Fulminant and Diffuse Cerebral Toxoplasmosis as the First Manifestation of HIV Infection: A Case Presentation and Review of the Literature.

BACKGROUND One of the most common causes of central nervous system (CNS) opportunistic infections in immunocompromised patients is toxoplasmosis. It can cause focal or disseminated brain lesions leading to neurological deficit, coma, and death. Prompt management with optimal antibiotics is vital. However, the diagnosis of cerebral toxoplasmosis is challenging in infected individuals with human immunodeficiency virus (HIV). The possible diagnosis is based on clinical presentation, imaging, and specific serologic investigations. The diagnosis can be confirmed by histopathological examination and/or by finding nucleic material in the spinal cerebrospinal fluid (CSF) examination. CASE REPORT We present a review of the literature with a rare illustrative case of diffuse CNS toxoplasmosis as the first manifestation of HIV infection in a young patient. Brain MRI showed diffuse, ring-enhancing lesions, and significant midline shift. Decompressive hemicraniectomy for control of intracranial pressure and anti-infectious therapy were performed. CONCLUSIONS This should raise awareness that cerebral toxoplasmosis can occur in pediatric patients with HIV infection, and, more importantly, as the first manifestation of AIDS. Although the prognosis is often poor, early diagnosis and immediate treatment of this life-threatening opportunistic infection can improve outcomes.

Surgical management of psoas abscess in the Human Immunodeficiency Virus era.

OBJECTIVES: Thai aims of this study were to provide an epidemiological and microbiological analysis of psoas abscess in the human immunodeficiency virus (HIV)-infected population, and to describe the optimal investigative and management approach of this condition. METHODS: A retrospective chart analysis of 20 patients with a diagnosis of psoas abscess admitted to a regional academic hospital from January 2012 to December 2014 was performed. RESULTS: Twenty patients with psoas abscess were identified, of which 14 were HIV positive (70%) and five HIV negative (25%). One patient remained untested (5%). The mean CD4 count was 402 cells/mL (range 150-796 cells/mL, median 367 cells/mL). Acid fast bacilli were positive in psoas abscess aspirates in 13 cases (65%). Staphylococcus aureus and Escherichia coli were identified in 15% of cases. The radioisotope bone scan showed increased vertebral uptake in 10 patients (62.5%), with the lumbar spine (L1-L4) being most commonly involved (31%). There was a statistically significant increase in radioisotope uptake in the lumbar vertebrae in tuberculous psoas abscess than in pyogenic psoas abscess (p=0.003). Ultrasound-guided percutaneous drainage was used in 16 patients (80%) with a success rate of 87.5%; only two cases required repeat drainage (12.5%). Open drainage was used in four patients (30%) with a 100% success rate. There were no mortalities at 30-day follow-up. CONCLUSION: Tuberculous psoas abscess from underlying vertebral osteomyelitis is more common than pyogenic psoas abscess. Ultrasound has high diagnostic accuracy and guides percutaneous drainage with excellent success rates. Ultrasound-guided percutaneous drainage should be regarded as the first-line therapeutic modality.

[Interdisciplinary Treatment of Patients with Pulmonary Tuberculosis]. / Interdisziplinäre Therapie der Lungentuberkulose.

Today surgical procedures for pulmonary tuberculosis are highly selective but owing to the increasing incidence of multidrug resistant tuberculosis has been becoming more and more relevant. Besides the treatment of tuberculosis foci in multidrug resistance tuberculosis to eliminate the source of relapse, complications as sequelae of tuberculosis are among the most frequent indications for surgery. In patients with cavernous lesions, destroyed lobe or lung, bronchiectasis, pleural empyema or hemoptysis thoracic surgical procedures may be warranted. However, in solitary pulmonary nodules operations with diagnostic purpose are necessary, not only to rule out a potential malignancy, but also to identify a so far unidentified tuberculoma. Considering the heterogenous group of patients with tuberculosis, surgical morbidity and mortality are in the known range for surgical resections in lung cancer patients.

Syphilitic orchitis mimicking a testicular tumor in a clinically occult HIV-infected young man: a case report with emphasis on a challenging pathological diagnosis.

BACKGROUND: Syphilitic orchitis is a rare manifestation of gumma in tertiary syphilis, microscopically typically characterized by multiple discrete granulomas with central necrosis and peripheral fibrosis. We report a case of syphilitic orchitis mimicking a testicular tumor with atypical histological features. CASE PRESENTATION: A 33-year-old clinically occult HIV-infected man had a testicular tumor. A radical orchiectomy was performed, and a histological examination showed an acute and chronic interstitial inflammatory lesion as well as spindle cell proliferation, without typical gumma formation, necessitating the differential diagnosis having to be made from a panel of etiological factors. Syphilitic orchitis was confirmed by both an immunohistochemical study and PCR testing for the Treponema pallidum DNA polymerase I gene using paraffin-embedded tissues. However, serology tests, including both the Venereal Disease Research Laboratory (VDRL) test and Treponema pallidum partical agglutination (TTPA), demonstrated false-negative results. CONCLUSION: Syphilitic orchitis may present atypical and unusual histological features, and should be included in the differential diagnoses of nonspecific interstitial inflammatory lesions of the testes by pathologists, especially in immunocompromised patients.

