[Treatment of neurotoxoplasmosis with the combination sulfamethoxazole-trimethoprim: report of 10 cases]. / Tratamento da neurotoxoplasmose com a associação sulfametoxazol-trimetoprim. Relato de 10 casos.

Toxoplasmosis is the most frequent parasitic infection of the CNS in the immunocompromised host. When promptly treated with the sulfadiazine-pyrimethamine combination patients with cerebral toxoplasmosis characteristically respond with clear clinical and CT improvement within 1-2 weeks. We report the results achieved with the combination sulfamethoxazole-trimethoprim, and conclude that both combinations have similar effects in the treatment of CNS toxoplasmosis.

[Amphotericin B in the treatment of neurocryptococcosis in patients subjected to renal transplantation]. / Anfotericina B no tratamento da neurocriptococose em pacientes submetidos a transplante renal.

Thirty-five cases of cryptococcosis of the central nervous system (CNS) were studied, 17 of them submitted to renal transplantation. The objective was to evaluate the therapeutic responses observed in the group of kidney transplant patients with CNS cryptococcosis. They were submitted to amphotericin B therapy, with emphasis to the renal function. The results in this group were compared with the outcome in the group of patients with the same infection, submitted to the same therapeutic scheme, but without previous impairment of renal function. Among the 35 patients, 20 were male; the age varied between 4 and 76 years. Associated clinical conditions were noticed in 25 patients, 17 of them with renal transplantation. Among 35 patients, 10 died in the first days of the treatment; 25 patients were effectively treated for CNS cryptococcosis, 18 of them with associated clinical conditions; 15 were kidney transplant patients. The drugs used in the treatment of CNS cryptococcosis were, as possible, the amphotericin B by intravenous and intrathecal route (lumbar puncture) associated with 5-fluorocytosine. Seven patients died during the treatment; then, of the 35 patients who were initially evaluated, 17 died and 18 were successfully treated, with a death rate of 48.57%. Various intercurrencies were observed with the use of amphotericin B and 5-fluorocytosine. The clinical and therapeutic results recorded in this study were compared with the information met in literature. The analysis of the results emphasizes the need of the discovery of better and less toxic drugs than those currently used. Amphotericin B still is the most important drug in the treatment of CNS cryptococcosis and the therapeutic scheme currently recommended consists in the association of amphotericin B and 5-fluorocytosine, and there has been also advantage in the simultaneous use of intravenous and intrathecal amphotericin B. Statistical analysis of the results showed that there is no harm with the use of intravenous amphotericin B in renal transplanted patients with cryptococcosis of the central nervous system.

[Neurocysticercosis and praziquantel. II. Evaluation of results in 20 patients]. / Neurocisticercose e praziquantel. II. Avaliação de resultados em 20 pacientes.

The effectiveness of praziquantel on the infestation of the central nervous system by Cysticercus cellulosae is evaluated considering observations of 20 patients followed from July, 1979 and October, 1980. Two series of 6 day oral administration of the drug were scheduled for each patient: 20 mg/kg/day were given to the first 10 patients in the two series and 30 mg/kg/day to the second 10 patients in the two series. Transient exhacerbation of the cerebrospinal fluid changes proper to neurocysticercosis coincidental the series of medication was the mainline to consider the results. Cytologic aspects of this response was previously reported, and the remarkable participation of eosinophil cells was pointed out. It occurred in 15 patients. Corticosteroids interfere both in the intensity and in the type of this response. Data support the action of praziquantel on cysticerci which parasites the central nervous system and suggest the use of larger doses of the drug and/or a larger period of administration to obtain more effective results.

[Orbito-rhino-cerebral phycomycosis (mucormycosis): report of a case]. / Ficomicose (mucormicose) órbito-rino-cerebral: registro de um caso.

