Radiological and pathological features of AIDS-related polypoid cholangitis.

A review of the radiographs obtained at ERCP from 31 patients with AIDS-related sclerosing cholangitis (ARSC) demonstrated intraluminal polypoidal defects within the common bile duct and larger intrahepatic ducts in eight cases (26%). The radiological features from this subgroup are described and correlated with the microbiological and histological findings from biopsy specimens including two patients who underwent post-mortem examination. At microscopy the polypoid lesions were demonstrated to consist of granulation tissue. The presence of these polyps did not adversely affect the prognosis nor were they associated with any particular infective agent. We propose recognizing the existence of this entity by the term AIDS-related polypoid cholangitis (ARPC).

Strongyloides stercoralis hyperinfection in an HIV positive patient.

A 25 year old British man of previous good health presented with persistent generalised lymphadenopathy and was found to be human immunodeficiency virus (HIV) antibody positive. Three years later after weight loss and loose stools Strongyloides stercoralis was identified in the latter and successfully treated with thiabendazole. Shortly afterwards, a further episode again responded rapidly, but was swiftly followed by a final and fatal illness with severe debility and metabolic imbalance unresponsive to all treatment. Necropsy showed widespread and heavy strongyloidiasis with pulmonary haemorrhage, bronchopneumonia, and meningitis.

The histopathology of the testis and epididymis in AIDS--a post-mortem study.

The right testis and epididymis were removed at necropsy from 31 patients who had died with AIDS and examined microscopically. The testes showed interstitial fibrosis in 22 cases, thickening of seminiferous tubule basement membranes in an overlapping 21, and varying degrees of maturation impairment in all. Arrest of spermatogenesis usually occurred at the spermatocyte or spermatid stage. Five epididymides showed an obstructive picture, two with an associated epididymal cytomegalovirus infection. We discuss the possible pathogenesis of the changes in the HIV-infected male genital system and briefly comment on the clinical implications of our findings.

Neurological presentations of AIDS--when to test for HIV.

Nine of 122 patients dead from AIDS in central London presented with neurological disease, confirmed pathologically in seven. Seven had no other major systemic manifestations. AIDS needs to be considered in the differential diagnosis of meningitis, dementia, diffuse and focal encephalopathies, brainstem syndromes, myelopathy, visual failure and peripheral nerve syndromes. As AIDS becomes more widespread there will be an increasing need for diagnostic HIV testing in many neurological syndromes.

Neuropathology of HIV infection in haemophiliacs: comparative necropsy study.

OBJECTIVE: To discover whether pathological and neuropathological findings at necropsy are different in haemophiliacs and other subjects positive for HIV. DESIGN: Pathological and neuropathological findings at necropsy were compared in haemophiliacs and non-haemophiliacs, most of them homosexual men. SETTING: Necropsies performed in the south of England. SUBJECTS: 11 Haemophiliacs (mean age 41, range 15-69) and 31 non-haemophiliacs, 29 of whom were homosexual men (mean age 40, range 21-60). AIDS was diagnosed before death in four haemophiliacs and all but one of the non-haemophiliacs. MAIN OUTCOME MEASURES: Prevalence of various forms of neuropathology and systemic pathology in the haemophiliacs and non-haemophiliacs, compared with Fisher's exact test. RESULTS: The prevalences of opportunistic infections of the central nervous system were significantly higher in the non-haemophiliacs (cerebral toxoplasmosis 23% (7), progressive multifocal leucoencephalopathy 10% (3), and cerebral cytomegalovirus infection 19% (6) in the non-haemophiliacs v no cases in the haemophiliacs). The prevalences of fresh and old intracranial haemorrhages and cirrhosis of the liver were significantly higher in the haemophiliacs (fresh intracranial haemorrhage 45% (5), old intracranial haemorrhage 36% (4), and cirrhosis of the liver 27% (3) in the haemophiliacs v no cases in the non-haemophiliacs). The prevalence of neuropathological changes in the non-haemophiliacs was similar to that found in other necropsy series. CONCLUSIONS: The main causes of death in haemophiliacs positive for HIV included intracranial haemorrhage and cirrhosis of the liver. The haemophiliacs died when the characteristic neuropathological changes associated with HIV infection were at a fairly early stage in their development.

Unusual development of polyoma virus in the brains of two patients with the acquired immune deficiency syndrome (AIDS).

Two HIV-positive male patients presented with a variety of symptoms including hemiparesis, unsteadiness, progressive loss of vision and poor memory. There were multiple non-enhancing lesions shown by CT scan in the white matter of the cerebral hemispheres. Specimens obtained by burr-hole biopsy showed the features of progressive multifocal leucoencephalopathy (PML) in both cases. Electron microscopy demonstrated round and rod shaped particles of papovavirus in the nuclei and cytoplasm of oligodendrocytes and in processes of astrocytes where abnormal and florid modes of viral replication were seen. Additional features observed were viral particles suggestive of an enterovirus in Case 1 and, in both specimens, massive membrane proliferation within both nuclei and cytoplasm of infected cells together with the presence of tubuloreticular structures (TRS) in the cytoplasm of endothelial cells. At post-mortem, the brain of patient 2 showed PML and HIV encephalitis. The presence of HIV was confirmed by immunohistochemical methods. We suggest that in AIDS patients the abnormality of the immune system induced by HIV causes abnormal replication patterns of papovavirus in the brain. In addition, these cases confirm the frequent occurrence in AIDS patients of TRS, now considered to be a marker for HIV.

Combined HIV-CMV encephalitis presenting with brainstem signs.

Two cases of combined HIV-CMV encephalitis are described. One presented with a sixth nerve palsy and a tetraparesis, the other with an internuclear ophthalmoplegia. Pathologically brain stem involvement was predominantly due to CMV.

