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Histology shows invasion of yeast forms of cryptococci in choroid plexus (periodic acid-Schiff; magnification, × 200).
Source publication
To study the spectrum of neuropathological brain lesions in HIV/AIDS cases.
Retrospective autopsy study between 1988 and mid-1996 at a tertiary level public hospital.
Eighty-five adult brains, with at least 21 sections from each, were examined using routine and special stains.
Risk factors in 64 men (75%) and 21 women (25%) included heterosexual co...
Context in source publication
Context 1
... was present in seven cases (8%), and all were diagnosed by the presence of the typical slippery, mucoid appearance of the brain. Although cystic lesions were most frequently observed in the basal gan- glia, cryptococci could be demonstrated in all parts of the brain including the choroid plexus (five out of seven cases) and corpus callosum (three out of seven cases; Fig. 3). In one case, cryptococci had extended beyond the cystic cavities and diffusely infiltrated the cerebral parenchyma. This case also showed numerous cryptococci and cytomegalovirus (CMV) inclusions in the ventricular lining. CMV infection was seen in six cases (7%). Although all cases had the characteristic cytomegalic cells with Cowdry type A intranuclear inclusions in neuronal and subependymal glial cells, microglial nodules were observed in five cases, focal parenchymal necrosis in three cases, ventriculoen- cephalitis in two cases, and choroid plexitis in one ...
Citations
... counts could not be done in rest of the cases as they presented in very advanced stages of the disease and died before CD4 count could be done (Table 10). (80%) and Gongora-Rivera who reported 89% male involvement (8,9). Agricultural labourers and lorry drivers mostly comprise this group and their occupation involves travel to distant places and exposure to multiple partners. ...
Background & Aims: Nervous system involvement causes significant degree of morbidity in the patients with Human Immunodeficiency Virus (HIV) infection. At least 10% of the cases of Acquired Immune Deficiency Syndrome (AIDS) present with neurological symptoms and over the course of the illness symptomatic involvement of the central and peripheral nervous system has been found in 30 to 60% of the patients.
Materials & Methods: This study included the patients with HIV disease presenting various neurological manifestations admitted into Departments of Medicine and Neurology. In all cases provisional diagnosis was made by taking detailed history and clinical examination. All the cases were subjected to investigations like CD4 count, CSF analysis, EEG, nerve conduction studies, and CT scan and MRI of brain and spinal cord to establish the etiology.
Results: The predominant symptoms observed in the study were headache (70%) and fever (65%). Out of the 100 patients, 30 patients presented with seizures. Central nervous system tuberculosis is the underlying cause in 50% of the cases. Neck stiffness and positive kernig’s sign were seen in 55%. CSF analysis of the patients disclosed a picture suggestive of tuberculosis meningitis in 60%. The radiological evaluation in the form of CT or MRI brain showed lesions like cortical infarcts in 28%.
Conclusion: The study disclosed tuberculosis of the CNS to be the major cause for seizures and other neurological disorders in HIV. Even though neurological manifestations can occur at any level of CD4 count, prognosis is bad if CD4 count is less than 200.
... Similarly, PCNSL accounts for 2.5% of all CNS lesions in HIV-positive patients compared to 10-17% in the western population [36]. Autopsy series show similar findings with the only published Indian series reporting no cases of PCNSL over 8 years [37] while western studies report the share to be between 1.4 and 3% [38,39]. Shorter survival among AIDS patients in the Indian subcontinent could be the likely cause [40]. ...
Early suspicion, withholding steroids, stereotactic biopsy, and high-dose methotrexate (HD-MTX) are essential for the treatment of primary CNS lymphoma (PCNSL) making its management in lower-middle-income countries (LMIC) challenging. Novel radiological methods, clinician awareness about the disease, and utilization of drugs like thiotepa and ibrutinib which can be given on an outpatient basis may allow better management of these patients in resource-poor settings. Combined with a late presenting demographic, this results in poorer outcomes in the Indian subcontinent as compared to its western counterparts. In this review, we summarize the currently available data on PCNSL in the Indian subcontinent. We also review the current standard of care for PCNSL and present potential modifications or research areas that may potentially improve outcomes in LMIC.
