Diagnosing HIV-associated cerebral diseases - the importance of Neuropathology in understanding HIV.

The study aims to compare two aspects concerning the diagnosis of acquired immune deficiency syndrome (AIDS)-associated central nervous system (CNS) pathology (neuroAIDS): clinical diagnoses issued ante mortem with pathology results issued post mortem. The group of 39 human immunodeficiency virus (HIV)-positive patients was created over 23 years and is limited by marked heterogeneity. The enrolled cases were treated at the "Prof. Dr. Matei Bals" National Institute for Infectious Diseases, Bucharest, Romania, deceased due to AIDS-related complications and underwent brain necropsies performed in the Pathology Laboratory at the "Colentina" Clinical Hospital, Bucharest. The level of superposition between clinical and the necroptic diagnoses of neurological AIDS-associated diseases was: 60% for progressive multifocal leukoencephalopathy (PML), 50% for cerebral cryptococcosis, 33% for cerebral toxoplasmosis, 20% for cerebral lymphoma, null for cerebral tuberculosis, HIV encephalopathy (HIVE), neurosyphilis and cytomegalovirus cerebral infection. Half of the cases without an AIDS-associated CNS lesion were previously clinically overdiagnosed. We observed that the rate of overdiagnosis concerning an AIDS-associated cerebral illness has risen from 36% in 1993 to 124% in 2015, an elevation with statistical relevance [p=0.037, confidence interval (CI) 95%]. The rate of underdiagnosis has slowly risen from 24% in 1993 to 40% in 2015, however, with no statistical relevance. The rate of clinical confirmation has been stagnant in linear regression from 1993 to 2015. The results of our study reveal a gap between ante mortem and post mortem diagnoses, with many instances of overdiagnosis and underdiagnosis of several major AIDS-associated CNS illnesses, highlighting the need for a more detailed, multidisciplinary approach of neuroAIDS.

Immune reconstitution inflammatory syndrome in central nervous system tuberculosis.

BACKGROUND: Immune reconstitution inflammatory syndrome (IRIS) related to tuberculosis (TB) is an exacerbation of an inflammatory response that most often occurs in HIV-infected patients but it has also been observed in non-HIV immunocompromised hosts. We describe two cases of TB associated IRIS with CNS involvement, one in a patient diagnosed with HIV infection and the other in a patient with immunosuppression due to anti tumor necrosis factor treatment. CASE REPORT; The first case was a 40-year-old man, newly diagnosed with HIV infection, who developed right hemiplegia and expressive aphasia. Lumbar puncture and MRI sustained the diagnosis of TB meningoencephalitis. He initially improved understandard antituberculous therapy (ATT). After 6 weeks of ATT antiretroviral treatment (ART) was initiated and one week later the patient experienced worsening of his symptoms (left hemiparesis and mixed aphasia), of CSF and MRI changes. He improved after he was starting on corticosteroids in tapering doses, with clinical deterioration at lower doses over a 5-month period. The second case was a 56-year-old male, treated for 3 years with Infliximab for ankylosing spondylitis. He was diagnosed with disseminated TB (CNS tuberculomas and pulmonary TB), histological and bacteriological confirmed the diagnosis. His neurological symptoms improved after starting ATT but after 2 weeks of therapy he presented with diplopia and generalized tonic-clonic seizures. These symptoms improved only after corticosteroids were added (tapering doses during the next 6 months). CONCLUSION: TB-associated IRIS with CNS involvement is potentially life threatening. Corticosteroids should be used to control the IRIS symptoms in those patients. The dosing and duration should be tailored to each patient.