Development of a risk scoring system for prognostication in HIV-related toxoplasma encephalitis.

BACKGROUND: This study aims to evaluate specific risk factors influencing prognosis of HIV-infected patients with toxoplasma encephalitis (TE) in order to develop a prognostic risk scoring system for them. METHODS: This is a six-center retrospective study of hospitalized HIV/TE patients. Data including six-week mortality after diagnosis, baseline characteristics, clinical features, laboratory tests and radiological characteristics of eligible patients were assimilated for risk model establishing. RESULTS: In this study, the six-week mortality among 94 retrospective cases was 11.7% (11/94). Seven specific risk factors, viz. time from symptom onset to presentation, fever, dizziness, CD4+ T-cell counts, memory deficits, patchy brain lesions, and disorders of consciousness were calculated to be statistically associated with mortality. A criterion value of '9' was selected as the optimal cut-off value of the established model. The AUC of the ROC curve of this scoring model was 0.976 (p < 0.001). The sensitivity and specificity of the risk scoring model was 100.0 and 86.9%, respectively, which were 81.8 and 94.1% of this scoring model in the verification cohort, respectively. CONCLUSIONS: The developed scoring system was established with simple risk factors, which also allows expeditious implementation of accurate prognostication, and appropriate therapeutic interventions in HIV-infected patients with TE.

Safety and diagnostic value of brain biopsy in HIV patients: a case series and meta-analysis of 1209 patients.

Early brain biopsy may be indicated in HIV patients with focal brain lesion. This study aimed to evaluate and compare the safety and diagnostic value of brain biopsy in HIV patients in the pre-highly active antiretroviral therapy (HAART) versus post-HAART era via meta-analysis. Appropriate studies were identified per search criteria. The local database was retrospectively reviewed to select a similar patient cohort. Patient demographics, brain biopsy technique, histopathology and patient outcomes were extracted from each study. Study-specific outcomes were combined per random-effects model. Outcomes were compared between the pre-HAART and post-HAART era. Correlations between outcomes and baseline characteristics were assessed via meta-regression analysis. The proportions of histopathological diagnosis were tabulated and compared between the pre- and post-HAART era. Survival analysis was performed for patients in the post-HAART era. A total of 26 studies (including the local database) with 1209 patients were included in this meta-analysis. The most common indications for brain biopsy were diagnosis unlikely to be toxoplasmosis (n=8, 42.1%), focal brain lesion (n=5, 26.3%) or both (n=3, 15.8%). The weighted proportions for diagnostic success were 92% (95% CI 90.0% to 93.8%), change in management 57.7% (45.9% to 69.1%) and clinical improvement 36.6% (26.3% to 47.5%). Morbidity and mortality were 5.7% (3.6% to 8.3%) and 0.9% (0.3% to 1.9%), respectively. Diagnostic success rate was significantly higher in the post-HAART than the pre-HAART era (97.5% vs 91.9%, p=0.047). The odds ratio (OR) for diagnostic success in patients with contrast-enhanced lesions was 2.54 ((1.25 to 5.15), p<0.01). The median survival for HIV patients who underwent biopsy in the post-HAART era was 225 days (90-2446). Brain biopsy in HIV patients is safe with high diagnostic yield. Early brain biopsy should be considered in patients without classic presentation of toxoplasmosis encephalitis.

[Follow-up study of HIV-infected patients with prior cerebral toxoplasmosis].

AIM: To assess follow-up study results in human immunodeficiency virus (HIV)-infected patients with prior cerebral toxoplasmosis (CT). SUBJECT AND METHODS: Follow-up study results were assessed in HIV-infected patients with prior CT. RESULTS: The fate of only 97 out of 137 (66% of the hospitalized) patients discharged from hospital is known, as 40 convalescents have been lost to follow up. Thereafter, relapses developed in 19 patients, of whom 6 died. Eleven more patients with HIV infection died due to its progression and development of other secondary lesions. Five more patients died from narcotic overdose, staphylococcal sepsis, and acute pancreatic necrosis. The main peak of fatal outcomes was within the first 2 years after discharge. 3.5-year survival rates after TC were 75%. The causes of recurrent and progressive HIV infection were non-compliance with secondary prevention of CT and low adherence to an antiretroviral therapy regimen, the blame of which fell not only on the patients, but also their attending physicians and specialists who had advised how to enhance treatment motivation. CONCLUSION: Further follow-up of convalescent CT patients calls for closer attention to the possible development of recurrences within the first three years after discharge in particular, regardless of CD4 cell counts.

