most patients who showed clinical amelioration after specific therapy and all patients with good or excellent responses were found in the group of patients with identical clinical and biopsy diagnoses. This might be at least partly explained by the kind of cerebral disease found, since these patients more often showed cerebral lymphoma or toxoplasmosis, both with good treatment options and life expectancy. In contrast, patients with a different clinical and biopsy diagnosis showed a broader spectrum of cerebral diseases (5 vs 3) and a higher proportion of patients with PML, a disease associated with a poor prognosis. Moreover, these patients showed a tendency to higher numbers of HIVassociated disease manifestations before biopsy. Likewise, initiation of specific therapy, response to therapy, and life expectancy were significantly decreased in this group. Why is it that a more complex clinical and imaging appearance is associated with a worse response to therapy for a histologically confirmed diagnosis? One explanation may be residual manifestation of a previous disease, or the coexistence of other cerebral pathologic processes, in addition to the one diagnosed by biopsy. Multiple coexisting cerebral diseases may account for the less characteristic clinical and imaging features as well as for the low response rate to therapy, a worse clinical outcome, and decreased survival time despite specific therapy in this group of patients. Heterogeneous underlying cerebral disease was found in more than half of cases examined by magnetic resonance imaging and neuropathologic studies, especially in brains with diffuse white matter lesions. 34 Multiple coexisting cerebral diseases in more than a third of all patients who died of HIVassociated neurologic disorders were reported in a large neuropathologic study. 2 The same study reported a high percentage of pathologic cerebral alterations in neurologically intact HIV-positive patients. Autopsy was performed in only 6 patients in the present series, and multiple coexisting cerebral diseases were found in half of them. Autopsy added more cerebral pathologic processes to the biopsy diagnosis in 2 patients and invalidated the SBB diagnosis in another 2 patients (false positive). This might be explained by therapeutic cure of the disease subjected to biopsy and subsequent development of a new pathologic process, 2 or more coexisting diseases, or erroneous histopathologic interpretation. Indeed, one of these patients was given radiotherapy for biopsy- proved Kaposi sarcoma; he showed a transient clinical response but died 51 days later. The other patient did not receive specific treatment. However, this throws light on 2 important issues that may limit the value of SBB. First, what is the rate of false-positive results after SBB in HIV-positive patients? Even though examination of the tissue obtained may show a pathologic process, it might not necessarily represent the leading cause of the neurologic deficit. Second, can SBB identify multiple coexisting cerebral pathologic processes? To answer these questions, further studies are necessary to compare biopsy and autopsy diagnosis. In conclusion, this study favors the view that selected HIV-positive patients with cerebral mass lesions harbor a high proportion of treatable lesions and can benefit from information added by SBB. In more than half of patients in the subgroup who show clinical and imaging features in accord with the SBB result, specific therapy achieved excellent or good clinical responses. Excellent or good clinical response was found in less than half of the patients treated. However, contradicting clinical and imaging features represent a poor prognostic factor despite the introduction of specific treatment. It is, however, safe to say that this is an estimate of the worst scenario, as the proportion of patients responding to therapy should increase with the advent of new and more efficient treatment protocols, as well as with stricter patient selection for SBB. Accepted for publication March 2, Presented in part as a poster at the annual meeting of the American Association of Neurological Surgeons, Denver, Colo, April 12-17, Nicolas de Tribolet, MD, Department of Neurological Surgery, University Hospitals in Lausanne and Geneva, Switzerland, provided continuous support and encouragement. Reprints: Luca Regli, MD, Department of Neurosurgery, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland ( Luca.Regli@chuv.hospvd.ch). REFERENCES 1. Cirillo SF, Rosenblum ML. Use of CT and MRI imaging to distinguish intracranial lesions and to define the need for biopsy in AIDS patients. J Neurosurg. 1990; 73: Matthiesen L, Marche C, Labrousse F, Trophilme D, Fontaine C, Vedrenne C. Etude neuropathologique de l encéphale de 174 patients morts du SIDA dans un hôpital parisien, de 1982 à Ann Med Interne (Paris). 1992;143: Pierce MA, Johnson MD, Maciunas RJ, et al. Evaluating contrast-enhancing brain lesions in patients with AIDS by using positron emission tomography. Ann Intern Med. 1995;123: Rosenblum ML, Levy RM, Bredesen DE, So YT, Wara W, Ziegler JL. Primary central nervous system lymphomas in patients with AIDS. Ann Neurol. 1988;23: Rosenblum ML, Bredesen DE, Levy RM. Algorithms for the treatment of AIDS patients with neurological disease. In: Berger JR, Levy R, eds. AIDS and the Nervous System. New York, NY: Raven Press; 1988: Andrews BT, Kenefick TP. Neurosurgical management of the acquired immunodeficiency syndrome: an update. West J Med. 1993;158: Cimino C, Lipton RB, Williams A, Feraru E, Harris C, Hirschfeld A. The evaluation of patients with human immunodeficiency virus related disorders and brain mass lesions. Arch Intern Med. 1991;151: Bishburg E, Eng RHK, Slim J, Perez G, Johnson E. Brain lesions in patients with acquired immunodeficiency syndrome. Arch Intern Med. 1989;149: Dannemann BR, Israelski DM, Leoung GS, McGraw T, Mills J, Remington JS. Toxoplasmosis serology, parasitemia and antigenemia in patients at risk for toxoplasmic encephalitis. AIDS. 1991;5: Lexa FJ. Neuroradiological manifestation of acquired immunodeficiency syndrome. Semin Roentgenol. 1994;39: Hoffman JM, Waskin HA, Schifter T, et al. FDG-PET in differentiating lymphoma from nonmalignant central nervous system lesions in patients with AIDS. J Nucl Med. 1993;34: Dina TS. Primary central nervous system lymphoma versus toxoplasmosis in AIDS. Radiology. 1991;179:

