Beware of cryptococcomas when treating Cryptococcal meningitis

2020 ◽  
Vol 10 (5) ◽  
pp. 183-184
Author(s):  
Rafael Ferreira Nascimento ◽  
Diogo Raposo André, ◽  
Fabiana Gouveia ◽  
Nancy Faria ◽  
Ana Paula Reis
Keyword(s):  
Immunocompromised Patient ◽  
Brain Mri ◽  
Hiv Positive ◽  
Rare Presentation ◽  
Neck Stiffness ◽  
Viral Loads ◽  
Hiv Rna ◽  
Neurological Exam ◽  
History Of ◽  
The Brain

Introduction: The authors describe a rare presentation of central nervous system cryptococcosis in an immunocompromised patient. Case description: An HIV-positive patient, with poor adherence to the treatment, presented with a seventeen days history of severe headache. On the neurological exam there was only evidence of neck stiffness, he had a CD4 count of 23 cells/μl and plasma HIV RNA viral loads of 364,000 copies/ml. Lumbar puncture revealed positive for cryptococcal antigen virus and so treatment with amphotericin B was started. During his admission the patient developed an expressive aphasia with visual hallucinations and the brain MRI revealed cerebral cryptococcomas. After 98 days of treatment general and neurological examination was normal and the patient was discharged home. Conclusion: This case highlights a rare and severe complication of Cryptococcus neoformans infection in immunocompromised patients.

How Do You Make the Diagnosis?

2014 ◽  
pp. 5-6
Author(s):  
David L Brody
Keyword(s):  
Brain Function ◽  
The Other ◽  
Physical Force ◽  
Neurological Exam ◽  
History Of ◽  
The Brain ◽  
Rule Out

To make a diagnosis of concussion, you need a reliable history of two things: (1) an acute external physical force applied to the brain and (2) an impairment in the function of the brain directly caused by the external physical force. One or the other is not enough. You need both. You do not need a scan to make the diagnosis. No scan can “rule in” or “rule out” concussion. You do not need to perform a detailed neurological exam to make the diagnosis. The neurological exam is usually unremarkable except for immediately after the concussion. no exam findings “rule in” or “rule out” concussion. A collateral source is key to obtaining a reliable history. The impairment in brain function occurs immediately after the event. The impairment is worst immediately after the event, then gradually improves. There is no other obvious explanation for the impairment.

scholarly journals Causal Link between Ventricular Ectopy and Concussion

2020 ◽  
Vol 2020 ◽  
pp. 1-8
Author(s):  
J. Patrick Neary ◽  
Jyotpal Singh ◽  
Jonathan P. Christiansen ◽  
Taylor A. Teckchandani ◽  
Kirsty L. Potter
Keyword(s):  
Brain Mri ◽  
Causal Link ◽  
Pharmacological Intervention ◽  
Ventricular Ectopy ◽  
Remarkable Change ◽  
Significant Incidence ◽  
Male Individual ◽  
Case Study Report ◽  
History Of ◽  
The Brain

We present a unique case study report of a male individual with a history of mild nonischaemic cardiomyopathy, with no ventricular ectopy, that at the age of 76 years sustained multiple concussions (i.e., mild traumatic brain injury) within a week of each other. Concussion symptoms included cognitive difficulties, “not feeling well,” lethargy, fatigue, and signs of depression. He was later medically diagnosed with postconcussion syndrome. The patient, WJT, was referred for cardiac and neurological assessment. Structural neuroimaging of the brain (MRI) was unremarkable, but electrocardiography (ECG) assessments using a 24-hour Holter monitor revealed significant incidence of ventricular ectopy (9.4%; 9,350/99,836 beats) over a period of 5–6 months after injury and then a further increase in ventricular ectopy to 18% (15,968/88,189 beats) during the subsequent 3 months. The patient was then prescribed Amiodarone 200 mg, and his ventricular ectopy and concussion symptoms completely resolved simultaneously within days. To the authors’ knowledge, our study is the first to show a direct link between observable and documented cardiac dysregulation and concussion symptomology. Our study has important implications for both cardiac patients and the patients that sustain a concussion, and if medically managed with appropriate pharmacological intervention, it can reverse ventricular ectopy and concussion symptomology. More research is warranted to investigate the mechanisms for this dramatic and remarkable change in cardiac and cerebral functions and to further explore the brain-heart interaction and the intricate autonomic interaction that exists between the extrinsic and intracardiac nervous systems.

scholarly journals Prevalence and viral loads of polyomaviruses BKPyV, JCPyV, MCPyV, TSPyV and NJPyV and hepatitis viruses HBV, HCV and HEV in HIV-infected patients in China

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Xianfeng Zhou ◽  
Kenji Nakashima ◽  
Masahiko Ito ◽  
Xiaoling Zhang ◽  
Satoshi Sakai ◽  
...  
Keyword(s):  
Hiv Positive ◽  
Hepatitis Viruses ◽  
Positive Group ◽  
Viral Loads ◽  
Hiv Rna ◽  
Cell Counts ◽  
Cd4 Cell Counts ◽  
Significant Difference ◽  
Potential Risk Factors ◽  
Cd4 Cell