[Treatment of neuro-AIDS on a neurological intensive care unit: epidemiology and predictors of outcome]. / Behandlung von Neuro-Aids auf der neurologischen Intensivstation : Epidemiologie, Outcome und Prädiktoren des Verlaufs.

BACKGROUND: Investigations concerning the outcome for patients suffering from neuro-AIDS treated on a neurological intensive care unit and specific predictors indicating "dead" were analyzed. MATERIAL AND METHODS: A total of 56 patients with a mean age of 39 ± 0.7 years, a mean CD4+ cell count of 130 ± 166 CD4+ cells/µl and viral load of 146,520 ± 198,059 copies/ml were treated on a neurological intensive care unit due to different forms of neuro-AIDS. RESULTS: Of the patients, 34% were immigrants of whom 74% came from sub-Saharan regions. In 57% of the patients the diagnosis of HIV infection was made during therapy on the neurological intensive care unit. The median for the time between diagnosis of HIV infection and the treatment on the neurological intensive care unit was 8 days for immigrants and 10 years for residents. The most common manifestations of neuro-AIDS were cerebral toxoplasmosis, cryptococcosis and progressive multifocal leukoencephalopathy (PML). Fifty per cent of the patients (n=28) died during treatment on the neurological intensive care unit. Negative predictors for the outcome "dead" were (a) artificial ventilation, (b) antiretroviral naïve immigrant, (c) primary cerebral lymphoma and (d) missing antiretroviral therapy as a result of admission to the intensive care unit. DISCUSSION: The rate of death during treatment of neuro-AIDS on a neurological intensive care unit is much higher than during treatment of internal medicine problems of HIV infection. Antiretroviral naïve immigrants show a much higher rate of death compared to residents in Germany. A lot of research and effort is necessary to improve the availability of the Highly Active Anti-Retroviral Therapy (HAART) worldwide in order to improve the outcome especially for immigrants with neuro-AIDS treated on a neurological intensive care unit.

Toxoplasma gondii in individuals with schizophrenia: association with clinical and demographic factors and with mortality.

BACKGROUND: Increased rates of exposure to Toxoplasma gondii have been found in individuals with schizophrenia as compared with control groups, but the correlates of Toxoplasma exposure in schizophrenia have not been defined. METHODS: We measured IgG class antibodies to Toxoplasma gondii in 358 individuals with schizophrenia. We correlated Toxoplasma antibody status with clinical and demographic variables and examined the effect of Toxoplasma seropositivity on mortality in a follow-up period of up to 5 years. RESULTS: Individuals with schizophrenia who had serological evidence of Toxoplasma infection were more likely to be female but did not differ in age, race, total symptom score, or other demographic or clinical characteristics. However, we found that serological evidence of Toxoplasma was associated with a significantly increased risk of dying of natural causes during the follow-up period (Cox proportional hazard ratio of 4.70; 95% confidence interval, 1.27-17.31, P = .020) adjusted for age, gender, and other clinical and demographic variables. CONCLUSIONS: Toxoplasma infection may confer an increased risk for mortality from natural causes in schizophrenia. An understanding of the pathogenesis of Toxoplasma infections in individuals with schizophrenia might lead to new approaches to the management of this disorder.

Incidence, presentation and outcome of toxoplasmosis in HIV infected in the combination antiretroviral therapy era.

BACKGROUND: HIV-associated incidence and prognosis of cerebral toxoplasmosis (CTX) is not well established during later years. METHODS: From the Danish HIV Cohort Study, we identified 6325 HIV-infected individuals. We assessed incidence, mortality, predictive and prognostic factors of CTX during the pre-combination antiretroviral therapy (pre-cART; 1995-1996) and cART-era (1997-2014). Adjusted incidence rate ratios (aIRR), mortality rate ratios (aMRR) and 95% confidence intervals (CI) were assessed using Poisson regression analysis. RESULTS: CTX IR was 1.17/1000 PYR (95% CI 0.93-1.47). We observed no change in CTX-risk in the first year after HIV-diagnosis, but a substantial reduction in mortality in the first 3 months after CTX diagnosis when comparing the cART-era to the pre-cART-era; {(aIRR: 0.79; 95% CI: 0.37-1.72) (aMRR: 0.15; 95% CI: 0.06-0.38)}. For individuals surviving the first year after HIV-diagnosis or the first 3 months after CTX-diagnosis, IRR and MRR had declined to minimal levels {(aIRR: 0.06; 95% CI: 0.03-0.10); (aMRR: 0.02; 95% CI: 0.01-0.05)}. Three years after CTX-diagnosis 30% of the patients still had neurological deficits. CONCLUSION: Although, CTX remains an important cause of morbidity and mortality in the cART-era, with high prevalence of neurological sequelae, incidence and mortality has largely declined, especially among those surviving the first year after diagnosis.