... Despite the disease's spread in India, very few reports on the prevalence and pathology of AIDS have been published. 4 Therefore we attempted to assess the relative prevalence with respect to age, sex and occupation, clinical profile and autopsy analysis of HIV positive cases. ...
This is a retrospective study of deaths in human immunodeficiency virus (HIV) infected patients at GrantMedical college and Sir JJ group of hospitals, Mumbai from July 2000 up to June 2005 to determine statisticaldistribution with respect to age, sex and occupation , study clinical profile and causes of deaths among theHIV positive cases. For this we analysed the clinical records and autopsy reports of total 11092 deathsoccurred during study period; out of these 1466 (13.2%) were HIV positive deaths. Out of those 1466 HIV,maximum cases (54%) were in the age group 31-40 years; Males (78%) clearly outnumbered the femalepopulation in the present study. Regarding occupation wise incidence, in 5% cases factory workers weremainly affected. In the present study, clinically pulmonary tuberculosis was found in 40% cases, tuberculousmeningitis was found in 21% cases and pneumonia was found in the 15% cases. Pulmonary tuberculosis wasthe immediate cause of death in 40% cases in the present study. Tuberculous meningitis and pneumonia werealso the common causes of death in the present study.
... Due to the dynamics of the disease spread in our population as discussed below, males are more likely to be in an advanced disease state as compared to females, which reflects in the greater percentage of widowhood in females. Females have generally been diagnosed as HIV-positive during either routine Ante Natal checkups or when their husbands came with OI [7][8][9]. The most common symptom in our study was a headache with vomiting. ...
Objective: The objective of the study was to describe, evaluate, and analyze neurological manifestation in human immunodeficiency virus HIV positive patients admitted to a tertiary care center. Methods: The study was a prospective cross-sectional study, in which 103 HIV patients were analyzed. All patients were interviewed face to face and evaluated by the investigator with particular reference to neurological manifestations. They were classified into various stages of HIV using the World Health Organization staging system. Results: The mean age in males was 37 (standard deviation [SD] 8.0) years and in females 35 (SD 7.0) years. A greater proportion of females were diagnosed in the asymptomatic state during screening, either during pregnancy or when the spouse was found to be positive. Headache was the most common neurologic symptom and fundus abnormalities were the most common neurological sign documented in patients. The mean CD4 counts in males are 156.5/mm 3 and in females are 229.57/mm 3 whereas the mean absolute leukocyte count in males is 1088.30/mm 3 and in females is 1473.52/mm 3. The CD4 counts showed a better correlation with the occurrence of neurological manifestations than absolute leukocyte count. Conclusion: Headache was a significant predictor of the occurrence of neurological complications (p=0.01). CD4 counts were significantly lower in patients with neurological complications and most of the neurological manifestations; on the contrary, all the opportunistic infections were documented in patients with CD4 counts below 200/mm 3. Neurological complications did not show any correlation with the patient being on anti-retroviral therapy.
... 2 It can also be useful in patients who do not improve under treatment, to find an alternate diagnosis or to identify patients with dual diagnosis. Indeed, dual pathological diagnosis in CNS lesions have been previously reported in several HIV patients through autopsy studies 3,4 or studies that pooled blood and CSF analysis and brain biopsy samples. [5][6][7] This work aimed to describe 4 HIV patients with neurological disease of unknown etiology in which a brain biopsy disclosed a dual diagnosis and to discuss the value of brain biopsy in these patients. ...
... The management of neurological lesion of unknown etiology in HIV patient is challenging because of the variety of diseases affecting CNS. 4,8 The advent of MRI of the brain and CSF molecular analysis strongly contributed to increase the rate of diagnosis in HIV patient. Yet, in the absence of diagnosis, after failure of empirical treatment, or in quickly deteriorating patients, brain biopsy is a very useful technique. ...
... The rate of dual brain pathological diagnosis in autopsy studies from HIV patients ranges from 1% to 17%, 3,4 although a 6% frequency of dual diagnosis in alive HIV patients have been reported. [11][12][13][14][15][16] Interestingly, the dual diagnosis in our 4 patients were obtained from the same brain sample and were therefore collocated, conversely to previous reports where biopsies and CSF provided a diagnosis each. ...
