An unusual cause of isolated secondary ovarian failure due to cerebral toxoplasmosis in an African woman with AIDS.

Primary ovarian failure is common. However, isolated secondary ovarian failure due to gonadotrophin deficiency is rare. A few cases of isolated gonadotrophin deficiency, due to congenital cerebral toxoplasmosis, have been described in children. We report the case of a 34-year-old African woman positive for HIV, who developed secondary amenorrhoea following the successful treatment of cerebral toxoplasmosis. Investigations revealed that she developed an isolated gonadotrophin deficiency due to pituitary lesion. The rest of the pituitary function dynamic tests were normal.

Acute recurrent lymphocytic meningitis in an immunocompetent HIV-positive African woman: Is it a Mollaret's meningitis or not?

We report a case of acute recurrent meningitis in an HIV-positive immunocompetent woman. In this case, a 34-year-old African woman with a known HIV infection presented with symptoms of acute meningitis. She was on combination antiretroviral therapy with abacavir, lamivudine, and nevirapine. Her HIV RNA level was <70 IU/mL, and CD4 counts were 640 cells/mm3. This indicates that she was not immunocompromised. She was febrile on examination, with marked neck stiffness. Her cerebrospinal fluid revealed raised white cell counts with 100% lymphocytes and mildly raised protein. Polymerase chain reaction confirmed herpes simplex type 2 meningitis. She recovered fully with aciclovir 800 mg three times a day. However, she was readmitted with a similar presentation 5 months after the initial admission. Her cerebrospinal fluid confirmed recurrent herpes simplex type 2 meningitis. This case alerts the profession to the possibility of non-opportunistic infections in an immunocompetent HIV-positive patient and of herpes simplex virus type 2 causing recurrent lymphocytic meningitis.

Life-threatening digoxin toxicity due to drug-drug interactions in an HIV-positive man.

Drug-drug interactions with corticosteroids, causing Cushing's syndrome with secondary adrenal suppression, are well known in HIV patients. Corticosteroids are widely prescribed in the HIV-positive population. However, digoxin is rarely used in HIV patients; hence, digoxin toxicity due to drug-drug interaction is not widely recognised. Nevertheless, this practice might change in the future as HIV cohorts of patients are ageing, due to the successful treatment of HIV infection with combination antiretroviral therapy. We report a case of digoxin toxicity in an HIV-positive 51-year-old man, due to a combination of drug-drug interaction and renal impairment. The first case report of digoxin toxicity due to drug-drug interaction with ritonavir in an HIV-positive woman was published in 2003. To the best of our knowledge, no similar case report has since been published in the literature. This case alerts the profession to the importance of drug-drug interaction and highlights the clinical features of digoxin toxicity.

Perforation of the bowel due to cytomegalovirus infection in a man with AIDS: surgery is not always necessary!

Cytomegalovirus (CMV) infection is the most common viral opportunistic infection in immunocompromised patients and is a rare cause of bowel perforation. It invariably requires surgical intervention and is often fatal. We report a 50-year-old Caucasian man with AIDS, presented 3 weeks after developing abdominal pain and distension. He was treated for CMV retinitis in the past. His adherence to antiretroviral therapy was poor. Examination revealed a recurrence of active CMV retinitis. His abdomen was tender and distended. The plain X-ray of the abdomen revealed a double wall sign (Rigler's sign), indicating pneumoperitoneum due to the bowel perforation. The upper endoscopy was normal. His CD4 count was 30 cells/mm(3) He was treated with cidofovir infusion. He made a full recovery, without requiring any form of surgery. However, he died of adult respiratory distress syndrome 14 months later, due to iatrogenic acute pancreatitis.

Isolated bilateral inguinal lymphadenopathy in the absence of other symptoms, due to LGV in known HIV-positive MSM: is it more common than we think?

The current resurgence of lymphogranuloma venereum (LGV) has drawn most attention to its potential for causing proctitis; however, this case highlights the need for awareness of LGV as a cause of isolated painful bilateral inguinal lymphadenopathy in a high-risk population and the importance of routine screening for LGV. We describe a case of a 37-year-old HIV positive man, in the population of men who have sex with men (MSM) who presented with bilateral enlarged inguinal lymph nodes and no other symptoms or signs. Urine nucleic acid amplification test was positive for chlamydia LGV-specific DNA. Tests from other sites were negative.

An unusual cause of abdominal pain in an HIV-positive man.

We report a case of an HIV-positive man on antiretroviral therapy (ART) who developed abdominal pain due to acute-on-chronic intestinal ischaemia secondary to superior mesenteric vein thrombosis (SMVT) requiring emergency surgery. He was found to have persistently low levels of protein C on thrombophilia screening. To the best of our knowledge, the association linking SMVT to protein C deficiency in an HIV-infected patient has never been reported in the literature.

Late onset of cryptococcal cervical lymphadenitis following immune reconstitution inflammatory syndrome in a patient with AIDS.

A 32-year-old woman was diagnosed HIV positive with disseminated cryptococcal infection in May 2006. Her initial CD4 was 7 cells/µL and she had a right supraclavicular nodal mass, which was biopsied and shown to be consistent with cryptococcal lymphadenitis. She was treated for disseminated cryptococcal infection and was started on antiretroviral medications subsequently. Two years later, she developed a left supraclavicular mass. Her CD4 count was 320 cells/µL and HIV RNA level was undetectable. Investigations and biopsy results were consistent with a late presentation of cryptococcal immune reconstitution inflammatory syndrome (IRIS). She was treated with oral corticosteroids and her symptoms resolved completely. IRIS is a recognised complication of HIV treatment and occurs in a significant percentage of patients within the first 3 months of starting antiretroviral therapy. This case report illustrates the importance of recognising late presentations of IRIS. It is vital to differentiate true cryptococcal lymphadenitis from IRIS-induced cryptococcal lymphadenitis.