Alternative treatment approach to cerebral toxoplasmosis in HIV/AIDS: experience from a resource-poor setting.

The current standard treatment for cerebral toxoplasmosis (pyrimethamine/sulfadiazine) often encounters problems of poor tolerability, adverse effects, frequent dropouts and non-availability of pyrimethamine/sulfadiazine in some parts of India. We have had to use the combination of two effective alternative agents for toxoplasmosis, cotrimoxazole and clindamycin, on compassionate grounds. This retrospective observational study reports superior efficacy and better tolerability of cotrimoxazole/clindamycin compared to the recommended regimen. Primary end-point (complete response) was defined as more than 50% improvement of clinical status or more than 50% decrease in the size of brain lesions after two weeks of treatment initiation. Complete response occurred more commonly with cotrimoxazole/clindamycin than with pyrimethamine/sulfadiazine group (80% vs. 31.25%, respectively, relative risk 2.56, 95% confidence interval: 1.21-5.43). There was a trend towards higher on-treatment mortality in the pyrimethamine/sulfadiazine group in comparison to the cotrimoxazole/clindamycin (mortality rate 37.5% in pyrimethamine/sulfadiazine vs 12% in cotrimoxazole/clindamycin, p = 0.07, relative risk = 3.125, 95% confidence interval: 0.91-10.75). Overall, 62.5% (10/16) of patients on pyrimethamine/sulfadiazine suffered drug-related adverse reactions compared to 24% (6/25) on cotrimoxazole/clindamycin (p = 0.02, relative risk = 2.60, 95% confidence interval: 1.17-5.76). The commonest complication of pyrimethamine/sulfadiazine was severe thrombocytopenia with major bleeding (4/16, 25%). We propose that the new combination chemotherapy, which is widely available, effective and safe, can be used in developing countries.

Atovaquone as long-term suppressive therapy for toxoplasmic encephalitis in patients with AIDS and multiple drug intolerance. Atovaquone Expanded Access Group.

OBJECTIVE: To evaluate the efficacy and tolerance of atovaquone used as long-term maintenance therapy in patients with toxoplasmic encephalitis and intolerant of conventional anti-Toxoplasma therapies. DESIGN: Uncontrolled open-label study of atovaquone given through an expanded access programme; statistical analysis was performed on an intent-to-treat basis. PATIENTS: Sixty-five patients intolerant of conventional toxoplasmic encephalitis therapies-pyrimethamine, sulphadiazine or clindamycin-received atovaquone as maintenance therapy after resolution of an acute episode of toxoplasmic encephalitis. Patients were clinically and neurologically evaluated monthly. Toxoplasmic encephalitis relapse was defined as the occurrence of neurological abnormalities, except in the case of a proven alternative diagnosis. RESULTS: Sixty-five patients were treated with atovaquone 750 mg four times daily and followed up for a mean period of 1 year. Mean CD4 lymphocytes count was 29 x 10(6)/l. Prior to starting atovaquone, patients had experienced a total of 129 episodes of intolerance to conventional anti-Toxoplasma drugs. Atovaquone was used as a single anti-toxoplasmic agent in 75% of the cases. Seventeen patients (26%) experienced a toxoplasmic encephalitis relapse. Sixty-three patients (97%) were able to tolerate and continued taking atovaquone. Two patients had to discontinue therapy because of side-effects. In a multivariate analysis, only the duration of pyrimethamine-sulphadiazine therapy during the acute therapy phase of toxoplasmic encephalitis was significantly associated with a decreased risk of toxoplasmic encephalitis relapse during maintenance therapy [relative risk, 0.64 for each week of pyrimethamine-sulphadiazine; 95% confidence interval (CI), 0.42-0.96; P = 0.03]. The survival probability was 70% at 1 year after the episode of toxoplasmic encephalitis (95% CI, 57-83). CONCLUSION: These results suggest that atovaquone is a well-tolerated alternative anti-Toxoplasma treatment for maintenance therapy in patients who are intolerant to conventional anti-Toxoplasma drugs.