The case of a 15 year old white man, diabetic in cetoacidosis, with a orbit-rhino-cerebral phycomycosis is reported. The illness had an acute onset and the treatment was iniciated early with Amphotericin-B and unilateral osteotomy of maxillary and ethmoidal sinus. With this treatment the patient did well with residuals of ophtalmoplegia and amaurosis on the right. Interesting investigation aspects are the occluded internal carotid on the same side of the affected orbit and the CAT-SCAN finding of moderated ventricular dilatation (two months after hospital admission). Mycology, pathophysiology, histopathology, clinical aspects, diagnosis and therapy are discussed, comparing the findings of this case with avaliable literature. An increased number of survivors can be expected with earlier recognition and more aggressive therapy. Treatment of the underlying debilitating disease, Amphotericin-B and surgical debridement of necrotic tissue, are frequently necessary such as observed in the case reported. The favorable results obtained with the proposed managment are stressed.

[Adrenoleukodystrophy (melanodermic leukodystrophy). Report of an anatomo-clinical case]. / Adrenoleucodistrofia (leucodistrofia melanodérmica). Registro de um caso anátomo-clínico.

The case of a 14-year-old boy with "diffuse cerebral sclerosis", preceded by signs of primary adrenal cortical insufficiency for 7 years with familiar antecedents is reported. This disorder, named adrenoleukodystrophy, has a sex-lin(ed recessive inheritance. The clinical picture is characterized by mental deterioration, gait disturbances, visual impairment, associated with primary adrenal cortical insufficiency. Confirming the data from literature, in our case the pathological study showed myelin degeneration and diffuse gliosis in the cerebral white matter, with no involvement of subcortical fibers. Inflammatory cells are common, and have a perivascular distribution. In the fasciculata and reticular zones of the adrenal gland, "baloon-shaped" cells are evident, most of them presenting a vacuolized and striated cytoplasm. Similar lipidic inclusions have been found in the Schwann cells of the periheral nerves and testis. The findings are compared with twenty cases from the literature.

[ELISA (IgG and IgM) of the CSF and serum in neurocysticercosis under treatment with praziquantel: comparison with complement fixation reactions and immunofluorescence]. / ELISA (IgG e IgM) no LCR e soro na neurocisticercose em tratamento com praziquantel: comparação com reações de fixação do complemento e imunofluorescncia.

Cerebrospinal fluid (CSF) and serum samples of 10 patients with neurocysticercosis under treatment by praziquantel were studied in four occasions: before treatment (day 0) and during treatment on three occasions (days 1, 7 and 21). The immunological reaction analyzed were: ELISA-G and ELISA-M; immunofluorescence-G and immunofluorescence-M; complement fixation. The changes and the variability of results observed through these reactions in this study bring new data that confirm neuroimmunological findings already described in the disease. Acute phase response was found in CSF in 6 cases and only in one case in serum by ELISA-M and immunofluorescence-M. ELISA-G in CSF and serum showed a better sensitivity than the other reactions for diagnosis and for follow-up. Emphasis is given to the importance of the simultaneous realization of several immunological reactions in CSF and serum in patients with neurocysticercosis.

[Histoplasmosis of the central nervous system. Clinical aspects in 8 patients]. / Histoplasmose do sistema nervoso central. Aspectos clínicos em oito pacientes.

Clinical approach has been made in eight patients with histoplasmosis of the central nervous system. All patients had no evidence of immunodepression. Time disease at diagnosis ranged from 6 to 108 months (median 36 months). Main signs and symptoms were: intracranial hypertension in 6 patients; impairment of memory in 4; confusion in 4; seizures in 2; urinary incontinence in 2; sexual impotency in 1. Meningo-encephalitic form was present in 6 patients, while the granulomatous form was found in 2. Diagnostic confirmation was based on: biopsy, in 1 case; necropsy, in 2 cases; cerebrospinal fluid (CSF) sediment culture, in 1; detection of antibodies against Histoplasma capsulatum in the CSF, in 5 cases. There was, in all patients, an expressive difference between CSF alterations (intense, merging acute and chronic phase elements) and clinical symptomatology (patients in general oligosymptomatic).

