High Prevalence of Cervical High-Grade Lesions and High-Risk Human Papillomavirus Infections in Women Living with HIV: A Case for Prioritizing Cervical Screening in This Vulnerable Group.

INTRODUCTION: Women living with HIV (WLHIV) are at an increased risk of developing cervical precancerous lesions and cervical human papillomavirus (HPV) infection. This study aimed at evaluating the prevalence of cervical lesions and high-risk HPV (HR-HPV) infection in WLHIV in comparison to the HIV-negative women undergoing opportunistic screening. In addition, these findings among WLHIV were correlated with the clinic-demographic factors. METHODS: A cross-sectional study was conducted among WLHIVs at a tertiary hospital and linked antiretroviral therapy (ART) center, while HIV-negative women were recruited from the health promotion clinic at our institute. With informed consent, a semi-structured questionnaire was filled on demographic and epidemiological parameters. Conventional cervical smears and samples for HPV DNA detection by HC2 high-risk HPV DNA test were collected in all participants. Cervical smears were reported using the Bethesda system 2014. Appropriate statistical analysis was performed for bivariate and multivariate logistic regression analysis for comparison between WLHIV and HIV-negative women and for correlation of abnormal cervical cytology and HR-HPV infection among WLHIVs. RESULTS: The clinic-demographic characteristics of WLHIVs and HIV-negative women were similar. On cytology, the prevalence of cervical cytological abnormalities were significantly higher (p < 0.001) among WLHIVs (14.1%) compared to HIV-negative women (3.1%). High-grade lesions were seen in 3.7% of WLHIVs, while no high-grade lesions were detected in HIV-negative women. Cervical HR-HPV infection was also significantly higher (p < 0.001) in WLHIVs (28.9%) than HIV-negative women (9.3%). Cervical precancerous lesions in WLHIVs showed positive association with current sexually transmitted infection (STI), multiple sexual partners, tobacco use, and CD4 count less than 200/µL, while cervical HPV was positively associated with current STI, tobacco use, CD4 count less than 200/µL and negatively with ART intake. On multivariate logistic regression, cervical cytological abnormalities showed a significant association with multiple sexual partners (p < 0.001), while cervical HR-HPV infection was positively associated with current STI (p = 0.01), nadir CD4 count <200/µL (p = 0.004), abnormal cervical cytology (p = 0.002) and negatively with ART intake (p = 0.03). CONCLUSION: Women living with HIV have a significantly higher prevalence of cervical precancerous lesions and HR-HPV infection compared to the general population. Considering the lack of an organized population-based cervical cancer screening program in many low-resource countries like ours, specific focus on screening this highly vulnerable population to reduce the morbidity and mortality due to cervical cancer is imperative.

Cervical Cancer Screening: Is the Age Group 30-65 Years Optimum for Screening in Low-Resource Settings?

BACKGROUND: An Operational Framework document for population-wide screening of common cancers in India was launched in 2016. The target age for screening is 30-65 years for cervical, breast and oral cancers. This study was designed to review the frequency and distribution of cervical lesions among women aged 21-29, 30-65 and > 65 years. STUDY DESIGN: A retrospective review of all satisfactory cervical smears (n = 79,896) received over a ten-year period (2010-2019) was conducted. Three age bands were defined: 21-29 years, 30-65 years and > 65 years. The frequency and distribution of the various epithelial cell abnormalities (ECAs) across the three age bands were calculated. Cytohistologic correlation was performed wherever available. RESULTS: Of the 1357 ECAs (1.7% of all smears), about 16.9% were seen in the age band 21-29 years, while 4.5% presented in > 65 years of age. About 80% of the ECAs seen in younger women were low-grade squamous lesions, while 75% of lesions in women > 65 years were high-grade squamous abnormalities. Among the total 512 significant high-grade and malignant (squamous and glandular) lesions, 5.6% presented in women 21-29 years, while 10.1% were seen in > 65 years of age. CONCLUSION: Majority of the significant cervical lesions would be detected if the screening focuses on the 30-65 years age group. However, about 19% of high-grade squamous preneoplastic lesions (ASC-H/ HSIL) and 13% of preneoplastic glandular lesions (AGC-N) are likely to be missed if women 21-29 years and > 65 years are excluded. The cost of screening incurred by including these age groups has to be weighed against the benefits derived, especially in low-resource settings. In the absence of universal implementation of HPV immunization, there is a felt need to enhance cervical cancer awareness and encourage screening, more so in high-risk category and symptomatic females beyond the selected age group.

