Headache in HIV-1-related disorders.

To define the causes, clinical significance and characteristics of headaches in HIV-1-related disorders, we studied 49 consecutive HIV-1 infected patients who presented with headache. Work-up included CT scans, cerebrospinal fluid examinations (in the absence of a contraindication) and serologic studies. Overall, 40 of 49 patients (82 percent) had an identifiable serious cause of headache. Cryptococcal meningitis (39 percent) and CNS toxoplasmosis (16 percent) were the leading headache etiologies. Serious causes were more likely in patients diagnosed with AIDS prior to presentation but also occurred in most patients in early stages of infection. Based on this study, we suggest that patients with HIV-1 infection must be managed with a high index of suspicion when they present with new onset headaches.

The evaluation of patients with human immunodeficiency virus-related disorders and brain mass lesions.

In patients at risk for acquired immunodeficiency syndrome who present with a mass lesion, a dilemma arises as to whether to treat empirically for toxoplasmosis or perform a brain biopsy. We present data that further define the indications for performing brain biopsy vs empiric treatment. We reviewed charts on 59 patients with acquired immunodeficiency syndrome--related disorders and cerebral mass lesions. Thirty-two patients met diagnostic criteria for toxoplasmosis. Bayesian analysis demonstrated that the prior probability of toxoplasmosis was increased by the presence of contrast enhancement on computed tomographic scans (0.68) and toxoplasmosis titers greater than 1:64 (0.81). Features associated with decreasing probabilities of toxoplasmosis included the absence of contrast enhancement on computed tomographic scans (0.29) and toxoplasmosis titers less than or equal to 1:64 (0.14). Ten percent of patients had complications of brain biopsy. Treatment with pyrimethamine and sulfadiazine produced complications in 29% and serious complications in 8% of treated patients. These data favor empiric therapy for patients with typical features of toxoplasmosis and brain biopsy for defined subsets of patients with atypical features.

Neonatal herpes simplex meningoencephalitis: EEG investigations and clinical correlates.

We studied the sequential EEGs of 15 neonatal herpes simplex virus meningoencephalitis (NHSV-ME) patients and correlated them with corresponding clinical and laboratory findings. During days 1 to 4 of the illness, 8 had EEGs. All but 1 had abnormal tracings and 3 (38%) showed the multifocal periodic pattern (MPP). Three had an early abnormal EEG at a time when their cranial CT/ultrasound studies were normal. During days 5 to 11, 13 had EEGs: all were abnormal and 3 showed the MPP. After day 11, EEGs (available on 10) showed a very low voltage background in 9, and only 1 had normal EEG and development. During 1 year in which 1 patient with NHSV-ME was observed, we noted that 9/324 (2.8%) of neonates with other CNS conditions manifested the MPP. All, however, had CSF findings that distinguished them from herpes cases. We conclude that: (1) In patients with suspected NHSV-ME, EEG is a sensitive test that is superior to radiologic procedures in detecting early cerebral involvement. Most of the early EEGs show nonspecific background and paroxysmal abnormalities. (2) In the presence of inflammatory CSF, the MPP, an otherwise nonspecific finding, is highly suggestive of NHSV-ME. (3) Sequential EEGs may be important in the follow-up of neonates with NHSV-ME.

Neurosyphilis in AIDS patients: initial CSF VDRL may be negative.

We report 2 HIV-seropositive patients with neurosyphilis whose initial CSF VDRL tests were negative. The CSF VDRL became positive after 12 days of IV penicillin treatment for syphilitic meningitis in the 1st patient. The 2nd patient developed syphilitic polyradiculopathy and a positive CSF VDRL 3 months after treatment with IV penicillin. Serial CSF VDRL determinations may be required in AIDS patients when a diagnosis of neurosyphilis is suspected.