[Histoplasmosis of the central nervous system: study of cerebrospinal fluid in 8 patients]. / Histoplasmose do sistema nervoso central. Estudo do líquido cefalorraqueano em 8 pacientes.

One hundred and thirteen samples of CSF from eight patients with chronic meningitis were studied in a 12 years period (September, 1980-August, 1992). None of them had AIDS. In all, CNS histoplasmosis diagnosis was made by CSF examination. All cases tested positive for antibodies to Histoplasma capsulatum in CSF; in one case the yeast grew in Sabouraud culture in three different occasions. The main findings in CSF by the time of the diagnosis were: moderate hypercytosis marked by lymphocytes and monocytes, neutrophils-being present and in some cases eosinophil cells; moderate increase of total proteins content; decrease in the glucose content; and moderate increase of gamma globulins sometimes with oligoclonal reaction. Patients were followed-up from 7 to 102 months, and periodically submitted to CSF examinations according to clinics. Cell number and total protein content of CSF showed marked episodes of exacerbation in the follow-up, with a dissociated profile favoring total protein content which got higher with the chronification of the disease. Changes in the CSF pattern with treatment were: rapid decrease of hypercytosis; disappearence of neutrophil and eosinophil cells; increase in glucose content; and slow reduction of the increased contents of total proteins and gamma globulins.

[Neurocysticercosis and praziquantel: long-term development in 100 patients]. / Neurocisticercose e praziquantel: evolução a longo prazo de 100 pacientes.

Evaluation of results observed in a prospective study on the long term follow-up of 100 patients with neurocysticercosis (NC) is reported. Praziquantel (PZQ) was administered to the patients at their admission to the study. Follow-up time was over two years in 63 patients (maximum 118 months). Clinical conditions, TC findings and CSF changes were taken into account for the evaluation. Patients were evaluated periodically during the follow-up. Satisfactory results predominate (72.5%). Satisfactory results maintain a close relationship with clinical forms of the disease: good results predominate among those patients with clinical manifestations of NC which are not marked by intracranial hypertension of progressive character. Results of this long term follow-up evaluation favour the administration of PZQ to patients with NC.

[Cerebrospinal fluid in acquired immunodeficiency syndrome. Analysis of 50 cases]. / Líquido cefalorraqueano na síndrome de imunodeficiência adquirida. Análise de 50 casos.

Cerebrospinal fluid (CSF) was analysed in 50 AIDS patients in this investigation. CSF analysis included: pressure, aspect, colour, cytology (cell number, cytomorphology, and lymphocyte subpopulations), proteins concentration and their electrophoretic distribution, chloride and glycosis concentration, GOT and LDH activity, immunology for cysticercosis, syphilis and toxoplasmosis, bacteriology, and mycological examinations (direct, cultures, Cryptococcus neoformans antigen test). Diagnostic changes were: lymphoma cells in one patient, cryptococcosis in 10, toxoplasmosis in 4, candidiasis in 1, and syphilis in 3. Cryptococcosis occurred in association with toxoplasmosis in one patient who developed syphilis in the follow-up; oligoclonal distribution of gamma globulins occurred in this case. In another case of cryptococcosis, candidiasis appeared during the course of the disease. Changes in the CSF composition observed are discussed in order to evaluate: aspects of CSF inflammatory response in report to immunodeficiency; blood-brain barrier involvement; CNS damage; intracranial mass effects.

[Cerebrospinal fluid in cerebrovascular disorders. Study of 1500 cases]. / Líqüido cefalorraqueano em acidentes vasculares cerebrais. Estudo de 1500 casos.

In order to evaluate information on acute stroke through the study of cerebrospinal fluid (CSF) data em 1500 patients were analysed in the first 48 hours following stroke. Cases were distributed in three groups according to CSF basic findings: type 1, CSF without erythrocytes and without xanthochromia; type 2, CSF without erythrocytes and with xanthochromia; type 3, CSF with erythrocytes and with xanthochromia. Data on each type are discussed as well as correlation findings. Systemic metabolic disturbances, blood-brain barrier impairment and central nervous system lesions are discussed as to the role they have in CSF changes observed in stroke. Indication of CSF exam in stroke is reviewed taking into account progress in neuroimaging techniques.