Clinical and pathological features and treatment of AIDS-related cutaneous Kaposi's sarcoma in Chinese Han patients.

This retrospective study aimed to observe the clinicopathological features and immunological phenotypes, and explore effective treatment and prognosis for 12 Chinese Han patients with acquired immunodeficiency syndrome-related cutaneous Kaposi's sarcoma. All 12 patients were human immunodeficiency virus-positive, and underwent the standard highly active antiretroviral therapy (HAART). Skin lesions mainly presented as purple, or rufous papules, or plaques; skin biopsy showed diffuse or flaky infiltration of spindle cells, active proliferation of slit-like vasculature, erythrocyte exudation, hemosiderin deposition, and inflammatory cell infiltration. Immunohistochemical analysis showed the expression of Ubiquitin C-terminal hydrolase L1 (+), and CD31 (+) in T-cells; factor VIII (+) and HHF-35 (+) in the proliferating vascular endothelial cells; vimentin (+) and S-100 protein (-) in the vessel wall; and CD34 (+++) in the spindle cells of 6 cases, with 1 case of negative CD34 expression. Four patients with confined lesions underwent surgery and microwave therapy, and received a favorable prognosis. Two patients with limited lesions underwent microwave therapy, and the lesions subsided. Of six patients with widely distributed sarcomas, five underwent microwave therapy and one received combined chemotherapy; five attained significant efficacy, and one died. There were no significant differences in the clinicopathological features and immunological phenotypes between the Chinese Han patients and those from other populations. Along with basal HAART, patients in early stages, with sarcomas <2 cm in diameter should undergo surgery and microwave therapy, while patients with sarcomas >2 cm in diameter should undergo chemotherapy and microwave therapy.

Salmonella paratyphi B mycotic aneurysm of the abdominal aorta in an HIV-infected patient: a case report.

An HIV-infected 49-year-old man was admitted with polyuria, fever, chills and a dull left lumbar pain. Laboratory tests showed increased C-reactive protein while urine analysis and abdomen ultrasound scan were negative. Blood cultures revealed a Salmonella paratyphi B, identified through MALDI-TOF mass spectrometry. Targeted antibiotic therapy with intravenous piperacillin/tazobactam was started and a multi-phase contrast-enhanced abdomen CT-scan was performed at 24 hours from admission showing a saccular aneurysm of the abdominal aorta with a 1 cm penetrating aortic ulcer on posterior wall. The patient underwent emergency vascular surgery at 34 hours from admission for debridement and homo-graft placement of sub-renal aorta, and surgical samples were sent for microbiological analysis. Unfortunately, the patient died on post-surgical day 7 after haemorrhagic shock due to laceration of his graft. Salmonella paratyphi infection can be responsible for sepsis in severely immunosuppressed patients with poorly controlled HIV, requiring careful work-up for cardiovascular involvement.

[Possibilities of surgical treatment of patients with HIV/AIDS in conditions of phthysiosurgical hospital].

The results of surgical treatment of 158 patients in phthysiosurgical stationary, in whom HIV/AIDS was diagnosed, were presented. In the main group 103 (65.2%) patients were included, who were operated for tuberculosis of various localization. In 70 (44.3%) patients, suffering HIV/AIDS, videoscopy with pleural biopsy was performed, and in 50 (31.6%)--biopsy of lymphatic nodes for lymphadenopathy of occult genesis. The rate of postoperative complications was 4.4%. A priority of performance of videoscopic interventions in the patients, suffering HIV/AIDS, was substantiated.

Long-term clinical and radiographic stability after clip reconstruction of a midbasilar dissecting mycotic aneurysm.