7 13. Moret H, Guichard M, Matheron S, et al. Virological diagnosis of progressive multifocal leukoencephalopathy: detection of JC virus DNA in cerebrospinal fluid and brain tissue of AIDS patients. J Clin Microbiol. 1993;31: Zimmer C, Märzheuser S, Patt S, et al. Stereotactic brain biopsy in AIDS. J Neurol. 1992;239: Cinque P, Brytting M, Vago L, et al. Epstein-Barr virus DNA in cerebrospinal fluid from patients with AIDS-related primary lymphoma of the central nervous system. Lancet. 1993;342: De Luca A, Antinori A, Cingolani A, et al. Evaluation of cerebrospinal fluid EBV- DNA and IL-10 as markers for in vivo diagnosis of AIDS-related primary central nervous system lymphoma. Br J Haematol. 1995;90: Baumgartner JE, Rachlin JR, Beckstead JH, et al. Primary central nervous system lymphomas: natural history and response to radiation therapy in 55 patients with acquired immunodeficiency syndrome. J Neurosurg. 1990;73: Antinori A, Ammassari A, Murri R, et al. Primary central nervous system lymphoma and brain biopsy in AIDS. Lancet. 1993;341: Levine KA. Acquired immunodeficiency syndrome related lymphoma. Blood. 1992; 80: McGuire D, Barhite S, Hollander H, Miles M. JC virus in cerebrospinal fluid of human immunodeficiency virus infected patients: predictive value for progressive multifocal leukencephalopathy. Ann Neurol. 1995;37: Albrecht H, Hoffmann C, Degen O, et al. Highly active antiretroviral therapy significantly improves the prognosis of patients with HIV-associated progressive multifocal leukoencephalopathy. AIDS. 1998;12: Brink NS, Miller RF. Clinical presentation, diagnosis, and therapy of progressive multifocal leukoencephalopathy. J Infect. 1996;32: Editorial. Lancet. 1992;340: Iacoangeli M, Roselli R, Antinori A, et al. Experience with brain biopsy in acquired immune deficiency syndrome related focal lesions in the central nervous system. Br J Surg. 1994;81: Martinez E, Marcos A, Martinez-Chamorro E, Martinez-Chamorro C, Domingo P. Brain biopsy for intracranial mass lesions in AIDS [letter]. Lancet. 1993; 341: O Doherty MJ, Lewis P, Nunan TO. Brain biopsy for intracranial mass lesions in AIDS [letter]. Lancet. 1993;341: Preuss M, Schumacher HC, Bergs C, Brock M. Brain biopsy for intracranial mass lesions in AIDS [letter]. Lancet. 1993;341: Luzzati R, Ferrari S, Nicolato A, et al. Stereotactic brain biopsy in human immunodeficiency virus infected patients. Arch Intern Med. 1996;156: Hammer SM, Squires KE, Hughes MD, et al. A controlled trial of two nucleoside analogues plus indinavir in persons with human immunodeficiency virus infection and CD4 cell counts of 200 per cubic millimeter or less. N Engl J Med. 1997; 337: Hecht FM, Grant EM, Petropoulos CJ, et al. Sexual transmission of an HIV-1 variant resistant to multiple reverse-transcriptase and protease inhibitors. N Engl J Med. 1998;339: Centers for Disease Control and Prevention Revised classification system of HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. JAMA. 1993;269: Ledergerber B, von Overbeck J, Egger M, Luthy R. The Swiss HIV Cohort Study: rationale, organization and selected baseline characteristics. Soz Praventivmed. 1994;39: Nicolato A, Gerosa M, Piovan E, et al. Computerized tomography and magnetic resonance guided sterotactic brain biopsy in nonimmunocompromised and AIDS patients. Surg Neurol. 1997;48: Everall IP, Chong WK, Wilkinson ID, et al. Correlation of MRI and neuropathology in AIDS. J Neurol Neurosurg Psychiatry. 1997;62:

Stereotactic Brain Biopsies in AIDS Patients - Early Local Experience

Stereotactic Brain Biopsies in AIDS Patients - Early Local Experience Singapore Med J 2000 Vol 41(4) : 161-166 O r i g i n a l A r t i c l e Stereotactic Brain Biopsies in AIDS Patients - Early Local Experience K K Yeo, T T Yeo, C Y Chan, Y Y Sitoh, J Teo, S Y Wong ABSTRACT

More information

Neuroradiology of AIDS

Neuroradiology of AIDS Neuroradiology of AIDS Frank Minja,, HMS IV Gillian Lieberman MD September 2002 AIDS 90% of HIV patients have CNS involvement 1 10% of AIDS patients present first with neurological symptoms 2 73-80% of

More information

Deborah J. Nicolls. 2 ND YEAR RESEARCH ELECTIVE RESIDENT S JOURNAL Volume VI, A. Study Purpose and Rationale

Deborah J. Nicolls. 2 ND YEAR RESEARCH ELECTIVE RESIDENT S JOURNAL Volume VI, A. Study Purpose and Rationale Combined Diagnostic Approach to AIDS-Related Primary CNS Lymphoma Using EBV-DNA Polymerase Chain Reaction in CSF, Thallium-201 Single-Photon Emission Computed Tomography, and Toxoplasma gondii Serologies.

More information

Immunodeficiencies HIV/AIDS

Immunodeficiencies HIV/AIDS Immunodeficiencies HIV/AIDS Immunodeficiencies Due to impaired function of one or more components of the immune or inflammatory responses. Problem may be with: B cells T cells phagocytes or complement

More information

The diffusion-weighted imaging (DWI) MR sequence showed an hyposignal of the lesion eliminating a cerebral pyogenic abscess which usually presents an

The diffusion-weighted imaging (DWI) MR sequence showed an hyposignal of the lesion eliminating a cerebral pyogenic abscess which usually presents an Cerebral toxoplasmosis is one of the most common opportunistic neurological infections in AIDS patients, and is typically observed in the later stages of human immunodeficiency virus (HIV) infection. 1,2

More information

Overview on Opportunistic Infections of the Central Nervous System

Overview on Opportunistic Infections of the Central Nervous System Second HIV Infection and the Central Nervous System: Developed and Resource-Limited Settings Venice, Italy April 14 16, 2007 Overview on Opportunistic Infections of the Central Nervous System Adriana Ammassari

