Cryptococcal meningitis in human immunodeficiency virus (HIV)-positive and HIV-negative patients.

This study compared clinical manifestations, blood biochemistry and cerebrospinal fluid (CSF) results of HIV-positive and HIV-negative patients with cryptococcal meningitis. We collected 57 cases of cryptococcal meningitis from cytological specimens submitted to the Department of Tropical Pathology, Faculty of Tropical Medicine. Pertinent clinical data were analyzed retrospectively in 47 cases for clinical manifestations, laboratory features and outcomes of 38 HIV-positive and 9 HIV-negative patients. Headache was the most common symptom seen in all cases, of which 70.2% occurred with fever. CSF examination of both groups revealed elevated opening pressure. Increased CSF protein and depressed CSF glucose levels were seen in HIV-negative cases, which differed from HIV-positive cases, where a slight change was noted. CSF pleocytosis in HIV-positive patients was variable. Forty-eight percent of HIV-positive patients had CSF leukocyte counts below 20 cells/ mm3. None was found in the HIV-negative patients. Specific treatments with amphotericin B and fluconazole were given. Five fatal cases of cryptococcal meningitis were noted, all of which were HIV-positive. There were statistically significant differences in blood neutrophils, blood eosinophils, CSF leukocyte counts, CSF neutrophils, CSF lymphocytes, CSF glucose, and CSF total protein, in HIV-positive and HIV-negative patients (p = 0.050, p = 0.022, p = 0.002, p = 0.016, p = 0.047, p = 0.031, p = 0.009, respectively).

Cerebrospinal fluid analysis in eosinophilic meningoencephalitis.

Eosinophilic meningoencephalitis (EME) remains an important neurological disease and is widely distributed in Thailand. We analyzed the cytological specimens of 56 EME cases. Pertinent clinical data were analyzed retrospectively and correlated with the cerebrospinal fluid (CSF)analysis. Headache was the commonest symptom seen in all EME cases. History of raw or partially cooked Pila snail ingestion was elicited from most patients. There was a marked seasonal occurrence between July to January. Patients received specific treatment as supportive therapy, which included spinal taps, analgesics and corticosteroids, was adequate. No fatal cases were seen. The CSF specimens were sorted into two categories: fresh CSF and hematoxylin and eosin (H&E) stained centrifuged CSF sediment. There was a statistically significant difference between the number of eosinophils and lymphocytes of fresh CSF and the H&E stained centrifuged CSF sediment (p = 0.001 and 0.001 respectively). The CSF glucose and the number of eosinophils in both methods were significantly correlated (p = 0.000, p = 0.008 for fresh CSF and the H&E stained centrifuged CSF sediment respectively). Moreover, the number of eosinophils was statistically significant with the protein in the CSF (p = 0.013), and intracranial pressure (ICP) (p = 0.025). Higher yields of eosinophils, especially in the early course of the disease, can readily be detected in the H&E stained centrifuged CSF sediment, whereas fresh specimens were negative. Further tests may increase the sensitivity and specificity of EME diagnostic results.

Opportunistic infections in the liver of HIV-infected patients in Thailand: a necropsy study.

Liver necropsy from patients infected with human immunodeficiency virus was analyzed in 117 cases. Wide ranges of opportunistic infections were recorded in 47%. Cryptococcosis (21.4%) was the most outstanding infection, followed by tuberculosis (16.2%), cytomegalovirus (5.1%) and penicillosis (3.4%). Non-specific alterations of the liver tissues included fatty steatosis (49.6%), fibrosis (55.6%), portal inflammation and reactive hepatitis. Cases of chronic active and chronic passive hepatitis and one case of hepatocellular carcinoma were reported. In the infected liver, predominant pathological changes included granuloma and spotty necrosis, which were attributed to tuberculous hepatitis. Infection with Cryptococcus usually showed no associated pathological change. The sensitivity for the clinical diagnosis of Cryptococcus was 88.8% and specificity was 91.7%. For tuberculosis, sensitivity was 20% and specificity was 67.9%.

Prognostic significance of skin and subcutaneous fat sequestration of parasites in severe falciparum malaria.

Intradermal blood smear, histopathologic and immunohistologic studies were performed in severe malaria (n=10) and uncomplicated malaria (n=10) patients during positive parasitemia and within 6 hours after negative parasitemia by finger prick smears. Intradermal blood smears showed asexual forms and intraleukocytic pigments when finger prick blood smears showed negative results; however intradermal blood smear did not indicate disease severity within 6 hours after negative parasitemia by finger prick. Histopathologic findings showed 15 fold higher parasitized red blood cells sequestered in vessels of subcutaneous fatty tissue in severe malaria than in uncomplicated malaria (p<0.001) and may indicate disease severity. A panel of polyclonal antibodies against cytokines applied to skin biopsies clearly detected a higher titer against tumor necrosis factor-alpha (TNFalpha) and interleukin-10 (IL-10) in dermal vessels and stratum granulosum respectively, in severe malaria compared with uncomplicated malaria. Results of the study suggest that histopathology and immunohistology of skin and subcutaneous fatty tissue may indicate prognostic severity of malaria and may be associated with focal accumulation of cytokines.

Cytokines associated with pathology in the brain tissue of fatal malaria.