HTLV-I associated myelopathy in Brazil: a preliminary report.

In this preliminary report the authors present the finding of a high prevalence (37.5%) of seropositivity of antibodies to HTLV-I tested by Western blotting in a sample of 16 Brazilian patients with chronic myelopathies of undetermined origin.

[Cryptococcosis of the central nervous system: evaluation of amphotericin-B, 5-fluorocytosine and miconazole therapy in 18 cases]. / Criptococose do sistema nervoso central: avaliação da terapêutica por anfotericina-B, 5-fluorocitosina e miconazole em 18 casos.

Results obtained in the treatment of cryptococcosis of the central nervous system with amphotericin-B, 5-fluorocytosine and miconazole are evaluated. The evaluation is based upon 18 cases. Emphasis is given to data pertinent to aspects proper to 7 of them, submitted to chronic immunosuppressive treatment due to previous kidney transplantation. Side effects varied from case to case in the patients submitted to amphotericin-B and 5-fluorocytosine treatment. The intrathecal and the intraventricular administration of amphotericin-B was followed by complications of several types. Miconazole was used in one case. Its intravenous and its intrathecal administration did not provoke remarkable side effects.

[Primary amebic meningoencephalomyelitis. Report of a case]. / Meningoencefalomielite amebiana primária. Registro de caso.

A case of primary amebic meningoencephalomyelitis due to Naegleria sp observed in a 14 years old boy is reported. Symptoms due to myelitis at the dorsal level assumed ascending character during the first days of disease. Manifestations due to encephalic involvemente were discrete. Cerebrospinal fluid changes were marked by pleocytosis, and the eosinophil cells participation in the cytomorphological profile was persitently high. Amphotericin-B was used intravenously (25 mgm/day) until 1,500 mgm of total dosis. Remission of encephalitis manifestations was prompt, as well as of meningeal signs. Cerebrospinal fluid changes disappeared progressively. Sensitive-motor changes due to spinal cord involvement persisted as permanent sequelae. Naegleria sp., was isolated from the cerebrospinal fluid in the acute stage of the disease, as well as, from the water of a lagoon where the patient used to swim.

[Neurosyphilis resistant to high doses of penicillin: report of a case]. / Neurossífilis resistente a altas doses de penicilina: registro de um caso.

A case of neurosyphilis that got worse despite several therapeutical trials with high doses of penicillin is described. The clinical condition was stabilized and cerebrospinal fluid data normalized following treatment with chloramphenicol.

CSF in 85 patients with AIDS and CNS cryptococcosis.

In an eight years time period (July 1984-June 1992) CSF samples of 40718 patients were studied, and 610 were from patients with AIDS clinically diagnosed and immunologically confirmed through HIV antibodies detection. Among opportunistic infections detected in them 85 were CNS cryptococcosis. For the purpose of this study the CSF of these 85 patients are the AIDS group of CNS cryptococcosis. For comparison, CSF data from 50 patients with CNS cryptococcosis but without AIDS were taken (non-AIDS group); in this group, 22 patients were immunosuppressed after renal transplant. In AIDS group, the more frequent CSF findings were: yeast presence at direct exam (Fuchs-Rosenthal cell counting chamber), growing of the yeast in cultures, and gamma globulins increase. In non-AIDS group were more frequent: hypercytosis, neutrophil cells presence, and total protein increase. Differences between the two groups are discussed taking into account CNS/CSF immune changes induced by HIV infection. It is concluded that in CNS cryptococcosis of patients with AIDS the CSF evidenced more extensive signs of the fungal opportunistic infection than signs of inflammatory response to the infection. The latter were more prominent among patients of the non-AIDS group of CNS cryptococcosis.

Praziquantel in the cerebrospinal fluid in neurocysticercosis.