Toxoplasma gondii infection in advanced HIV infection.

OBJECTIVE: To study Toxoplasma encephalitis (TE) in advanced HIV infection, including predictive factors, possible prophylactic regimens and impact on survival. DESIGN: Epidemiological analysis of data collected prospectively during the Alpha study, a double-blind, randomized clinical trial, comparing two doses of dideoxyinosine in patients with advanced HIV disease. PATIENTS: First episode of TE occurred in 75 out of 499 patients participating in the trial. METHODS: Kaplan-Meier estimates and semi-parametric Cox's model were used. RESULTS: A low CD4 cell count and a positive Toxoplasma serology were strongly predictive of the occurrence of TE. In patients with CD4 counts < 100 x 10(6)/l and a positive Toxoplasma serology at entry to the study, the 12-month TE incidence was 25.4%. Patients who were receiving at entry any of the following potentially antitoxoplasmic drugs: trimethoprim-sulphamethoxazole, pyrimethamine, dapsone, pyrimethamine-sulphadoxine or sulphadiazine, had a lower TE incidence than those who were not; 6.2 versus 18.8%, respectively (P < 0.001). The rate of survival 12 months after TE was 29.6%. Even after adjusting the major prognostic covariates, TE was predictive of death (P < 0.001; relative risk, 1.8). CONCLUSIONS: The high HIV incidence, morbidity and mortality in high-prevalence areas suggests that primary prophylaxis should be given in patients at high risk for toxoplasmic reactivation.

Invasive pneumococcal disease in patients infected with HIV: still a threat in the era of highly active antiretroviral therapy.

We studied all human immunodeficiency virus (HIV)-infected patients with invasive pneumococcal disease who received their diagnosis during 1996-2002 to investigate the incidence of this disease in the highly active antiretroviral therapy era and to study the influence of CD4 lymphocyte count on the clinical presentation and outcome of disease. The overall incidence of invasive pneumococcal disease was 11.3 cases per 100,000 person-years in adult patients without known HIV infection and 677 cases per 100,000 person-years in HIV-infected patients. This incidence remained stable over the study period. Clinical presentation, severity of illness, and number of recurrent episodes were similar in patients with CD4+ cell counts of >200 or < or =200 cells/ microL. Patients receiving trimethoprim-sulfamethoxazole (TMP-SMZ) were more likely to present with TMP-SMZ-resistant pneumococci than were those who were not receiving this agent (76.7% vs. 43.6%; P=.007). The mortality rate was high (21%).

Second unrelated bone marrow transplantation without additional conditioning therapy after engraftment failure.

A 37-year-old female highly alloimmunized by multiple transfusions received a sex matched HLA-identical unrelated bone marrow transplant for hypoplastic MDS-RA with moderate myelofibrosis. Conditioning consisted of total body irradiation, cyclophosphamide and ATG, GVHD prophylaxis consisted of CsA, MTX and prednisolone. The CD34+ stem cell content of the first graft was relatively low due to an inadequate harvest. The patient appeared not to have engrafted by day 23 post-BMT. She therefore received a second sex mismatched HLA-identical unrelated bone marrow graft on day 25 after two days of 3.5 mg/kg methylprednisolone from a different donor. Over the ensuing days, the first marrow showed slow engraftment followed by engraftment of the second graft. The first graft was then rejected, as monitored by peripheral blood studies of chimerism. No signs of acute GVHD were observed. Despite successful trilineage engraftment and complete second donor chimerism, the patient died from disseminated toxoplasmosis encephalitis and pneumonia on day +104.

Management of intracerebral lesions in patients with HIV: a retrospective study with discussion of diagnostic problems.