... In complete autopsy studies, the occurrence of disseminated cryptococcosis varied from 8.3% to 12.5% [11,12]. In a study conducted in India in Mumbai, cryptococcal meningoencephalitis was detected in 7 (8%) out of 85 cases on neuropathological examination [13]. A complete autopsy study by the same group revealed disseminated cryptococcosis in 5 (5.5%) out of 92 cases [5]. ...
BACKGROUND: Autopsy studies of AIDS form an important database for evaluation of pattern of lesions of the opportunistic infection and its association with other opportunistic infections. There is paucity of such autopsy studies in Indian literature. AIMS AND OBJECTIVES: This study was undertaken Ÿ To observe variations in the histomorphological patterns such as spectrum of lesions, distribution and variations in the tissue responses in Cryptococcal infection in AIDS. Ÿ To study different organs of the same patient and patient to patient variations. Ÿ To note other concurrent opportunistic infections with Cryptococcosis in AIDS.
... Up to 33% of HIV-infected children show bilateral and symmetrical basal ganglia calcifications, involving putamen and globus pallidus and are usually not seen before 10 months of age [96]. In a retrospective autopsy study, 85 HIV-infected adult brains were examined and calcifications were observed in four cases (5%, calcific vasculopathy in three cases and parenchymal calcification in one case) [97]. ...
Basal ganglia calcifications could be incidental findings up to 20% of asymptomatic patients undergoing CT or MRI scan. The presence of neuropsychiatric symptoms associated with bilateral basal ganglia calcifications (which could occur in other peculiar brain structures, such as dentate nuclei) identifies a clinical picture defined as Fahr’s Disease. This denomination mainly refers to idiopathic forms in which no metabolic or other underlying causes are identified. Recently, mutations in four different genes (SLC20A2, PDGFRB, PDGFB, and XPR1) were identified, together with novel mutations in the Myogenic Regulating Glycosylase gene, causing the occurrence of movement disorders, cognitive decline, and psychiatric symptoms. On the other hand, secondary forms, also identified as Fahr’s syndrome, have been associated with different conditions: endocrine abnormalities of PTH, such as hypoparathyroidism, other genetically determined conditions, brain infections, or toxic exposure. The underlying pathophysiology seems to be related to an abnormal calcium/phosphorus homeostasis and transportation and alteration of the blood-brain barrier.
... In this study, we had only a single case of HIV-associated PCNSL (approximately 1%), which is similar to rates from many other reports from India-from 0% to 8.6%including one autopsy study, [13][14][15][16][19][20][21][22][23] and which is far less than the US incidence-from 26.2% (1980 to 2007) to 36.3% (1992 to 2011). 1 The most plausible explanation is the earlier death of these patients as a result of opportunistic infections and tuberculosis. 16,23 The median age among the immunocompetent patients in this study was 50 years; median ages reported by other centers in India, though, ranged from 42 to 59 years [14][15][16][19][20][21][22]24 and reports from the West suggest that those patients are a decade older as well. ...
... In this study, we had only a single case of HIV-associated PCNSL (approximately 1%), which is similar to rates from many other reports from India-from 0% to 8.6%including one autopsy study, [13][14][15][16][19][20][21][22][23] and which is far less than the US incidence-from 26.2% (1980 to 2007) to 36.3% (1992 to 2011). 1 The most plausible explanation is the earlier death of these patients as a result of opportunistic infections and tuberculosis. 16,23 The median age among the immunocompetent patients in this study was 50 years; median ages reported by other centers in India, though, ranged from 42 to 59 years [14][15][16][19][20][21][22]24 and reports from the West suggest that those patients are a decade older as well. 25,26 This difference could be a result of the different age structure in India (only approximately 8% of the population is older than 60 years) or from the referral bias, but contribution of environmental or genetic factors cannot be excluded. ...
Purpose:
The information about the outcome of primary CNS lymphoma (PCNSL) in India is scarce, because there is no population-based or large hospital-based data.
