Cytomegalic inclusion virus encephalitis in patients with AIDS: CT, clinical, and pathologic correlation.

The computed tomographic (CT) scans of 10 patients with acquired immunodeficiency syndrome who had central nervous system (CNS) involvement by cytomegalovirus (CMV) were retrospectively reviewed and correlated with clinical data and pathologic findings. Diagnosis was established in all 10 patients by autopsy, which showed the pathognomonic "owl's eye" intracellular inclusions of CMV. In six patients CMV caused an initial CNS infection that was directly responsible for the patient's progressive encephalopathy and death. In four patients CMV caused a superimposed nondominant CNS infection that had no clinical expression in two. Cortical atrophy and mild hydrocephalus ex vacuo were seen on CT in all 10 patients. Positive findings on CT that could be attributed to infection with CMV were present in only three of the 10 patients, and in these three symptomatic cases autopsy correlation revealed that CT underestimated the degree of CNS involvement. In the other three symptomatic patients, CT showed no parenchymal abnormalities, while autopsy demonstrated diffuse cerebral involvement. In the four patients whose CNS was secondarily involved by CMV, CT showed changes proven at autopsy to be related only to the dominant infection with Toxoplasma gondii and to postoperative hematomas. CT did not demonstrate any abnormalities at the sites of CMV involvement, which were found at autopsy in this latter group. It was concluded that CT is not very sensitive for the detection of CMV encephalitis.

Immunohistologic identification of fungi in systemic and cutaneous mycoses.

Using specific antibodies and the peroxidase-antiperoxidase technique, we were able to demonstrate a variety of fungal organisms in smears and sections of formaldehyde-fixed, paraffin-embedded tissue. The procedure is simple, fast, and accurate and may be used as an alternative to, or in conjunction with, cultural methods to identify fungi specifically.

Pure squamous cell carcinoma of the breast.

Pathological curiosities have always fascinated the surgical community, and management of breast cancer by the physician has, at times, revealed such rarities. A recent case of squamous cell carcinoma in a clear fluid breast cyst has prompted a review of our experience with this rare pathology, and allowed us to make the following statements: We propose that squamous cell carcinoma of the breast arises from ductal metaplasia. When the T.N.M. system is applied to the squamous cell lesion, the apparent poor prognosis that it is believed to carry may not be so apparent. If no other primaries are identified after extensive metastatic work-up, surgical therapy consisting of total mastectomy with complete axillary dissection, is very effective in local control of tumor progress. Nodal status will indicate the need for additional modalities of therapy.

Central nervous system disease in acquired immunodeficiency syndrome: prospective correlation using CT, MR imaging, and pathologic studies.

A prospective study compared the abilities of high-resolution computed tomography (HRCT) and magnetic resonance (MR) imaging in detection and evaluation of central nervous system disease in neurologically symptomatic patients with acquired immunodeficiency syndrome (AIDS). Eighteen CT scans and 19 MR images in 14 patients were compared. HRCT images with contrast material enhancement were superior to unenhanced 0.35-T MR images for differentiating a lesion from surrounding edema, discriminating between lesions in close proximity, locating lesions for biopsy, judging lesion activity, detecting small cortical lesions with minimal edema, and spatial resolution. MR imaging was superior to CT scanning in evaluation of white-matter lesions and detection of small lesions surrounded by edema. MR imaging exhibited higher contrast resolution and greater sensitivity. Complementary uses of MR and CT imaging are suggested.

Cranial CT in acquired immunodeficiency syndrome: spectrum of diseases and optimal contrast enhancement technique.

A retrospective review of cranial CT scans obtained over a 4 year period in patients with acquired immunodeficiency syndrome (AIDS) and documented central nervous system (CNS) pathology is presented. The spectrum of diseases and the value of CT in detecting new, recurrent, and superimposed disease processes were determined. Fifty-one AIDS patients with confirmed CNS pathology were identified. Six of them had two coexistent diseases. Opportunistic infections predominated, especially Toxoplasma encephalitis and cryptococcal meningitis, while tumor was seen infrequently. Initial CT was positive in 76% of cases. In contrast to meningeal processes, where it was not very effective, CT was very sensitive in detecting most parenchymal disease processes. Characteristic although not pathognomonic CT patterns were found for certain diseases. Improvement or resolution of CT abnormalities in patients on medical therapy for Toxoplasma encephalitis correlated well with clinical improvement. Recurrence of CT abnormalities correlated well with medical noncompliance. The optimal contrast enhancement technique for detecting CNS pathology and for monitoring the effectiveness of medical therapy was also evaluated by a prospective study in which both immediate (IDD) and 1 hr delayed (DDD) double-dose contrast CT scans were compared. The examination found to be diagnostically superior in 30 of the 41 IDD/DDD studies was the delayed scan. It is recommended that CT be used routinely and with the 1 hr DDD scan to evaluate and follow AIDS patients with neurologic symptoms and/or signs.

Frequency and anatomic distribution of lymphadenopathic Kaposi's sarcoma in the acquired immunodeficiency syndrome: an autopsy series.

Histologic material from 52 autopsies of persons who had died of the acquired immunodeficiency syndrome (AIDS) were reviewed. The study group included 23 Haitians, 19 homosexual men, five intravenous drug abusers, two hemophiliacs (type A), and three persons at unknown risk. Nineteen of the patients (36.5 per cent) had typical Kaposi's sarcoma alone, but 49 (94.2 per cent) had the inflammatory variant of Kaposi's sarcoma as well as typical Kaposi's sarcoma. Inflammatory Kaposi's sarcoma was found in all risk groups studied. In all cases of typical Kaposi's sarcoma, histomorphologic transitions of inflammatory Kaposi's sarcoma to typical Kaposi's sarcoma were observed. Lymph nodes and spleen were the organs most commonly involved by both typical and inflammatory Kaposi's sarcoma. The findings indicate that Kaposi's sarcoma is more common and has a wider morphologic spectrum in AIDS than is generally appreciated.