More information

Incidence and prevalence of neurological disorders associated with HIV since the introduction of highly active antiretroviral therapy (HAART)

Incidence and prevalence of neurological disorders associated with HIV since the introduction of highly active antiretroviral therapy (HAART) 376 Neurology, University Clinic Essen, Hufelandstrasse 55, 45122 Essen, Germany M Maschke O Kastrup A Hufnagel Dermatology S Esser U Hengge Internal Medicine B Ross Correspondence to: Dr Matthias Maschke

More information

Natural History of Untreated HIV-1 Infection

Natural History of Untreated HIV-1 Infection Opportunistic infections Dr. Guido van den Berk December 2009 HIV [e] EDUCATION Natural History of Untreated HIV-1 Infection 1000 + CD4 Cells 800 600 400 Constitutional Symptoms Early Opportunistic Infections

More information

Opportunistic infections in the era of cart, still a problem in resource-limited settings

Opportunistic infections in the era of cart, still a problem in resource-limited settings Opportunistic infections in the era of cart, still a problem in resource-limited settings Cristiana Oprea Victor Babes Clinical Hospital for Infectious and Tropical Diseases, Bucharest, Romania Assessment

More information

Cerebral Toxoplasmosis in HIV-Infected Patients. Ahmed Saad,MD,FACP

Cerebral Toxoplasmosis in HIV-Infected Patients. Ahmed Saad,MD,FACP Cerebral Toxoplasmosis in HIV-Infected Patients Ahmed Saad,MD,FACP Introduction Toxoplasmosis: Caused by the intracellular protozoan, Toxoplasma gondii. Immunocompetent persons with primary infection

More information

May He Rest in Peace

May He Rest in Peace May He Rest in Peace Neurologic Complications of AIDS Medical Knowledge Fiesta 2012 Paul K. King MD pkingmd@yahoo.com Objectives definition of HIV/AIDS what are the neurologic complications of AIDS how

More information

HIV Update For the Internist

HIV Update For the Internist HIV Update For the Internist Disclosures I declare that I have received no incentives, financial or otherwise, from pharmaceutical or biomedical companies relevant to the content of this talk. As an Infectious

More information

The Neurology of HIV Infection. Carolyn Barley Britton, MD, MS Associate Professor of Clinical Neurology Columbia University

The Neurology of HIV Infection. Carolyn Barley Britton, MD, MS Associate Professor of Clinical Neurology Columbia University The Neurology of HIV Infection Carolyn Barley Britton, MD, MS Associate Professor of Clinical Neurology Columbia University HIV/AIDS Epidemiology World-wide pandemic, 40 million affected U.S.- Disproportionate

More information

Robert J. Young, Munir V. Ghesani, Nolan J. Kagetsu, and Andrew J. DeRogatis

Robert J. Young, Munir V. Ghesani, Nolan J. Kagetsu, and Andrew J. DeRogatis AJNR Am J Neuroradiol 26:1973 1979, September 2005 Lesion Size Determines Accuracy of Thallium- 201 Brain Single-Photon Emission Tomography in Differentiating between Intracranial Malignancy and Infection

More information

Dr Keerti Gedela. Chelsea and Westminster Hospital NHS Foundation Trust, London. 19 th Annual Conference of the British HIV Association (BHIVA)

Dr Keerti Gedela. Chelsea and Westminster Hospital NHS Foundation Trust, London. 19 th Annual Conference of the British HIV Association (BHIVA) 19 th Annual Conference of the British HIV Association (BHIVA) Dr Keerti Gedela Chelsea and Westminster Hospital NHS Foundation Trust, London 16-19 April 2013, Manchester Central Convention Complex Value

More information

Central Nervous System Immune Reconstitution Disease: Pathology

Central Nervous System Immune Reconstitution Disease: Pathology Central Nervous System Immune Reconstitution Disease: Pathology F.Gray, H.Adle-Biassette, F.Héran, G. Pialoux, A.Moulignier, APHP Hôpital Lariboisière Université Paris VII Introduction of HAART, which

More information

Lahey Clinic Internal Medicine Residency Program: Curriculum for Infectious Disease

Lahey Clinic Internal Medicine Residency Program: Curriculum for Infectious Disease Lahey Clinic Internal Medicine Residency Program: Curriculum for Infectious Disease Faculty representative: Eva Piessens, MD, MPH Resident representative: Karen Ganz, MD Revision date: February 1, 2006

More information

HIV and CNS Stereotactic Biopsy in the diagnosis of brain lesions in AIDS patients

HIV and CNS Stereotactic Biopsy in the diagnosis of brain lesions in AIDS patients HIV and CNS Stereotactic Biopsy in the diagnosis of brain lesions in AIDS patients Department of Neurosurgery Infectious Diseases Hospital, University of Buenos Aires, Argentina Definition AIDS Patients

More information

Infections in immunocompromised host

Infections in immunocompromised host Infections in immunocompromised host Immunodeficiencies Primary immunodeficiencies Neutrophil defect Humoral: B cell defect Humoral: Complement Cellular: T cells Combined severe immunodeficiency Secondary

More information

Management of Immune Reconstitution Inflammatory Syndrome (IRIS)

Management of Immune Reconstitution Inflammatory Syndrome (IRIS) Management of Immune Reconstitution Inflammatory Syndrome (IRIS) Adult Clinical Guideline from the New York State Department of Health AIDS Institute www.hivguidelines.org Purpose of the IRIS Guideline

More information

OI prophylaxis When to start, when to stop. Eva Raphael, MD MPH Family and community medicine, pgy-2 University of California, San Francisco

OI prophylaxis When to start, when to stop. Eva Raphael, MD MPH Family and community medicine, pgy-2 University of California, San Francisco OI prophylaxis When to start, when to stop Eva Raphael, MD MPH Family and community medicine, pgy-2 University of California, San Francisco Learning Objectives o Recognize when to start OI prophylaxis

More information

Measure #161: HIV/AIDS: Adolescent and Adult Patients with HIV/AIDS Who Are Prescribed Potent Antiretroviral Therapy