A total of 95 patients who presented in 1994 and 1995 with focal brain lesions at a London HIV centre were studied retrospectively. Patients were allocated to "definite" or "presumed" diagnostic categories of toxoplasma encephalitis (TE), primary CNS lymphoma (PCNSL) or progressive multifocal leukoencephalopathy (PML), based on strict criteria. The number in each category was: TE, 20; PCNSL, 9; PML, 7; presumed TE, 12; presumed PCNSL, 8 and presumed PML, 17. There were 20 patients in whom a diagnosis could not be made, and there were three non-HIV diagnoses. Demographic data, features at presentation and routine CSF analysis were not discriminatory in making a diagnosis. Toxoplasma titres were a median of 1:256 in those with TE compared to 1:16 in all other groups (p < 0.001) and those with TE were less likely to be on toxoplasma prophylaxis compared to those with PCNSL (p < 0.002). Survival with TE (median of 446 days) was significantly longer than survival in all other groups. Survival with either confirmed or presumed PML was similar. The problems of diagnosis of focal brain lesions in HIV patients are discussed and a management flow chart for mass lesions is proposed.

A retrospective study of treatment of cerebral toxoplasmosis in AIDS patients with trimethoprim-sulphamethoxazole.

AIMS OF THE STUDY: a retrospective study was designed to evaluate efficacy and tolerance of trimethoprim-sulphamethoxazole (TMP-SMZ) in AIDS patients with cerebral toxoplasmosis (TE). PATIENTS AND METHODS: we reviewed 471 patients with AIDS, and we analysed 71 AIDS patients with TE, who received intravenous therapy with TMP-SMZ (TMP: 10 mg/kg/day, SMZ: 50 mg/kg/day) for 4 weeks. RESULTS: 35 patients (49.2%) had a complete regression of clinical signs, and a complete resolution of radiological lesions was noted in 41 patients (57.7%). Improvement of clinical signs and radiological lesions were observed in 27 patients (38%), and in nine patients (12.6%), respectively. In contrast, nine patients (12.6%) did not show any clinical change, or worsened. Twenty-two patients (30.9%) suffered from adverse cutaneous reactions, whereas many patients had haematological toxicity. CONCLUSIONS: TMP-SMZ seems to be an efficient therapy for TE in AIDS patients, although further prospective, randomized therapeutic trials are required to confirm these results.

Clinical features, outcome and survival from cerebral toxoplasmosis in Edinburgh AIDS patients.

Nineteen cases of cerebral toxoplasmosis (CTOX) are reported from a group of Edinburgh AIDS patients. All patients were severely immunodeficient at the time of presentation with CD4 count < 50 cells/mm3. Thirteen patients had suffered a previous AIDS-defining illness. In Edinburgh, CTOX has developed in 48% of patients who are seropositive for toxoplasma and have a CD4 count < 50 cells/mm3. It is estimated that at least half of the toxoplasma seropositive patients will develop CTOX if they survive for 21 months after reaching a time in their illness when the CD4 count = 50 cells/mm3. The incidence of CTOX in toxoplasma-seronegative patients with a CD4 count < 50 cells/mm3 is 1.3%. All patients showed improvement on treatment and there was no correlation between clinical or radiological features and patient survival. Those patients unable to tolerate first choice anti-toxoplasma therapy had a significantly shorter survival than the remainder but there was no single therapeutic regimen which conferred a survival advantage. Eighteen patients had died at the time of study and the median survival following diagnosis of cerebral toxoplasmosis was 10 months (range 3-38 months). Postmortem examination of the brain was available in 8, 4 of whom had concomitant cerebral lymphoma. The survival from AIDS or CD4 count = 50 cells/mm3 did not differ significantly between those with treated CTOX and a control group who had no toxoplasma infection, suggesting that treatment is reasonably effective. CTOX is a disease associated with severe HIV-related immunodeficiency and, in those with a CD4 count < 50 cells/mm3, occurs more than 35 times as frequently in toxoplasma-seropositive than toxoplasma-seronegative patients. Treatment is effective but the outcome of treated disease cannot be predicted from presenting clinical or radiological features. Concomitant space-occupying cerebral pathology is evident in 50% of post-mortem examinations.

Toxoplasma encephalitis in AIDS patients in São Paulo during 1988 and 1991. A comparative retrospective analysis.