A single-center experience of post-transplant lymphomas involving the central nervous system with a review of current literature.

BACKGROUND: Central Nervous System (CNS) lymphoma is a rare presentation of post-transplantation lymphoproliferative disorder (PTLD). METHODS: This single center retrospective study reviewed presentations, management and outcomes of CNS lymphomas in kidney transplant patients transplanted 1968 to 2015, and reviews relevant current literature. RESULTS: We identified 5773 adult kidney transplant recipients of who 90 had a PTLD diagnosis confirmed. CNS disease was diagnosed in 6/90 (7%). Median age at presentation was 60 years and time from transplant 4.5 years. Immunosuppression at diagnosis included mycophenolate mofetil and prednisolone without calcineurin inhibitor in 5/6 patients. Histological analysis diagnosed monomorphic disease in 5/6, and one polymorphic case with tissue positive for Epstein-barr virus (EBV) in 5/6 cases. Despite this 2/4 EBV positive cases had no detectable EBV in peripheral blood or CSF at diagnosis. Treatment strategies included reduction in immunosuppression in all, chemotherapy (n=5), radiotherapy (n=3), Cytotoxic T-Lymphocytes and Craniotomy (n=2). Patient survival was 40% at 1 year with CTL treated patients surviving beyond three years from diagnosis. CONCLUSION: This study supports observational data suggesting MMF treated patients without CNI may have increased risk of disease. Peripheral blood screening for EBV DNAemia does not seem helpful in early identification of those at risk.

Case Series of Severe Neurologic Sequelae of Ebola Virus Disease during Epidemic, Sierra Leone.

We describe a case series of 35 Ebola virus disease (EVD) survivors during the epidemic in West Africa who had neurologic and accompanying psychiatric sequelae. Survivors meeting neurologic criteria were invited from a cohort of 361 EVD survivors to attend a preliminary clinic. Those whose severe neurologic features were documented in the preliminary clinic were referred for specialist neurologic evaluation, ophthalmologic examination, and psychiatric assessment. Of 35 survivors with neurologic sequelae, 13 had migraine headache, 2 stroke, 2 peripheral sensory neuropathy, and 2 peripheral nerve lesions. Of brain computed tomography scans of 17 patients, 3 showed cerebral and/or cerebellar atrophy and 2 confirmed strokes. Sixteen patients required mental health followup; psychiatric disorders were diagnosed in 5. The 10 patients who experienced greatest disability had co-existing physical and mental health conditions. EVD survivors may have ongoing central and peripheral nervous system disorders, including previously unrecognized migraine headaches and stroke.

Symptomatic stroke complicating central skull base osteomyelitis following otitis media in a 2-year old boy: Case report and review of the literature.

We describe the youngest case to date of a 2 year old child who developed central skull base osteomyelitis (SBO) initially presenting with a fever, vomiting and sore throat. An extremely rare complication of mastoiditis following otitis media in children is SBO which can present with non-specific symptoms. This report describes the first case of symptomatic ischaemic stroke secondary to SBO in an immunocompetent child. We review the literature of the management and the potential cerebrovascular complications of central SBO in children secondary to otolaryngological infection.

Nonotogenic Skull Base Osteomyelitis in Children: Two Cases and a Review of the Literature.

Skull base osteomyelitis is a rare condition in childhood and can be described according to whether it is associated with spread of infection from the middle ear (otogenic) or not (nonotogenic). Early recognition of this serious disease and prompt treatment are key to preventing extension to adjacent vascular and nervous system structures. Diagnosis can be challenging due to the variable presentation of the disease and potentially subtle radiological appearances. We present 2 cases of nonotogenic skull base osteomyelitis in childhood both affecting the clivus and review the 6 cases previously described. Both children presented with fever, headache and neck stiffness and responded well to medical management alone; detailed imaging was key to making a diagnosis.