Measure #161: HIV/AIDS: Adolescent and Adult Patients with HIV/AIDS Who Are Prescribed Potent Antiretroviral Therapy Measure #161: HIV/AIDS: Adolescent and Adult Patients with HIV/AIDS Who Are Prescribed Potent Antiretroviral Therapy 2012 PHYSICIAN QUALITY REPTING OPTIONS F INDIVIDUAL MEASURES: REGISTRY ONLY DESCRIPTION:

More information

Title: Revision of the Surveillance Case Definition for HIV Infection and AIDS Among children age > 18 months but < 13 years

Title: Revision of the Surveillance Case Definition for HIV Infection and AIDS Among children age > 18 months but < 13 years 06-ID-02 Committee: Infectious Disease Title: Revision of the Surveillance Case Definition for HIV Infection and AIDS Among children age > 18 months but < 13 years Statement of problem: Advances in HIV

More information

medical monitoring: clinical monitoring and laboratory tests

medical monitoring: clinical monitoring and laboratory tests medical monitoring: clinical monitoring and laboratory tests Purpose of monitoring Check on the physical, psychological and emotional condition of the patient Detect other treatable conditions Identify

More information

Reasons why we will never forget. Andrea Antinori INMI L. Spallanzani IRCCS, Roma

Reasons why we will never forget. Andrea Antinori INMI L. Spallanzani IRCCS, Roma Reasons why we will never forget Andrea Antinori INMI L. Spallanzani IRCCS, Roma SMRs according to time spent with CD4 count >500/mm3 after cart initiation in MSM 80,642 HIV-infected individuals eligible

More information

To interrupt or not to interrupt Are we SMART enough?

To interrupt or not to interrupt Are we SMART enough? SMART To interrupt or not to interrupt Are we SMART enough? highly active antiretroviral therapy 5 1996 1997 10 25 43 45 35 metabolism 50 copies/ml lipodystrophy [fat redistribution syndrome] lactic acidosis

More information

10/17/2015. Chapter 55. Care of the Patient with HIV/AIDS. History of HIV. HIV Modes of Transmission

10/17/2015. Chapter 55. Care of the Patient with HIV/AIDS. History of HIV. HIV Modes of Transmission Chapter 55 Care of the Patient with HIV/AIDS All items and derived items 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. History of HIV Remains somewhat obscure The earlier

More information

Human Immunodeficiency Virus. Acquired Immune Deficiency Syndrome AIDS

Human Immunodeficiency Virus. Acquired Immune Deficiency Syndrome AIDS Human Immunodeficiency Virus Acquired Immune Deficiency Syndrome AIDS Sudden outbreak in USA of opportunistic infections and cancers in young men in 1981 Pneumocystis carinii pneumonia (PCP), Kaposi s

More information

EVALUATION AND MANAGEMENT OF INTRACRANIAL MASS LESIONS IN AIDS

EVALUATION AND MANAGEMENT OF INTRACRANIAL MASS LESIONS IN AIDS EVALUATION AND MANAGEMENT OF INTRACRANIAL MASS LESIONS IN AIDS Report of the Quality Standards Subcommittee of the American Academy of Neurology Mission statement. The Quality Standards Subcommittee of

More information

CLINICIAN INTERVIEW PHARMACY MANAGEMENT OF HIV AND OPPORTUNISTIC INFECTIONS IN A HOSPITAL SETTING. Interview with Christopher Miller, PharmD, BCPS

CLINICIAN INTERVIEW PHARMACY MANAGEMENT OF HIV AND OPPORTUNISTIC INFECTIONS IN A HOSPITAL SETTING. Interview with Christopher Miller, PharmD, BCPS PHARMACY MANAGEMENT OF HIV AND OPPORTUNISTIC INFECTIONS IN A HOSPITAL SETTING Interview with Christopher Miller, PharmD, BCPS Dr Miller is currently employed in a joint position as an assistant professor

More information

The importance of cohort collaborations for guiding clinical management of individuals with HIV infection

The importance of cohort collaborations for guiding clinical management of individuals with HIV infection The importance of cohort collaborations for guiding clinical management of individuals with HIV infection Caroline Sabin Professor of Medical Statistics and Epidemiology Royal Free and University College

More information

Medical monitoring: tests available at central hospitals

Medical monitoring: tests available at central hospitals medial monitoring: tests available at central hospitals: 1 medical monitoring: tests available at central hospitals Medical monitoring: tests available at central hospitals medial monitoring: tests available

More information

GOALS AND OBJECTIVES INFECTIOUS DISEASE

GOALS AND OBJECTIVES INFECTIOUS DISEASE GOALS AND OBJECTIVES INFECTIOUS DISEASE Infectious Disease and HIV Overview: The Infectious Diseases Program at the University of Southern California prepares trainees for the management of problems in

More information

Mortality Rates Among People With HIV, Long on the Wane, Continue to Drop HIV Medicine Feb 2013

Mortality Rates Among People With HIV, Long on the Wane, Continue to Drop HIV Medicine Feb 2013 John F. White III, MD, MBA, FLMI VP and Medical Director American National Insurance Company 1 Mortality Rates Among People With HIV, Long on the Wane, Continue to Drop HIV Medicine Feb 2013 2 1 3 My Opinions

More information

CLINICAL PRESENTATION AND RADIOLOGY QUIZ QUESTION

CLINICAL PRESENTATION AND RADIOLOGY QUIZ QUESTION Donald L. Renfrew, MD Radiology Associates of the Fox Valley, 333 N. Commercial Street, Suite 100, Neenah, WI 54956 3/12/2011 Radiology Quiz of the Week # 11 Page 1 CLINICAL PRESENTATION AND RADIOLOGY

More information

Index. B Biological factors, 2 Brain stem encephalitis, Burkitt s lymphoma, 83, 105

Index. B Biological factors, 2 Brain stem encephalitis, Burkitt s lymphoma, 83, 105 Index A Acquired immunodeficiency syndrome (AIDS) abdomen gallbladder complications, 97, 107 109 gastrointestinal complications, 96, 105 106 liver complications, 97, 107 109 neoplasm, 99, 110 111 pancreas