The neuropathology of acquired immune deficiency syndrome.

We reviewed the neuropathologic characteristics of 52 cases of acquired immune deficiency syndrome (AIDS) at autopsy. Histologically significant neuropathologic lesions were found in 38 cases. We believed that infection was the predominant pathologic process in 26 cases; occasionally, multiple infectious agents were present. This included Toxoplasma encephalitis (n = 16), fungal abscess (n = 1), tuberculous abscess (n = 1), progressive multifocal leukoencephalopathy (n = 2), cysticercosis (n = 1), and Escherichia coli meningoencephalitis (n = 1). Microglial nodules or perivascular inflammation suggested that encephalitis was the most likely cause in five cases. In two additional cases, a primary demyelinating process that was apparently related to cytomegalovirus was present. Vascular or hypoxic diseases were present in nine cases. The findings included intracerebral hemorrhage (n = 1), subarachnoid hemorrhage (n = 2), infarction (n = 2), diffuse hypoxic changes (n = 5), cerebral edema (n = 1), and rare thromboemboli with extravasation of RBCs (n = 1). One case of primary lymphoma was observed. The CNS lesions were the proximate cause of death in 15 patients. The CNS complications of AIDS are varied and often are the major manifestation of the syndrome.

Brain biopsies in patients with acquired immune deficiency syndrome.

Seven brain biopsies from patients with the acquired immune deficiency syndrome (AIDS) were reviewed. Toxoplasmic encephalitis was diagnosed in five patients, neurotuberculosis in one patient, and no diagnosis was made in the seventh patient. Frozen sections and smears enabled a rapid diagnosis to be made in four patients. Routine histochemical analysis was diagnostic in five patients, and the immunoperoxidase technique for Toxoplasma gondii was required for diagnosis in an additional case. Brain biopsy is a valuable and safe method in the evaluation of mass lesions in patients with AIDS.

Toxoplasma encephalitis in recent Haitian entrants.

We evaluated clinical features of five cases of Toxoplasma encephalitis (TE) occurring in recent Haitian entrants into the United States. None of the patients had any underlying malignancy or known immunosuppressive therapy. Histopathologic findings of TE at autopsy were confirmed by peroxidase-antiperoxidase method. Four patients had an antecedent episode of disseminated tuberculosis and all five were receiving antituberculous therapy when neurologic manifestations of lethargy, seizures, and motor weakness first developed. These symptoms progressed into coma and death within 15 days. Peripheral lymphocytopenia was noted in all patients; three were anergic. Parenchymal lesions were identified by CT brain scans and total proteins were elevated in spinal fluid in all cases. TE appears to be a manifestation of the acquired immune deficiency syndrome in Haitians; it should be suspected in those with a febrile illness and multiple focal lesions of the central nervous system.

Unusual causes of death in Haitians residing in Miami. High prevalence of opportunistic infections.

Twenty-one (100%) Haitians and 42 (21.5%) of 192 native black Americans autopsied in a 33-month period at Jackson Memorial Hospital, Miami, were included in this review. All autopsied materials were examined. Among the Haitians autopsied, infectious diseases accounted for 11 (52%) of 21 deaths. Toxoplasma encephalitis was the leading cause of death (five cases). Other infectious causes of death included disseminated cryptococcosis (one), disseminated cytomegalovirus diseases (one), Pneumocystis carinii pneumonia (one), chronic active hepatitis B (two), and bacterial pneumonia (one). Malignant neoplasms were also found to be causes of death and these included a single cases of each of the following: adenocarcinoma of the lung, multiple myeloma, diffuse histiocytic lymphoma, hepatoma, and Kaposi's sarcoma. Deaths of the remaining cases were due to hypertensive cardiovascular diseases (two), rheumatic heart disease (one), glomerulonephritis (one), and intimal fibroplasia of coronary arteries (one). Seven Haitian cases fulfilled the Centers for Disease Control case definition for the acquired immune deficiency syndrome (AIDS). For comparison, autopsies of black Americans were chosen from conditions that would most likely predispose them to opportunistic infections. Among the autopsies on black Americans there were no cases of opportunistic infections or Kaposi's sarcoma that were considered to be consistent with the AIDS.

Toxoplasma encephalitis in Haitian adults with acquired immunodeficiency syndrome: a clinical-pathologic-CT correlation.

The clinical data, histologic findings, and computed tomographic (CT) abnormalities in eight adult Haitians with toxoplasma encephalitis were analyzed retrospectively. Diagnosis was established by identification of Toxoplasma gondii on autopsy in five and brain biopsy in three specimens and subsequently confirmed by the immunoperoxidase method. All these patients, six of whom had been in the United States for 24 months or less, had severe idiopathic immunodeficiency syndrome. All were lymphopenic and six were on treatment for tuberculosis when the toxoplasma encephalitis developed. All patients were studied with CT when they developed an altered mental status and fever associated with seizures and/or focal neurologic deficits. Scans before treatment showed multiple intraparenchymal lesions in seven and a single lesion in the thalamus in one. Ring and/or nodular enhancement of the lesions was found in six and hypodense areas in two. Progression of abnormalities occurred on serial studies. These CT findings that were best shown on axial and coronal thin-section double-dose contrast studies were useful but not diagnostically pathognomonic. In patients with similar clinical presentation CT is recommended to identify focal areas of involvement and to guide brain biopsy or excision so that prompt medical therapy of this often lethal infection can be instituted.