Oesophageal symptoms, their causes, treatment, and prognosis in patients with the acquired immunodeficiency syndrome.

In a prospective study of 154 AIDS patients, 48 (31%) complained of pain on swallowing both liquids and solids and 32 (21%) of these also had dysphagia. While candidiasis was the most common cause of symptoms (26 patients), discrete ulceration of the oesophagus occurred in 12 instances in 10 patients (four cytomegalovirus, four herpes simplex virus, three aphthous ulcer, one peptic ulcer). One patient had a diffuse oesophagitis caused by Mycobacterium avium intracellulare. No cause was found for the oesophageal symptoms in four patients. Kaposi's sarcoma (KS) was found in seven patients associated with other pathology in four. All 26 patients with oesophageal candidiasis only, also had oral involvement. All the patients with herpes simplex virus (four) and aphthous ulcers (three) had obvious perioral involvement. Three of the four patients with cytomegalovirus ulceration had evidence of disease elsewhere (colon or retina). All patients with Kaposi's sarcoma lesions had skin and buccal cavity involvement. The cause of oesophageal disease was usually obvious at endoscopy. The appearance of candidiasis was typical and the various ulcerating lesions also had different macroscopic configurations. Cytomegalovirus infection produced deep linear ulcers in the distal oesophagus, herpes simplex oesophagitis is similar in appearance to the typical perioral lesions of fluid filled vesicles. Diagnostic radiology was not helpful in most patients. In nine of 17 patients with candidiasis, the barium swallow examination performed within 24 hours of presentation was normal. In only three of seven patients with oesophageal ulceration (three cytomegalovirus, two herpes simplex virus, one aphthous, one peptic) was there evidence of an abnormality. Treatment produces symptomatic relief. All patients with candidiasis responded to ketoconazole, the four with herpes simplex virus to acyclovir and one of three with aphthous ulceration had a dramatic response to thalidomide. The three patients with cytomegalovirus infection who were treated with foscarnet had a prolonged remission of symptoms. The overall prognosis of patients with oesophageal symptoms is poor, with an average survival time from a definitive diagnosis of five months (range one to 13).

Biopsy pathology of HIV infection: experience at St Stephen's Hospital, London.

In a 3 year period from the beginning of January 1985 to the end of December 1987, 474 biopsies obtained from 266 patients with serological evidence of human immunodeficiency virus infection were examined. Most frequent were skin biopsies of which 52% showed Kaposi's sarcoma, and transbronchial lung biopsies of which 40% showed Pneumocystis carinii pneumonia. Other opportunistic infections were much less common; Mycobacterium avium intracellulare was found in six biopsies and Cytomegalovirus in three. Non-Hodgkin's lymphoma was diagnosed in six patients.

Nature, incidence and prognosis of neurological involvement in the acquired immunodeficiency syndrome in central London.

Clinical neurological involvement at various times throughout the illness was recorded in 52% of 122 patients seen in central London who died from acquired immunodeficiency syndrome (AIDS). Various metabolic encephalopathies, dementias, focal encephalopathies, retinopathies and peripheral nerve pathology were the most frequent manifestations. Seven of 9 patients with a neurological presentation had no other major systemic illness. The median time from diagnosis of AIDS to death was 9 months and from onset of neurological symptoms to death 4 months. Human immunodeficiency virus dementia, central nervous system opportunistic infections, presence of Kaposi sarcoma, neurological presentations and minor symptoms were not associated with major change in survival time.

Fibreoptic bronchoscopy in diagnosis of bronchopulmonary Kaposi's sarcoma.

Kaposi's sarcoma of the lung patients with the acquired immune deficiency syndrome is often indistinguishable by clinical and radiographic criteria from opportunistic pneumonia. Pulmonary Kaposi's sarcoma and pneumonia may frequently be present in the same patient. Previous observers have commented on the repeated failure to establish a diagnosis of Kaposi's sarcoma of the lung by fibreoptic bronchoscopy. Thirteen fibreoptic bronchoscopies were performed in a series of 11 patients with thoracic manifestations of AIDS and Kaposi's sarcoma was identified in transbronchial or bronchial biopsy specimens in four patients. This diagnostic yield is comparable to that obtained only by open lung biopsy procedures in previous reports. Fibreoptic bronchoscopy may contribute to the correct management of the patient and facilitate an accurate prognosis by differentiating between opportunistic pneumonia and pulmonary Kaposi's sarcoma.

Clinical investigations of lymphadenopathy, including lymph node biopsies, in 24 homosexual men with antibodies to the human T-cell lymphotropic virus type III (HTLV-III).

The findings of 27 lymph node biopsies performed on 24 homosexual patients with lymphadenopathy are presented. Six had acquired immune deficiency syndrome (AIDS) and 18 lymphadenopathy only, of whom one subsequently developed AIDS. All these patients had antibodies to the human T-cell lymphotropic virus type III (HTLV-III) suggesting that HTLV-III is currently the commonest cause of lymphadenopathy in homosexual men. The histopathological findings of six of seven nodes from AIDS patients showed either follicular depletion alone or follicular and paracortical lymphocyte depletion. Nodes from four patients showed Kaposi's sarcoma, three of which also showed follicular hyperplasia. In two of these patients there were no cutaneous manifestations of this condition. One lymph node from a patient with persistent generalized lymphadenopathy (PGL) showed Mycobacterium tuberculosis. Six nodes from six other patients have had features of toxoplasmosis although there was no serological or clinical evidence of recent toxoplasma infection. The remaining 11 lymph nodes from patients with PGL and one node from a patient with transient lymphadenopathy, showed reactive follicular hyperplasia only. We conclude that homosexuals with lymphadenopathy who are HTLV-III antibody positive do not need a routine node biopsy unless an alternative diagnosis is strongly suspected.