More information

Prescriber s Guide IMPORTANT INFORMATION ON MINIMISING THE RISK OF ADVERSE EVENTS

Prescriber s Guide IMPORTANT INFORMATION ON MINIMISING THE RISK OF ADVERSE EVENTS MAVENCLAD 10 mg Tablets (cladribine) Prescriber s Guide IMPORTANT INFORMATION ON MINIMISING THE RISK OF ADVERSE EVENTS Reporting Adverse Events Adverse events should be reported. Reporting forms and information

More information

Stereotactic Biopsy of Brain Tumours

Stereotactic Biopsy of Brain Tumours Stereotactic Biopsy of Brain Tumours Pages with reference to book, From 176 To 178 Shahzad Shams, Rizwan Masood Butt, Afaq Sarwar ( Department of Neurosurgery Unit 1, Lahore General Hospital, Lahore. )

More information

Measurement of JCV DNA in CSF for diagnosis and monitoring of PML

Measurement of JCV DNA in CSF for diagnosis and monitoring of PML Measurement of JCV DNA in CSF for diagnosis and monitoring of PML Paola Cinque Department of Infectious Diseases San Raffaele Scientific Institute Milano, Italy SoGAT Clinical Diagnostics Istambul, 30

More information

Clinical Aspect and Application of Laboratory Test in Herpes Virus Infection. Masoud Mardani M.D,FIDSA

Clinical Aspect and Application of Laboratory Test in Herpes Virus Infection. Masoud Mardani M.D,FIDSA Clinical Aspect and Application of Laboratory Test in Herpes Virus Infection Masoud Mardani M.D,FIDSA Shahidhid Bh BeheshtiMdi Medical lui Universityit Cytomegalovirus (CMV), Epstein Barr Virus(EBV), Herpes

More information

Alberta Health Public Health Notifiable Disease Management Guidelines December Subacute Sclerosing Panencephalitis (SSPE)

Alberta Health Public Health Notifiable Disease Management Guidelines December Subacute Sclerosing Panencephalitis (SSPE) December 2015 Subacute Sclerosing Panencephalitis (SSPE) Revision Dates Case Definition Reporting Requirements Remainder of the Guideline (i.e., Etiology to References sections inclusive) Case Definition

More information

Discontinuation of Secondary Prophylaxis against Disseminated Mycobacterium avium Complex Infection and Toxoplasmic Encephalitis

Discontinuation of Secondary Prophylaxis against Disseminated Mycobacterium avium Complex Infection and Toxoplasmic Encephalitis HIV/AIDS MAJOR ARTICLE Discontinuation of Secondary Prophylaxis against Disseminated Mycobacterium avium Complex Infection and Toxoplasmic Encephalitis Valérie Zeller, 1 Chantal Truffot, 2 Rachid Agher,

More information

Original Article. Noparat Oniem, M.D., Somnuek Sungkanuparph, M.D.

Original Article. Noparat Oniem, M.D., Somnuek Sungkanuparph, M.D. Original Article Vol. 29 No. 1 Primary prophylaxis for cryptococcosis with fluconazole:- Oniem N & Sungkanuparph S. 5 Primary prophylaxis for cryptococcosis with fluconazole among HIV-infected patients

More information

CNS Infections in the Pediatric Age Group

CNS Infections in the Pediatric Age Group CNS Infections in the Pediatric Age Group Introduction CNS infections are frequently life-threatening In the Philippines, bacterial meningitis is one of the top leading causes of mortality in children

More information

INTEGRATING HIV INTO PRIMARY CARE

INTEGRATING HIV INTO PRIMARY CARE INTEGRATING HIV INTO PRIMARY CARE ADELERO ADEBAJO, MD, MPH, AAHIVS, FACP NO DISCLOSURE 1.2 million people in the United States are living with HIV infection and 1 in 5 are unaware of their infection.

More information

Osimertinib Activity in Patients With Leptomeningeal Disease From Non-Small Cell Lung Cancer: Updated Results From the BLOOM Study

Osimertinib Activity in Patients With Leptomeningeal Disease From Non-Small Cell Lung Cancer: Updated Results From the BLOOM Study Osimertinib Activity in Patients With Leptomeningeal Disease From Non-Small Cell Lung Cancer: Updated Results From the BLOOM Study Abstract 9002 Yang JC, Kim DW, Kim SW, Cho BC, Lee JS, Ye X, Yin X, Yang

More information

Rapid recurrence of a malignant meningioma: case report

Rapid recurrence of a malignant meningioma: case report Romanian Neurosurgery Volume XXXI Number 2 2017 April-June Article Rapid recurrence of a malignant meningioma: case report Oguz Baran, Sima Sayyahmeli, Taner Tanriverdi, Pamir Erdincler TURKEY DOI: 10.1515/romneu-2017-0027

More information

Corporate Medical Policy

Corporate Medical Policy Corporate Medical Policy Identification of Microorganisms Using Nucleic Acid Probes File Name: Origination: Last CAP Review: Next CAP Review: Last Review: identification_of_microorganisms_using_nucleic_acid_probes

More information

R EVISION OF CDC/WHO CASE DEFINITION FOR ACQUIRED IMMUNODEFICIENCY SYNDROME-(AIDS) :

R EVISION OF CDC/WHO CASE DEFINITION FOR ACQUIRED IMMUNODEFICIENCY SYNDROME-(AIDS) : ity of the introduction of infection is low, but if it were introduced, current levels of domestic water contact would ensure transmission. Trinidad and Tobago. The potential intermediate host present

More information

MANAGEMENT OF SUSPECTED VIRAL ENCEPHALITIS IN CHILDREN

MANAGEMENT OF SUSPECTED VIRAL ENCEPHALITIS IN CHILDREN MANAGEMENT OF SUSPECTED VIRAL ENCEPHALITIS IN CHILDREN OVERVIEW 1980s: dramatically improved by aciclovir HSV encephalitis in adults Delays treatment(> 48h after hospital admission): associated with a