OBJECTIVE: Mycotic aneurysm rupture has been described as a rare, universally fatal complication of central nervous system Coccidioides immitis meningitis. Recently, however, we reported the successful surgical management of a midbasilar dissecting mycotic aneurysm related to C. immitis meningitis in a 24-year-old pregnant woman with acquired immune deficiency syndrome. METHODS: A 24-year-old pregnant woman with known acquired immune deficiency syndrome and a history of C. immitis meningitis presented to our institution with subarachnoid and intraventricular hemorrhage. Diagnostic cerebral angiography revealed a dissecting, midbasilar aneurysm involving the right anterior inferior cerebellar artery and causing stenosis of the proximal basilar artery. Through a retrosigmoid craniotomy, clip reconstruction of the basilar artery under hypothermic circulatory arrest was performed. The patient was neurologically intact at discharge (postoperative day 19) with the exception of mild disconjugate gaze and headache. RESULTS: At her 53-month follow-up, the patient was neurologically intact with only mild disconjugate gaze on upgaze. There was no evidence of local aneurysm recurrence or regional aneurysm formation, and the basilar artery was patent. Her C. immitis meningitis was well controlled. The patient is maintained on oral highly active antiretroviral therapy and an antifungal regimen. CONCLUSIONS: Our patient represents the only survivor of a C. immitis mycotic aneurysm rupture. In her case, long-term clinical and radiographic stability were achieved through a vigilant multidisciplinary approach.

Predictive clinical factors in the diagnosis of gastrointestinal Kaposi's sarcoma and its endoscopic severity.

BACKGROUND: The diagnosis of gastrointestinal (GI) involvement in Kaposi's sarcoma (KS) is important to make because the need for treatment depends on the extent of the disease. Moreover, severe GI lesions can cause serious complications. Endoscopy with biopsy is an extremely useful method to diagnose GI-KS. However, determining the indications for endoscopy is difficult because KS can occur without GI symptoms or cutaneous KS. This study sought to clarify predictive clinical factors for GI-KS and its severity on endoscopy. METHODOLOGY/PRINCIPAL FINDINGS: A total of 1,027 HIV-infected patients who underwent endoscopy were analyzed. Sexual behavior, CD4 count, HIV RNA, history of highly active antiretroviral therapy (HAART), GI symptoms, and cutaneous KS were assessed. Endoscopic severity including bulky tumor, ulceration, and number of lesions were evaluated. Thirty-three patients had GI-KS and 46 patients cutaneous KS. Among the GI-KS patients, 78.8% (26/33) had no GI symptoms and 24.2% (8/33) had no cutaneous KS. Univariate analysis identified men who have sex with men (MSM), CD4 <100 cells/µL, HIV RNA ≥10,000 copies/mL, no history of HAART, and cutaneous KS were significantly associated with GI-KS. Among these factors, cutaneous KS was closely related to GI-KS on multivariable analysis. Among patients without cutaneous KS, MSM and CD4 count <100 cells/µL were the only independent clinical factors related to GI-KS. Bulky tumor was significantly associated with CD4 <100 cells/µL and large number of lesions was significantly associated with HIV-RNA ≥10,000 copies/mL. CONCLUSIONS: To diagnose GI-KS, clinical factors need to be considered before endoscopy. The presence of GI symptoms is not useful in predicting GI-KS. MSM and CD4 count <100 cells/µL are predictive factors among patients without cutaneous KS. Caution should be exercised especially in patients with low CD4 counts or high HIV viral loads as they are more likely to develop severe GI-KS lesions.

Surgical implications of human immunodeficiency virus infections.

Pediatric HIV (human immunodeficiency virus) is a pandemic predominantly in sub-Saharan Africa. Approximately 2.2 million children aged less than 15 years are infected with HIV, representing almost 95% of the total number of children globally infected with HIV. Therefore, increasing numbers of HIVi or -exposed but uninfected children can be expected to require a surgical procedure to assist in the diagnosis of an HIV/acquired immune deficiency syndrome-related complication, to address a life-threatening complication of the disease, or for routine surgery encountered in HIV-unexposed children. HIVi children may present with both conditions unique to HIV infection and surgical conditions routine in pediatric surgical practice. HIV exposure confers an increased risk of complications and mortality for all children after surgery, whether they are HIV infected or not. This risk of complications is higher in the HIVi group of patients. These findings seem to be independent of whether patients undergo an elective or emergency procedure, but the risk of an adverse outcome is higher for a major procedure. Surgical implications of HIV infection are comprehensively reviewed in this article.

[Clinical diagnosis of HIV infection in patients with acute surgical diseases of the abdominal cavity organs and pulmonary tuberculosis].

The results of treatment of 81 patients, suffering tuberculosis and operated in emergency for an acute surgical diseases of the abdominal cavity organs, are adduced, in 29 of them--nonspecific diseases of nontuberculosis genesis were diagnosed. In 52 patients the indication for emergency operation performance were complications of abdominal tuberculosis (perforation of the tuberculosis ulcers of small intestine--in 37, the tuberculosis mesadenitis--in 15), of them in 34--pulmonary tuberculosis was in inactive phase, that's why the HIV presence was supposed. In 26 patients the diagnosis was confirmed, basing on serologic analysis data. The presence of intraabdominal catastrophe, caused by abdominal tuberculosis complications on inactive pulmonary tuberculosis background witnesses with 85.3% probability the HIV-infectioning of the patient.