Treatment of Involuntary Movements with Carbamazepine in Dystonic-Choreoathetoid Cerebral Palsy.

Choreoathetoid movements are quite common in cerebral palsy (CP). This is the first report of a patient with choreoathetoid CP who was successfully treated with carbamazepine. Therefore, clinicians should try carbamazepine for involuntary movements in CP patients before pursuing other procudures.

Rapidly progressive cerebellar ataxia in West Wales.

Progressive multifocal leucoencephalopathy (PML) is a severe demyelinating disease of the central nervous system that is caused by the JC virus infection. It is often fatal or severely disabling. PML exclusively happens in the context of cell-mediated immunosuppression. Prior to the era of HIV, PML was mainly confined to patients with haematological malignancies and rheumatological diseases. The HIV epidemic in the early eighties led to massive expansion in the incidence and prevalence of the disease. PML has also been recognised to happen due to treatment with monoclonal antibodies such as natalizumab, which is used as a disease-modifying agent for relapsing remitting multiple sclerosis and other monoclonal antibodies used in dermatological and haematological conditions. The clinical picture is that of cognitive decline, visual disturbance and hemiparesis. The correct clinicoradiological picture combined with demonstrating the JC virus DNA in the cerebrospinal fluid (CSF) using PCR (PMR) is enough to establish the diagnosis. Brain biopsy is rarely needed. Immune reconstitution represents the mainstay in the treatment of PML. We present a case of a 47-year-old man who presented with progressive cerebellar ataxia. Investigations confirmed PML. He was found to be HIV positive. We also review the literature.

Remission of progressive multifocal leukoencephalopathy following highly active antiretroviral therapy in a man with AIDS.

A 43-year-old Caucasian homosexual man with AIDS presented with blurring of vision, change of personality, and memory loss in March 1999. He had first been admitted 2 months previously for treatment of Pneumocystis jiroveci pneumonia. A magnetic resonance imaging scan on admission showed multiple white matter lesions involving both subcortical cerebral hemispheres and cerebellar regions, with no mass effect or surrounding edema. JC virus was detected by nested polymerase chain reaction in the cerebrospinal fluid. These findings were diagnostic of progressive multifocal leukoencephalopathy (PML). His CD4 count was 34 cells/mL, and his HIV ribonucleic acid level was 800,789 copies/mL. He was treated with a combination antiretroviral therapy. He was last reviewed in October 2011. He was fully independent socially and mentally, but he still had some residual neurologic signs with right-sided homonymous hemianopia and visual agnosia. His HIV ribonucleic acid level was undetectable, and his CD4 count was 574 cells/mm(3). Although the median survival of patients with PML was poor before the antiretroviral therapy era, our patient, who is now aged 55 years, is still alive 12 years after the diagnosis. The diagnosis of PML and differential diagnosis of focal neurologic signs in HIV-positive patients are discussed in this case report.

Cystoid macular edema secondary to immune recovery uveitis in a man with cytomegalovirus retinitis and AIDS.

Cytomegalovirus (CMV) is the most common intraocular opportunistic infection in profoundly immunocompromised patients with AIDS. It is characterized by an acute, progressive, necrotizing retinitis in patients with a CD4 count of <50 cells/µL. Although the incidence of CMV retinitis has declined because of the introduction of antiretroviral therapy (ART), a new syndrome of intraocular inflammation has emerged in patients with rising CD4 lymphocyte counts following ART. This is called immune recovery uveitis (IRU). It is thought to occur as a result of restored immunity to various infectious agents, commonly mycobacterial, Cryptococcus, and herpes virus infections. We report a man who was treated for CMV retinitis and later developed IRU in the form of cystoid macular edema (CMO) even though his CMV retinitis remained inactive. His CMO resolved and visual acuity improved 2 years after the onset of CMO without any treatment interventions.

A 'brain tumor' in an intravenous drug abuser.

A male intravenous drug abuser who was infected with hepatitis B and C, presented with a slowly progressive hemiplegia. Contrast enhanced computerized tomography of the head showed a solitary ring-enhanced mass with surrounding edema. Clinically brain tumor was suspected but a brain biopsy confirmed cerebral toxoplasmosis. An HIV test was not considered until the result of brain biopsy. He also had lymphopenia and positive serum toxoplasma antibody. His subsequent HIV test was positive. He deteriorated after a brain biopsy. Empirical antitoxoplasma treatment is recommended in HIV-positive patients with ring-enhanced lesions with surrounding edema and with positive toxoplasma serology. Cerebral toxoplasmosis is still the commonest cerebral opportunistic infection in HIV-infected patients even though the incidence has declined with the use of antiretroviral therapy. It is often diagnosed in those patients as an initial presentation of HIV infection or in those who failed to attend for disease monitoring. Clinical features and differential diagnosis of cerebral toxoplasmosis in immunocompromised patients are discussed.

Ischemic maculopathy in zidovudine-induced anemia in an HIV-positive man.

Opportunistic cytomegalovirus (CMV) infection is common in severely immunocompromised HIV-positive patients. The retina is the commonest site of involvement with hemorrhages a prominent feature. CMV retinitis affects 40% of HIV positive patients who have CD4 count of less than 100 cell/mm(3), and in these circumstances clinicians are likely to consider commencing anti-CMV therapy without considering other causes. We report a man with HIV who developed bilateral retinal hemorrhages and ischemic maculopathy in association with zidovudine (AZT)-induced anemia. Retinal hemorrhages resolved following blood transfusion.