We conducted a retrospective analysis of Toxoplasma encephalitis patients from Instituto de Infectologia Emílio Ribas, the main AIDS hospital of São Paulo, Brazil, during two different stages of the HIV epidemics, in 1988 (38 patients) and 1991 (33 patients). There were AIDS-related demographic differences, but the clinical presentation and diagnostic efficiency were similar, usually based on tomography and clinical response to therapy, with a clear distinction from other CNS infections, based on clinical and laboratory findings. Specific serologic studies were performed less often in 1991, with a high frequency of therapy change. The direct acute death rate from Toxoplasma encephalitis was high during both periods, i.e. 8/38 in 1988 and 10/33 in 1991. The direct acute death rate for the patients from the two periods as a whole was 25.4% (18/71), related to the time of HIV infection, absence of fever and presence of meningeal irritation at presentation, blood leukocytes higher than 10,000/mm3 and blood lymphocytes lower than 350/mm3. Toxoplasma encephalitis is a preventable disease when adequate prophylactic therapy is used and is relatively easy to treat in diagnosed HIV patients. Unfortunately, this severe and deadly disorder is the HIV diagnostic disease in several patients, and our data support the need for careful management of these patients, especially in those countries with a high toxoplasmosis prevalence where AIDS is concurrent with economic and public health problems.

Patterns of mortality in southern sea otters (Enhydra lutris nereis) from 1998-2001.

Detailed postmortem examination of southern sea otters (Enhydra lutris nereis) found along the California (USA) coast has provided an exceptional opportunity to understand factors influencing survival in this threatened marine mammal species. In order to evaluate recent trends in causes of mortality, the demographic and geographic distribution of causes of death in freshly deceased beachcast sea otters necropsied from 1998-2001 were evaluated. Protozoal encephalitis, acanthocephalan-related disease, shark attack, and cardiac disease were identified as common causes of death in sea otters examined. While infection with acanthocephalan parasites was more likely to cause death in juvenile otters, Toxoplasma gondii encephalitis, shark attack, and cardiac disease were more common in prime-aged adult otters. Cardiac disease is a newly recognized cause of mortality in sea otters and T. gondii encephalitis was significantly associated with this condition. Otters with fatal shark bites were over three times more likely to have pre-existing T. gondii encephalitis suggesting that shark attack, which is a long-recognized source of mortality in otters, may be coupled with a recently recognized disease in otters. Spatial clusters of cause-specific mortality were detected for T. gondii encephalitis (in Estero Bay), acanthocephalan peritonitis (in southern Monterey Bay), and shark attack (from Santa Cruz to Point Año Nuevo). Diseases caused by parasites, bacteria, or fungi and diseases without a specified etiology were the primary cause of death in 63.8% of otters examined. Parasitic disease alone caused death in 38.1% of otters examined. This pattern of mortality, observed predominantly in juvenile and prime-aged adult southern sea otters, has negative implications for the overall health and recovery of this population.

[Cerebral toxoplasmosis in AIDS. 73 cases. Clinical Epidemiology Group on AIDS in Aquitania]. / Toxoplasmose cérébrale au cours du SIDA. 73 observations. Groupe d'Epidémiologie clinique su SIDA en Aquitaine.

A presumptive diagnosis of toxoplasmic encephalitis was made in 73 of the 428 AIDS patients followed in the Bordeaux Regional Hospital between 1985 and 1990. The sex ratio (M:F) was 2.8:1. The mean age was 36.2 years. Forty-three percent were homosexuals, 30 percent intravenous drug abusers. The encephalitis revealed the HIV infection in 10 percent of the cases; it was the first opportunistic infection in 27 percent. The clinical manifestations were: focal neurologic deficit (62 percent), fever (58 percent), headaches (47 percent), altered consciousness (45 percent), seizures (18 percent). The CT scan findings were focal lesions with (60 percent) or without (40 percent) ring enhancement. Oedema was present in 58 percent of the lesions, and multiple lesions in 59 percent. At the time of diagnosis, the mean CD4 lymphocyte count was 72 per mm3. The initial therapeutic regimens were: pyrimethamine (P) plus sulfadiazine (n = 57), P plus clindamycin (n = 11) and P plus clarithromycin (n = 5). Following acute therapy the patients had a complete (64 percent) or partial (18 percent) response, and 18 percent died. Adverse reactions were noticed in 53 percent. Sixty patients received a maintenance therapy; after a mean follow-up of 8 months, 12 relapsed and died of toxoplasmic encephalitis; 17 died of another cause. The median survival after toxoplasmosis was diagnosed was 7.5 months.

[Secondary diseases in patients with HIV infection: 15-year follow-up]. / Vtorichnye zabolevaniia u bol'nykh c VICh-infektsiei - 15-letnee nabliudenie.