[Achalasia in a patient with HIV/HCV coinfection: detection of HCV in the esophageal tissue]. / Achalasie bei HIV/HCV-Koinfektion : HCV-Nachweis im Ösophagusgewebe.

Esophageal involvement in the context of opportunistic infections in human immunodeficiency virus (HIV) positive patients is a frequent phenomenon. However, worldwide esophageal achalasia has been described only twice in HIV-infected patients.We report the case of a 44-year-old Caucasian patient with HIV and Hepatitis C virus (HIV/HCV) coinfection who, within 2.5 years, displayed a progressive symptomatology with dysphagia, retrosternal pain, regurgitation as well as a considerable loss of weight before achalasia was finally diagnosed. Treatment was performed primarily surgically by means of laparoscopic Heller myotomy with an anterior 180° semifundoplication according to Dor.Histopathology of the specimens taken from the lower esophageal sphincter high-pressure zone proved alterations with abundant connective tissue and only scarce parts of the smooth muscular system without inflammatory infiltrations. In addition, the ganglia cells of the myenteric plexus as well as the interstitial cells of Cajal were significantly reduced. Interestingly, specific gene sequences of the hepatitis C virus could be detected in the esophageal tissue specimen. In contrast, analysis of specific HIV-gene sequences in the same tissue revealed a negative result.The possible but previously unknown relationship between esophageal achalasia and coinfection with HIV and HCV, also described as neurotropic viruses, will be discussed.

Postpartum endometritis caused by herpes and cytomegaloviruses.

BACKGROUND: Postpartum endometritis is usually a polymicrobial infection caused by organisms that are part of the normal vaginal flora. A pathologically confirmed case of postpartum endometritis secondary to herpes and cytomegalovirus in a human immunodeficiency virus (HIV)-positive patient is reported. CASE: A 29-year-old, HIV-positive woman presented 6 days postpartum with abdominal pain and foul-smelling vaginal discharge. Pelvic ultrasonography revealed retained products of conception. Dilation and evacuation was performed, and antibiotics were started. Despite adequate antibiotics and laparoscopic drainage of a pelvic collection, fevers and pain continued. A total abdominal hysterectomy, salpingectomy, and appendectomy were performed. Pathology reported herpes and cytomegalovirus infection of the uterus. CONCLUSION: Herpes simplex virus (HSV) and cytomegalovirus need to be considered as a potential cause of postpartum endometritis. When antibiotic therapy fails, an antiviral regimen should be considered.

[Tuberculosis of the pancreas: an unsuspected cause of abdominal pain and fever]. / Tuberculosis pancreática: una causa insospechada de dolor abdominal y fiebre.

BACKGROUND: Tuberculosis is frequently the form of presentation of human immunodeficiency virus (HIV) infection even in patients who have not developed acquired immune deficiency syndrome (AIDS). Nevertheless, pancreatic affection is uncommon. Tuberculosis of the pancreas (TBP) is a clinical rarity and mimics pancreatic carcinoma both clinically and radiologically. CLINICAL CASE: We present the case of a 42-year-old man with a 5-day evolution of moderate abdominal pain in the right lower quadrant and fever and vomiting without diarrhea. The patient had no history of abdominal surgery. CT scan revealed a heterogeneously enhancing, multicystic structure in the pancreatic head. Due to suspicion of malignancy, a pancreatoduodenectomy was performed with pathological result of pancreatic tuberculosis. The patient was discharged on the 10th postoperative day without surgical complications. He died 10 months later of Pneumocystis jirovecii pneumonia. By that time he had a positive serum HIV antibodies test. CONCLUSIONS: TBP diagnosis can be missed or significantly delayed because it is often not suspected prior to laparotomy unless there is evidence of pulmonary tuberculosis. TBP should be considered in the differential diagnosis of a mass in the head of the pancreas. The response to early antituberculosis treatment is very effective.

Recurrent haemophagocytic syndrome in an HIV-infected patient.

We describe a case of recurrent haemophagocytic syndrome (HS) in an HIV-infected patient.The first episode was associated with active human herpesvirus 8 infection and progressive Kaposi's sarcoma which was successfully treated with splenectomy, foscarnet and chemotherapy. The second episode was triggered by a Clostridium difficile colitis and resolved completely after treatment with metronidazole only. Recurrent HS has rarely been described in adult patients out of the setting of relapsing malignancy or autoimmune disease.The chronic immune dysregulation and suppression due to HIV-infection may predispose our patient to development of associated HS. Prognosis of HS remains poor, especially in HIV-infected patients. Rapidly unmasking the causative factor and timely instauration of adequate treatment are critical and may improve outcome.