More information

The Italian AIDS Epidemic Supports The Chemical AIDS Theory. Daniele Mandrioli

The Italian AIDS Epidemic Supports The Chemical AIDS Theory. Daniele Mandrioli The Italian AIDS Epidemic Supports The Chemical AIDS Theory Daniele Mandrioli EPIDEMIOLOGY France Population: 65.073.482 AIDS Incidence: 16/million Germany Population: 82.438.000 AIDS Incidence: 4/million

More information

Acute Retinal Necrosis Secondary to Varicella Zoster Virus in an Immunosuppressed Post-Kidney Transplant Patient

Acute Retinal Necrosis Secondary to Varicella Zoster Virus in an Immunosuppressed Post-Kidney Transplant Patient CM&R Rapid Release. Published online ahead of print September 20, 2012 as Aperture Acute Retinal Necrosis Secondary to Varicella Zoster Virus in an Immunosuppressed Post-Kidney Transplant Patient Elizabeth

More information

Interruptions thérapeutiques: Pour ou contre?

Interruptions thérapeutiques: Pour ou contre? Interruptions thérapeutiques: Pour ou contre? Lausanne, 19 avril 2007 Bernard Hirschel, Division of Infectious Diseases, Geneva University Hospital, Geneva, Switzerland. Bernard.hirschel@hcuge.ch The Giant

More information

Spectrums of opportunistic infections in HIV-infected patients at tertiary care hospital

Spectrums of opportunistic infections in HIV-infected patients at tertiary care hospital Original Research Article Spectrums of opportunistic infections in HIV-infected patients at tertiary care hospital ShashiKumar H. Mundhra 1, Krati S. Mundhara 2, Nimisha Sunilbhai Trivedi 3, Yash Shah

More information

Subject Index. Dry desquamation, see Skin reactions, radiotherapy

Subject Index. Dry desquamation, see Skin reactions, radiotherapy Subject Index Actinic keratosis disseminated disease 42 surgical excision 42 AIDS, see Kaposi s sarcoma Amifostine, skin reaction prophylaxis 111 Basal cell carcinoma, superficial X-ray therapy Bowen s

More information

Marchiafava Bignami Disease (MBD) and Diffusion Tensor Image (DTI) Tractography. Priscilla Chukwueke, MD, MPH

Marchiafava Bignami Disease (MBD) and Diffusion Tensor Image (DTI) Tractography. Priscilla Chukwueke, MD, MPH Marchiafava Bignami Disease (MBD) and Diffusion Tensor Image (DTI) Tractography Priscilla Chukwueke, MD, MPH INTRODUCTION Definition: A rare CNS disease characterized by demyelination of the Corpus Callosum.

More information

NON- HODGKIN LYMPHOMA

NON- HODGKIN LYMPHOMA NON- HODGKIN LYMPHOMA non - Hodgkin lymphoma This medical guide is designed for educational purposes to help patients understand. Please consult your doctor on specific questions and details about your

More information

11/19/2012. The spectrum of pulmonary diseases in HIV-infected persons is broad.

11/19/2012. The spectrum of pulmonary diseases in HIV-infected persons is broad. The spectrum of pulmonary diseases in HIV-infected persons is broad. HIV-associated Opportunistic infections Neoplasms Miscellaneous conditions Non HIV-associated Antiretroviral therapy (ART)-associated

More information

When the drugs don t work- a case of HSV encephalitis.

When the drugs don t work- a case of HSV encephalitis. When the drugs don t work- a case of HSV encephalitis. Nicky Price Consultant Virologist Public Health Wales 67 year old Caucasian Female Presenting complaint 2 day history of: Confusion Shivering Headache

More information

A challenging neurological complication in a young HIV-infected woman

A challenging neurological complication in a young HIV-infected woman A challenging neurological complication in a young HIV-infected woman Ianache Irina-Cristiana Vi tor Ba es Clini al Hospital for Infectious and Tropical Diseases Bucharest - HIV/AIDS department Assessment

More information

Dr Sneha Shah Tata Memorial Hospital, Mumbai.

Dr Sneha Shah Tata Memorial Hospital, Mumbai. Dr Sneha Shah Tata Memorial Hospital, Mumbai. Topics covered Lymphomas including Burkitts Pediatric solid tumors (non CNS) Musculoskeletal Ewings & osteosarcoma. Neuroblastomas Nasopharyngeal carcinomas

More information

Acyclovir treatment of herpes simplex encephalitis: experience

Acyclovir treatment of herpes simplex encephalitis: experience Postgraduate Medical Journal (1987) 63, 1037-1041 Acyclovir treatment of herpes simplex encephalitis: experience in a district hospital M.C. Gulliford, C.P. Chandrasekera, R.A. Cooper and R.P. Murphy Departments

More information

2. Clinical Manifestations (Pediatric HIV Infection)

2. Clinical Manifestations (Pediatric HIV Infection) Page 1 of 6 HOUSTON ROMANIA SOUTHERN AFRICA MEXICO HOME CONTACT Friday, July 25, 2003 Pediatric HIV Infection by Mark W. Kline, M.D. 1. Introduction 2. Clinical Manifestations 3. Diagnosis 2. Clinical

More information

HIV Transmission HASPI Medical Biology Lab 20

HIV Transmission HASPI Medical Biology Lab 20 HIV Transmission HASPI Medical Biology Lab 20 Background History of HIV/AIDS Acquired Immune Deficiency Syndrome (AIDS) was first seen in 1981 when large numbers of people with two rare diseases surfaced:

More information

A common case definition for PML

A common case definition for PML A common case definition for PML Transatlantic workshop: Drug-related Progressive Multifocal Leukoencephalopathy (PML) 25.-26.7.2011, EMA, London Paul-Ehrlich-Institut Dr. Dirk Mentzer, MD Paul-Ehrlich-Str.