AIM: To analyse the results of a 15-year study of opportunistic diseases in AIDS patients. MATERIAL AND METHODS: The spectrum of opportunistic diseases were made in AIDS patients in respect to clinical, laboratory and autopsy data for the periods: 1987-1992 (n = 27, 25 deaths--92.6%), 1993-1997 (n = 95, 58 deaths--61.8%), 1998-1999 (n = 70, 28 deaths--40%), 2000-2001 (n = 126, 31 deaths--24.6%), 2002 (n = 80, 32 deaths--40%). RESULTS: The spectrum of opportunistic diseases in AIDS patients was determined for the above time periods and causes underlying these diseases have been determined. CONCLUSION: Among opportunistic diseases associated with HIV infections most prevalent were the following: tuberculosis, cytomegaloviral infections, cerebral toxoplasmosis. Leading modern trends were identified: increasing morbidity of AIDS, tuberculosis, new AIDS cases at late stages with severe opportunistic diseases (2/3 of deaths).

Hyponatremia, acute kidney injury, and mortality in HIV-related toxoplasmic encephalitis.

BACKGROUND: There are no reports on hyponatremia and acute kidney injury (AKI) involved in the course of HIV-related toxoplasmic encephalitis (TE). The main objective of this study was to describe the occurrence of hyponatremia and its relationship with AKI and mortality in HIV-related toxoplasmic encephalitis (TE). METHODS: This was a retrospective cohort study on patients with HIV-related TE. AKI was considered only when the RIFLE (risk, injury, failure, loss, end-stage) criterion was met, after the patient was admitted. RESULTS: A total of 92 patients were included, with a mean age of 36±9 years. Hyponatremia at admission was observed in 43 patients (46.7%), with AKI developing in 25 (27.1%) patients during their hospitalization. Sulfadiazine was the treatment of choice in 81% of the cases. Death occurred in 13 cases (14.1%). Low serum sodium level correlated directly with AKI and mortality. Male gender (OR 7.89, 95% CI 1.22-50.90, p = 0.03) and hyponatremia at admission (OR 4.73, 95% CI 1.22-18.30, p = 0.02) were predictors for AKI. Independent risk factors for death were AKI (OR 8.3, 95% CI 1.4-48.2, p < 0.0001) and hyponatremia (OR 9.9, 95% CI 1.2-96.3, p < 0.0001). CONCLUSION: AKI and hyponatremia are frequent in TE. Hyponatremia on admission is highly associated with AKI and mortality.

Neurologic outcomes and adjunctive steroids in HIV patients with severe cerebral toxoplasmosis.

OBJECTIVES: Cerebral toxoplasmosis remains a common neurologic complication in patients with AIDS. In this study, we aimed to characterize the prognosis of patients with HIV infection with severe forms of cerebral toxoplasmosis and to investigate the effects of adjunctive steroids on outcomes. METHODS: We carried out a retrospective cohort study (2000-2011) on consecutive patients with cerebral toxoplasmosis admitted to the medical intensive care unit (ICU) of 5 hospitals. Functional prognosis was graded at 3 months using the modified Rankin Scale (mRS). RESULTS: We studied 100 patients with a CD4 cell count of 25 (8-62) cells/µL and a Glasgow Coma Scale (GCS) score of 11 (6-14). At follow-up, 51 patients had an mRS score of 0-2 (functional independence), 30 had an mRS score of 3-5 (severe disability), and 19 had an mRS score of 6 (death). Compared with other specific treatments, the use of pyrimethamine-sulfadiazine was associated with improved survival (p = 0.03). Two factors present at ICU admission were independently associated with a poor outcome (mRS score >2) at 3 months: a CD4 cell count <25 cells/µL (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.1-6.7) and a GCS score ≤8 (OR 3.1, 95% CI 1.2-7.7). In patients treated with pyrimethamine-sulfadiazine, the use of adjunctive steroids to treat cerebral edema associated with focal lesions appeared safe but was not associated with better neurologic outcomes. CONCLUSION: Severe forms of cerebral toxoplasmosis in patients with HIV infection are characterized by a good prognosis in approximately 50% of cases. Profound immunodepression and impaired consciousness represent major determinants of outcome. In our study, the benefit of adjunctive steroids to treat cerebral edema could not be demonstrated.