Cytoadherence of Plasmodium falciparum-infected erythrocytes to the brain microvascular endothelial cells is believed to be an important cause of circulatory blockage in cerebral malaria. Cytokines released during acute infection may activate brain endothelial cells leading to increased binding of infected erythrocytes in the brain and reduced cerebral blood flow. This effect may be direct and more potent with the tissue-localized cytokines in the brain. In order to establish this relationship, brain tissues of cerebral and noncerebral malaria were compared. The most prominent histopathologic changes in the brain included edema, neuronal degeneration, ring hemorrhage, and percentage of parasitized erythrocytes sequestration were observed in cerebral malaria. Immunohistochemical staining of the brain sections demonstrated that tissue-localized TNF-alpha, IFN-gamma, IL-I1B, and IL-10 were associated with the histopathology. However, IL-4 was the only cytokine presented at moderate level in the brain tissue of noncerebral malaria which histopathology was the least. No tissue-localized cytokine was observed in the brain of P. vivax infection or of the car accident control cases.

Cytomegalovirus and Cryptosporidium infections in AIDS: a necropsy study.

A case of coinfection of cytomegalovirus (CMV) and Cryptosporidium in an AIDS patient is reported. Chronic diarrhea was the presenting symptom. Etiologic agents were diagnosed only at postmortem evaluation. CMV intranuclear inclusions were seen in the terminal ileum, colon and vermiform appendix. Cryptosporidium oocysts were also present in the intestinal brush border of the colon. Improvement of diagnostic procedures such as colonic biopsy and the use of appropriate staining procedure for AIDS patients with diarrhea can help identify the cause of illness.

Opportunistic protozoa in stool samples from HIV-infected patients.

A retrospective study of stool samples of HIV-infected patients from January 1994 to December 1995 submitted to the Department of Tropical Pathology was analyzed. There were twenty-two cases, all of which presented with chronic diarrhea. Result showed that 50% were infected with protozoa. These include Microsporidium (27.27%), Cryptosporidium (9.09%), Isospora belli (4.54%) and Giardia intestinalis cysts (9.09%). Other infections were Candida sp, Strongyloides stercoralis larva and Opisthorchis viverrini ova. The data stress the importance of opportunistic protozoa in the HIV-infected patients. Awareness of their existence of the diseases is important areas with increasing number of HIV-infected patients for early detection and proper treatment.

Imported cutaneous leishmaniasis in Thailand.

Eleven cases of imported cutaneous leishmaniasis are described based on clinical features such as sex, age, occupation, country visited prior to consultation, sites and numbers of lesions, duration of illness, treatment and outcomes. Ketoconazole was shown to be effective against imported cutaneous leishmaniasis. With the increasing numbers of cutaneous leishmaniasis due to exchange workers going to the endemic areas and the presence of vectors in some localities in Thailand, primary transmission of the disease in this country is possible if feeding habits of the vectors change.

Microsporidium: modified technique for light microscopic diagnosis.

Microsporiodosis caused by Enterocytozoon bieneusi is one of the opportunistic infections in HIV positive patients with chronic diarrhea. The organism is difficult to diagnose because of its small size, previously the diagnosis of this infection relied on identification of the organism under electron microscope. Until recently, the spores of this organism in stool specimens could be seen under light microscope by using various staining techniques. In this study, the modified trichrome staining technique was used to identify microsporidia spores with characteristic red belt-like stripes. Less time and less reagent are required by this modified technique than the conventional method.

Dyspepsia in acute falciparum malaria: a clinico-pathological correlation.

Gastrointestinal symptoms are common in acute falciparum malaria. Dyspepsia often occurs in such patients and sometimes it is exceptionally severe. However, the pathogenesis of the dyspeptic symptoms in malaria has not been clearly defined. Upper gastrointestinal endoscopy was performed in 40 patients with acute falciparum malaria in order to correlate the dyspeptic symptoms with the macroscopic (endoscopic) and microscopic (histologic) pathology of stomach and duodenum. The patients were divided into a dyspeptic group (n = 20, male/female ratio = 17/3, age range 18-50 years, mean age = 28.85 + 9.14 years), and a non-dyspeptic group (n = 20, male/female ratio = 16/4, age range 15-47, mean age 26.05 + 9.98 years). The findings revealed that dyspepsia correlated with topographic endoscopic pangastritis (p = 0.0014), the category of endoscopic antral gastritis (p = 0.013), and the histologic severity of antral gastritis (p = 0.0434). The results suggested that gastritis should be considered in acute falciparum malaria patients presenting with dyspepsia.

Human pathology of Opisthorchis viverrini infection: a comparison of adults and children.

The pathology of human opisthorchiasis in 22 adults (20 to 68 years) and 7 children (7 to 15 years) at autopsy is described. The changes of the liver in adults and children are similar and are summarized as follows: Enlargement of the liver was a common finding. Pericholangitis was observed in most cases. The pathology was confined to the large and medium-sized bile ducts where the flukes inhabited. The small interlobular bile ducts had minimal or unremarkable changes. Dilatation of the bile ducts with hyperplasia, desquamation and proliferation of the bile duct epithelial cells, glandular formation and fibrous connective tissue infiltration of the walls were the most common features. The pathological changes were well established within 7 to 15 years. Dilatation of the gallbladder, chronic cholecystitis and carcinoma were found only in adults. Eight of ten cases were cholangiocarcinoma and two were hepatocellular carcinoma.

Subcutaneous phycomycosis mimics elephantiasis.

A case of subcutaneous phycomycosis involving the right thigh for 1 year duration which mimic elephantiasis was reported in a 21-year-old military man. An initial diagnosis was that of a subcutaneous tissue lesion attributed to parasitic manifestation but turned out to be that of subcutaneous fungal infection both clinically and histologically. The lesion was successfully treated with cotrimoxazole for a period of one month, and followed up for 4 1/2 months with complete cure.