More information

Herpes virus co-factors in HIV infection

Herpes virus co-factors in HIV infection Herpes virus co-factors in HIV infection Dr Jane Deayton Barts and the London Queen Mary School of Medicine Introduction Herpes viruses very common and often coexist with HIV Establish life-long latent

More information

COPYRIGHT 2012 THE TRANSVERSE MYELITIS ASSOCIATION. ALL RIGHTS RESERVED

COPYRIGHT 2012 THE TRANSVERSE MYELITIS ASSOCIATION. ALL RIGHTS RESERVED The Transverse Myelitis Association...advocating for those with acute disseminated encephalomyelitis, neuromyelitis optica, optic neuritis and transverse myelitis ACUTE DISSEMINATED ENCEPHALOMYELITIS (ADEM)

More information

Utility of 18 F-FDG PET/CT in metabolic response assessment after CyberKnife radiosurgery for early stage non-small cell lung cancer

Utility of 18 F-FDG PET/CT in metabolic response assessment after CyberKnife radiosurgery for early stage non-small cell lung cancer Utility of F-FDG PET/CT in metabolic response assessment after CyberKnife radiosurgery for early stage non-small cell lung cancer Ngoc Ha Le 1*, Hong Son Mai 1, Van Nguyen Le 2, Quang Bieu Bui 2 1 Department

More information

THE EFFECTIVE OF BRAIN CANCER AND XAY BETWEEN THEORY AND IMPLEMENTATION. Mustafa Rashid Issa

THE EFFECTIVE OF BRAIN CANCER AND XAY BETWEEN THEORY AND IMPLEMENTATION. Mustafa Rashid Issa THE EFFECTIVE OF BRAIN CANCER AND XAY BETWEEN THEORY AND IMPLEMENTATION Mustafa Rashid Issa ABSTRACT: Illustrate malignant tumors that form either in the brain or in the nerves originating in the brain.

More information

Billing and Coding for HIV Services

Billing and Coding for HIV Services Billing and Coding for HIV Services Financial Disclosure This speaker does not have any financial relationships with commercial entities to disclose. This speaker will not discuss any off-label use or

More information

Antimicrobial prophylaxis in liver transplant A multicenter survey endorsed by the European Liver and Intestine Transplant Association

Antimicrobial prophylaxis in liver transplant A multicenter survey endorsed by the European Liver and Intestine Transplant Association Antimicrobial prophylaxis in liver transplant A multicenter survey endorsed by the European Liver and Intestine Transplant Association Els Vandecasteele, Jan De Waele, Dominique Vandijck, Stijn Blot, Dirk

More information

Why is there not enough coordination and collaboration between programmes to implement collaboration TB/HIV activities

Why is there not enough coordination and collaboration between programmes to implement collaboration TB/HIV activities Why is there not enough coordination and collaboration between programmes to implement collaboration TB/HIV activities Olga P. Frolova Head of the TB/HIV Health Care Centre, Ministry of Health Social Development,

More information

Clinical Manifestations of HIV

Clinical Manifestations of HIV HIV Symptoms Diane Havlir, MD Professor of Medicine and Chief, HIV/AIDS Division University of California, San Francisco (UCSF) WorldMedSchool; July 2, 2013 1 Clinical Manifestations of HIV! Result from

More information

227 28, 2010 MIDTERM EXAMINATION KEY

227 28, 2010 MIDTERM EXAMINATION KEY Epidemiology 227 April 28, 2010 MIDTERM EXAMINATION KEY Select the best answer for the multiple choice questions. There are 64 questions and 9 pages on the examination. Each question will count one point.

More information

2046: Fungal Infection Pre-Infusion Data

2046: Fungal Infection Pre-Infusion Data 2046: Fungal Infection Pre-Infusion Data Fungal infections are significant opportunistic infections affecting transplant patients. Because these infections are quite serious, it is important to collect

More information

Immunohistochemical Confirmation of Infections

Immunohistochemical Confirmation of Infections Immunohistochemical Confirmation of Infections Danny A. Milner, Jr, MD, MSc, FCAP The Brigham and Women s Hospital Harvard Medical School Boston, Masschusetts USA Judicious Use of Immunohistochemistry

More information

Cryptococcosis of the Central Nervous System: Classical and Immune-Reconstitution Disease

Cryptococcosis of the Central Nervous System: Classical and Immune-Reconstitution Disease Cryptococcosis of the Central Nervous System: Classical and Immune-Reconstitution Disease Assist Prof. Somnuek Sungkanuparph Division of Infectious Diseases Faculty of Medicine Ramathibodi Hospital Mahidol

More information

NEW PATIENT REGISTRATION

NEW PATIENT REGISTRATION NEW PATIENT REGISTRATION Hospital No. Date of Visit : / / Surname : First Name : Date of birth : / / Country of Birth : Sex : Male Female Transman Transwoman Other (please specify): Is this patient from

More information

Viruses and cancer: Should we be more afraid?

Viruses and cancer: Should we be more afraid? Viruses and cancer: Should we be more afraid? Viruses and cancer: Should we be more afraid? During the past 30 years it has become exceedingly clear that several viruses play significant roles in the development

More information

Management of Neck Metastasis from Unknown Primary

Management of Neck Metastasis from Unknown Primary Management of Neck Metastasis from Unknown Primary.. Definition Histologic evidence of malignancy in the cervical lymph node (s) with no apparent primary site of original tumour Diagnosis after a thorough

More information

Magnetic resonance imaging, thallium-201 SPET scanning, and laboratory analyses for discrimination of cerebral lymphoma and toxoplasmosis in AIDS

Magnetic resonance imaging, thallium-201 SPET scanning, and laboratory analyses for discrimination of cerebral lymphoma and toxoplasmosis in AIDS 258 Sex Transm Inf 1998;74:258 264 Original article Magnetic resonance imaging, thallium- SPET scanning, and laboratory analyses for discrimination of cerebral lymphoma and toxoplasmosis in AIDS R F Miller,

More information

Goal of this chapter. 6.1 Introduction Good practices for linkage to care General care for people living with HIV 84

Goal of this chapter. 6.1 Introduction Good practices for linkage to care General care for people living with HIV 84 Clinical guidelines across THE CONTINuUM OF CARE: LINKING PEOPLE DIAGNOSEd WiTH hiv infection to hiv care and treatment 06 6.1 Introduction 84 6.2 Good practices for linkage to care 84 6.3 General care

