HIV-associated cavernous sinus disease.

INTRODUCTION: The underlying diagnosis of cavernous sinus disease is difficult to confirm in HIV-coinfected patients owing to the lack of histological confirmation. In this retrospective case series, we highlight the challenges in confirming the diagnosis and managing these patients. RESULTS: The clinical, laboratory and radiological data of 23 HIV-infected patients with cavernous sinus disease were analysed. The mean age of patients was 38 years. The mean CD4+ count was 390 cells/µL. Clinically, patients presented with unilateral disease (65%), headache (48%), diplopia (30%) and blurred vision (30%). Third (65%) and sixth (57%) nerve palsies in isolation and combination (39%) were most common. Isolated fourth nerve palsy did not occur. Tuberculosis (17%) was the most commonly identified disorder followed by high-grade B-cell lymphoma (13%), meningioma (13%), metastatic carcinoma (13%) and neurosyphilis (7%). In 22% of the patients, there was no confirmatory evidence for a diagnosis. The patients were either treated empirically for tuberculosis or improved spontaneously when antiretroviral therapy was started. Cerebrospinal fluid was helpful in 4/13 (31%) of patients where it was not contraindicated. Only 3/23 (13%) of the patients had a biopsy of the cavernous sinus mass. The outcomes varied, and follow-up was lacking in the majority of patients. CONCLUSION: In HIV-infected patients, histological confirmation of cavernous sinus pathology is not readily available for various reasons. In resource-limited settings, one should first actively search for extracranial evidence of tuberculosis, lymphoma, syphilis and primary malignancy and manage appropriately. Only if such evidence is lacking should a referral for biopsy be considered.

Prevalence and outcomes of central venous catheter-related bacteraemia in HIV-infected versus non-HIV-infected patients undergoing haemodialysis treatment for end-stage kidney disease.

BACKGROUND: Central venous catheter (CVC) haemodialysis (HD) to implement renal replacement therapy is the preferred choice in the urgent setting. Unfortunately, CVC placement is associated with multiple complications including nosocomial bloodstream infections. There is a paucity of data on the prevalence and pattern of pathogenic organisms in haemodialysed HIV-infected versus non-HIV-infected patients with end-stage kidney disease. METHOD AND RESULTS: We undertook a retrospective study of 228 patients who were dialysed using a CVC at a tertiary referral hospital in KwaZulu-Natal, South Africa. Seventy-eight patients (34.2%) complicated with bacteraemia and sepsis requiring antibiotics. Removal of the catheter was necessary in 58 patients (74.0%). The most common organisms isolated were Staphylococcus aureus (30.8%), Staphylococcus epidermidis (24.4%) and Klebsiella pneumoniae (15.4%). There was no statistically significant difference between HIV-infected and non-infected patients with regards to infection rate, time interval from insertion of CVC to infection and final outcome. However, HIV-infected patients took longer to recover; 54.3% of non-infected patients versus 10.3% HIV-infected patients had their sepsis controlled within one week. Acidosis, hypotension, line malfunction and line discharge were infrequent signs of sepsis. Fever, rigors and raised white cell count occurred in over 80.0% of patients. CONCLUSION: The infection rate in CVC HD is not more frequent in HIV-infected patients, provided that CD4+ count is ≥ 200 cells/µL and the patient is virologically suppressed. Outcomes following intravenous antibiotic and removal of the CVC are similar in HIV-infected and non-infected patients but response to treatment is slower in HIV-infected patients. A high index of suspicion is needed in detecting CVC-related bacteraemia.

Intracanalicular Optic Nerve Swelling and Signal Change in Fulminant Untreated Idiopathic Intracranial Hypertension.

The role of the optic canal in the pathogenesis of papilloedema has been under scrutiny recently. Whether a larger canal precedes more severe papilloedema or is the result of bone remodelling from chronically raised pressure across a pressure gradient is not clear. The authors present the magnetic resonance imaging findings of a 29-year-old female with fulminant and untreated idiopathic intracranial hypertension. Imaging showed focal expansion and intrinsic signal changes of the intracanalicular optic nerve. The authors discuss the possibility of either fluid accumulation within the optic nerves from a water hammer effect across blocked optic canals resulting from the steep pressure gradient or opticomalacia (optic nerve softening) from chronic ischaemia.