In 10 patients with neurocysticercosis (NC), an assessment was made of the praziquantel (PZQ) concentration in the cerebrospinal fluid (CSF), in non-deproteinized serum and in protein-free serum: before administration of the drug and the 1st., 7th. and 21st. days of oral administration (50mg/kg/day during 21 days). Samples of CSF and blood were collected three hours after the last administration of the daily total dosage, on the 1st. and 21st. days; and from 2 to 6 hours after drug administration on the 7th. day. The total daily dosage was distributed into three equal parts of 1/3 each, with a 4 hours' interval between intakes, except in the last 5 cases, who on the 21st. day only were given the total daily dosage on a single administration. Results have shown dispersion in serum concentrations, which are similar to those seen in normal subjects as recorded in literature. There is a correlation between PZQ levels in the CSF and in the serum, the latter being very close to those found in protein-free serum fraction. The statistical treatment of results allowed the following considerations: PZQ concentrations in the CSF and in the protein free serum are in balance from the pharmacodynamic standpoint on the first day; this balance is maintained up to the 21st. day although at different levels from those seen on the 7th. day; on the 21st. day PZQ contents in CSF goes back to its similar values as recorded on the 1st. day, and this suggests that the participation of drug interaction factors has been reduced to non-significant levels. However, several factors can influence PZQ concentration in CSF, as absorption rate, liver first-pass effect and blood-brain barrier changes, and individual dose should be established for each patient based on drug concentration monitoring in the serum and/or in the CSF.

Computed tomography in neurocysticercosis: a 10-year long evolution analysis of 100 patients with an appraisal of a new classification.

Three hundred and fifty seven computed tomography (CT) from 100 different patients with neurocysticercosis (NC) were studied between 1979 and 1988. All patients were treated with praziquantel (PZQ). A new classification attempting to recognize the CT evolution profile in NC as well as assigning a possible link between CT findings and biological conditions of cysts is evaluated. It was possible to conclude that: intact cysts remain unchanged in consecutive CTs by 11 months and exhibit signs of degeneration in about 18 months after PZQ drug therapy; degenerating cysts can be detected by 10.5 months, disappear in 11 months and become nodular calcifications in about 25 months. Therefore, a time period of at least 36 months can be estimated for the complete evolution profile of cysts in the brain parenchyma.

HTLV-1 antibodies in serum and cerebrospinal fluid in tropical spastic paraparesis in Brazil.

HTLV-1 antibodies were investigated in serum and in CSF of 150 patients with neurologic disorders mainly myelopathies. The patients were considered into three groups according to the possible relationship of their disease to the presence of HTLV-1 antibodies: no relationship risk (control group), occasional risk group, and possible risk group. In this latter are 56 patients with crural spastic paraparesis or paraplegia of unknown etiology (SP). HTLV-1 antibodies were tested by the passive particle-agglutination method for anti-ATLA antibody detection. The search was negative in all patients of the control group, and positive (serum and/or CSF) in 16.5% of the patients from the second group and in 55.4% of the SP patients group. Clinical patterns in SP cases with HTLV-1 antibodies were those of tropical spastic paraparesis (TSP). CSF patterns considered (cytology, protein content and gamma-globulins rate) were different between TSP group with HTLV-1 antibodies in CSF and SP group with no HTLV-1 antibodies detection either in serum or in CSF. The difference was significant. Results of this investigation confirm the high incidence of TSP in Brazil, and bring additional indication for searching HTLV-1 antibodies in the CSF.

Diffusion-weighted MR imaging of cystic lesions of neurocysticercosis: a preliminary study.

Neurocysticercosis is an endemic disease in some developing countries. It has pleomorfic clinical and imaging findings, which are variable from patient to patient. In this preliminary note, we studied the magnetic resonance (MR) diffusion-weighted images (DWI) of sixteen patients presenting with cystic lesions of this disease diagnosed by clinical and laboratorial findings. All the lesions had hypointense signal and the similar apparent diffusion coeficient (ADC) values as the cerebrospinal fluid (CSF).