Materials and methods:
This is a retrospective study that spanned 17 years (2001 to 2017) to study the outcome of PCNSL at the All India Institute of Medical Sciences (AIIMS), which is a tertiary care center in Northern India.
Results:
Only one of 99 patients was positive for HIV serology. Diffuse large B-cell lymphoma was the most common histology (97.7%). The median patient age was 50 years (range, 13 to 70 years), and the ratio of men to women was 1.9. The median duration of symptoms before diagnosis was 3.5 months (range, 0.5 to 48 months), and 58.5% had a performance status (PS) of 3 or more. Multiple intracranial lesions were present in 81.8% of patients. Surgical resection was performed in 45%, and approximately 22% of patients were ineligible for treatment. Most patients (n = 73) were treated with high-dose methotrexate (HDMTX)-based regimens (ie, methotrexate, vincristine, and procarbazine with or without rituximab). Pharmacokinetic monitoring of methotrexate was not available at our center. HDMTX-related mortality was 3.9%. The median follow-up duration, event-free survival (EFS), and overall survival (OS) were 34 months, 20.4 months, and 31.7 months, respectively. Addition of rituximab (n = 27) to MVP resulted in a higher objective response rate (88.9% v 73.9% without rituximab; P = .12), complete remission (81.5% v 56.5%; P = .03), 2-year EFS (57.3% v 40.4%; P = .02), and 2-year OS (61.6% v 53.4%; P = .056).
Conclusion:
This is the largest study of PCNSL from India. The patients were immunocompetent and young but presented with a high-burden disease that precluded treatment in approximately 22%. The treatment with HDMTX appears safe without pharmacokinetic monitoring. The outcome is comparable to those observed in the West, and rituximab use showed additional benefit. There are notable barriers with respect to management of PCNSL in the real world, and efforts are required to improve the outcome more.
... The typical initial pathological finding as described in cases from the pre-HIV era is a proliferative arachnoiditis producing a thick, gelatinous exudate that mostly affects the base of the brain in TBM, and often obliterates the subdural space in radiculomyelits [44]. Small studies have suggested that inflammation may be less severe in HIV-infected compared to HIV-uninfected TBM patients [45], however extensive central nervous system exudates have been shown pathologically [46,47] and by MRI [2] in the context of HIV. It is postulated that the histopathological findings in HIV-associated TB reflect the degree of immunosuppression with less advanced cases showing features more similar to those in HIV-uninfected patients [48]. ...
Objectives:
To describe the clinical presentation, spinal magnetic resonance imaging (MRI) findings and outcome of HIV-infected patients with tuberculosis (TB)-associated syringomyelia and to compare these findings between all HIV-infected and -uninfected cases published in the literature.
Methods:
A retrospective observational study conducted over a 12.5-year period at a public-sector referral hospital in South Africa. HIV-infected adults with neurological TB in whom MRI confirmed a syrinx were included. We searched PubMed to identify all published syringomyelia cases.
Results:
Ten patients were enrolled. Syringomyelia complicated neurological TB within four years of initial diagnosis in all patients (median: 21 months, range: 0-39) after initial diagnosis. Six patients were treated conservatively (TB treatment = 5, no treatment = 1); four improved, but only one was ambulant during follow-up. Four patients underwent syringoperitoneal shunting; three improved and one died three months later. Our literature review identified 50 additional cases (HIV-infected = 2, HIV-uninfected = 9, HIV status not documented = 39 [presumed HIV-uninfected]). Clinical and imaging findings and outcomes were similar between HIV-infected and -uninfected cases, except for time of presentation following neurological TB diagnosis, which was delayed (>4 years) in 46% of HIV-uninfected cases, compared to 8% of HIV-infected cases. Conclusions Syringomyelia is a disabling complication of neurological TB that usually presents early after neurological TB diagnosis in HIV coinfected patients.
... Central nervous system lesions were found in 11 (25%) patients, a finding consistent with a study in USA, [34] in which 32% of their patients had CNS affectation, but at variance with other studies in India [35] where they found CNS diseases in 79% of cases. This variation may be due to small sample size in this study. ...