More information

MID-TERM EXAMINATION

MID-TERM EXAMINATION Epidemiology 227 May 2, 2007 MID-TERM EXAMINATION Select the best answer for the multiple choice questions. There are 75 questions and 11 pages on the examination. Each question will count one point. Notify

More information

San Francisco AIDS Cases Reported Through December 31, 1998

San Francisco AIDS Cases Reported Through December 31, 1998 San Francisco AIDS Cases Reported Through December 31, 1998 San Francisco Department of Public Health HIV Seroepidemiology and Surveillance Section AIDS Surveillance Unit Contents Page Commentary: Trends

More information

Pneumocystis Pneumonia -- Los Angeles

Pneumocystis Pneumonia -- Los Angeles Pneumocystis Pneumonia -- Los Angeles As part of its commemoration of CDC's 50th anniversary, MMWR is reprinting selected MMWR articles of historical interest to public health, accompanied by a current

More information

PET-imaging: when can it be used to direct lymphoma treatment?

PET-imaging: when can it be used to direct lymphoma treatment? PET-imaging: when can it be used to direct lymphoma treatment? Luca Ceriani Nuclear Medicine and PET-CT centre Oncology Institute of Southern Switzerland Bellinzona Disclosure slide I declare no conflict

More information

OUTCOME CODES FOR MACS STATUS FORM

OUTCOME CODES FOR MACS STATUS FORM OUTCOME CODES FOR MACS STATUS FORM CODE CDC-DEFINED AIDS DIAGNOSES (Section C) 01 Kaposi's sarcoma 02 Pneumocystis carinii pneumonia 03 Toxoplasmosis (at a site other than or in addition to liver, spleen,

More information

5/15/2017. What Does HIV/AIDS Look Like in DC in Potpourri of Challenges With Opportunistic Infections

5/15/2017. What Does HIV/AIDS Look Like in DC in Potpourri of Challenges With Opportunistic Infections Potpourri of Challenges With Opportunistic Infections Henry Masur, MD Clinical Professor of Medicine George Washington University Washington, DC FORMATTED: 4/28/217 Learning Objectives After attending

More information

IMAGING OF INTRACRANIAL INFECTIONS

IMAGING OF INTRACRANIAL INFECTIONS IMAGING OF INTRACRANIAL INFECTIONS Dr Carolina Kachramanoglou LYSHOLM DEPARTMENT OF NEURORADIOLOGY NATIONAL HOSPITAL FOR NEUROLOGY AND NEUROSURGERY Plan Introduce MR sequences that are useful in the diagnosis

More information

Immunodeficiency. (2 of 2)

Immunodeficiency. (2 of 2) Immunodeficiency (2 of 2) Acquired (secondary) immunodeficiencies More common Many causes such as therapy, cancer, sarcoidosis, malnutrition, infection & renal disease The most common of which is therapy-related

More information

Repetitorium of selected human viruses HIV

Repetitorium of selected human viruses HIV Repetitorium of selected human viruses HIV Chair and Department of Medical Microbiology Poznan University of Medical Sciences Chairman: prof. dr hab. Andrzej Szkaradkiewicz Wieniawskiego Street 3, 61-712

More information

When to start: guidelines comparison

When to start: guidelines comparison The editorial staff When to start: guidelines comparison The optimal time to begin antiretroviral therapy remains a critical question for the HIV field, and consensus about the appropriate CD4+ cell count

More information

Estimates of New HIV Infections in the United States

Estimates of New HIV Infections in the United States Estimates of New HIV Infections in the United States CDC HIV/AIDS FACT S A UGUS T 28 Accurately tracking the HIV epidemic is essential to the nation s HIV prevention efforts. Yet monitoring trends in new

More information

MAJOR ARTICLE. Helsingør Hospital, Helsingør, Denmark. 96 Engsig et al.

MAJOR ARTICLE. Helsingør Hospital, Helsingør, Denmark. 96 Engsig et al. MAJOR ARTICLE Incidence, Clinical Presentation, and Outcome of Progressive Multifocal Leukoencephalopathy in HIV-Infected Patients during the Highly Active Antiretroviral Therapy Era: A Nationwide Cohort

More information

Lemuel Shattuck Hospital Consultation Service

Lemuel Shattuck Hospital Consultation Service Lemuel Shattuck Hospital Consultation Service a) Goals, Objectives, and ACGME Competencies Goals Learn how to manage complicated infectious disease problems in a public health setting. Learn how to provide

More information

Surveillance for encephalitis in Bangladesh: preliminary results

Surveillance for encephalitis in Bangladesh: preliminary results Surveillance for encephalitis in Bangladesh: preliminary results In Asia, the epidemiology and aetiology of encephalitis remain largely unknown, particularly in Bangladesh. A prospective, hospital-based

More information

ORIGINAL ARTICLE /j x

ORIGINAL ARTICLE /j x ORIGINAL ARTICLE 10.1111/j.1469-0691.2006.01367.x Endemic fungal infections caused by Cryptococcus neoformans and Penicillium marneffei in patients infected with human immunodeficiency virus and treated

More information

Surgical strategies in esophageal cancer

Surgical strategies in esophageal cancer Gastro-Conference Berlin 2005 October 1-2, 2005 Surgical strategies in esophageal cancer J. Rüdiger Siewert Department of Surgery, Klinikum rechts der Isar Technische Universität München Esophageal Cancer

More information

Adult intramedullary astrocytomas of the spinal cord

Adult intramedullary astrocytomas of the spinal cord J Neurosurg 77:355-359, 1992 Adult intramedullary astrocytomas of the spinal cord FRED J. EPSTEIN, M.D., JEAN-PIERRE FARMER, M.D., F.R.C.S., AND DIANA FREED Division of Pediatric Neurosurgery, Department

More information

Management of single brain metastasis: a practice guideline

Management of single brain metastasis: a practice guideline PRACTICE GUIDELINE SERIES Management of single brain metastasis: a practice guideline A. Mintz MD,* J. Perry MD, K. Spithoff BHSc, A. Chambers MA, and N. Laperriere MD on behalf of the Neuro-oncology Disease

More information