Abstract Human polyomaviruses (PyVs) and hepatitis viruses are often more prevalent or persistent in human immunodeficiency virus (HIV)-infected persons and the associated diseases are more abundant than in immunocompetent individuals. Here, we evaluated seroreactivities and viral loads of human PyVs and hepatitis viruses in HIV/AIDS patients and the general population in China in the combination antiretroviral therapy (cART) era. A total of 810 HIV-1-infected patients and age- and sex-matched HIV-negative individuals were enrolled to assess seroprevalence of PyVs BKPyV, JCPyV, MCPyV, TSPyV, and NJPyV and hepatitis viruses HBV, HCV, and HEV. 583 (72%) patients received cART, and among them, 31.2% had undetectable HIV RNA. While no significant difference was observed in prevalence of anti-PyV antibodies between HIV-positive and -negative groups, serum DNA positivity and DNA copy level of MCPyV were higher in the HIV-positive group. Among HIV-infected patients, BKPyV DNA positivity was significantly higher in patients with CD4 + cell counts < 200 cells/mm3 compared to those with CD4 + cell counts > 500 cells/mm3, suggesting possible reactivation caused by HIV-induced immune suppression. Higher HBV and HCV seropositivities but not HEV seropositivity were also observed in the HIV-positive group. Further correlation analyses demonstrated that HBV and HEV are potential risk factors for increased prevalence of PyV infection.

Activation-Resistant Homozygous Protein C R229W Mutation Causing Familial Perinatal Intracranial Hemorrhage

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 3587-3587
Author(s):  
Abdulrahman Alsultan ◽  
Andrew J. Gale ◽  
Kadijah Kurban ◽  
Mohammed Khalifah ◽  
Fahad B. Albadr ◽  
...  
Keyword(s):  
Intracranial Hemorrhage ◽  
Protein C ◽  
Conflicts Of Interest ◽  
Brain Mri ◽  
Purpura Fulminans ◽  
Amidolytic Activity ◽  
Protein Z ◽  
History Of ◽  
Hands And Feet ◽  
The Brain

Abstract Two first-degree cousins presented with similar phenotype characterized by neonatal intracranial hemorrhage and subsequent onset of thrombosis at the age of four months. One girl, now 9 yr old, was a full term baby presenting at 13 days of age with seizures and brain CT showing intracranial hemorrhage. At 4 months of age, she presented with multiple thrombotic lesions over both hands and feet that required extensive debridement and improved with anticoagulation and plasma replacement. She has been on enoxaparin with no new lesions afterward. At 9 years of age, protein C amidolytic activity (STACHROM® protein C) was 61% (nl 70-140%) and protein C antigen (ELISA) was 57% (nl 70-140%). Thrombophilia work up was otherwise normal. The second child is a 1 yr old boy who was delivered by cesarean section because of fetal distress. The mother gave history of decreased fetal movement for few weeks prior to his birth and was noted to be hypotonic. Brain MRI in the first week of life showed massive subacute hemorrhage in the brain parenchyma and upper spinal canal. Bleeding stopped with appropriate supportive care. He did not have purpura fulminans or any evidence of thrombosis during the neonatal period. At 4 months of age, a ventriculoperitoneal shunt was placed because of hydrocephalus and post operatively he developed thrombotic lesion in his left foot that resolved after starting enoxaparin and plasma replacement. He remains on enoxaparin with no new significant lesions. At 10 months of age, protein C amidolytic activity was 59% and protein C antigen was 73%. Both patients suffer from severe permanent neurological deficit and blindness. Dx of protein C homozygous deficiency was established after exome sequencing of the older child revealed a homozygous variant in exon 9 of PROC gene c.811 C>T (R271W equivalent to R229W in mature protein C numbering). Sanger sequencing validated this mutation. Both patients were homozygous (T/T) while tested parents and two siblings were heterozygous (C/T), and 55 controls were normal (C/C). No family history of thrombosis among family members who are heterozygous for this mutation was found. Complete exome sequence analysis also showed no mutations for ATIII, protein S, factors V or VIII, prothrombin, plasminogen, protein Z, or any ADAMTS genes. The R229W mutation is located in the calcium binding loop of protein C's protease domain that mediates thrombomodulin (TM) interactions. To define functional abnormalities caused by the patients' mutation, recombinant protein C mutants R229W, R229Q and R229A were studied. Each was strikingly defective in rate of activation by thrombin:TM, showing an activation rate that was only 1%, 2% and 4%, respectively, compared to wildtype protein C. Once activated, each activated protein C (APC) mutant was moderately affected, showing a 50% reduction in anticoagulant activity and in rate of cleavage of purified factor Va at Arg506. The amidolytic activities were less affected and close to wildtype APC. The plasma half-lives were similar to wildtype APC. These properties of recombinant R229W protein C strongly suggest a severe in vivo deficit in these children for generation of APC, implying a severe deficiency of APC in spite of half-normal levels of protein C zymogen. As routine coag assays utilize snake venom protease, they fail to detect TM-activation-resistant protein C mutants. In summary, homozygous protein C R229W mutation in two related cousins was associated with significant leaky brain blood vessels in the perinatal period and significant neurological insult even prior to the first evidence of clinical thrombosis. This highlights the importance of protein C and APC in maintaining the integrity of the brain vascular endothelium in humans. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Influence of HIV Infection on the Natural History of Hepatocellular Carcinoma: Results From a Global Multicohort Study

2019 ◽  
Vol 37 (4) ◽  
pp. 296-304 ◽  
Author(s):  
David J. Pinato ◽  
Elias Allara ◽  
Ting-Yi Chen ◽  
Franco Trevisani ◽  
Beatriz Minguez ◽  
...  
Keyword(s):  
Hepatocellular Carcinoma ◽  
Geographical Origin ◽  
Geographic Origin ◽  
Hiv Positive ◽  
Hiv Seropositivity ◽  
Hiv Rna ◽  
Cell Counts ◽  
Class B ◽  
History Of ◽  
Anticancer Treatment

PURPOSE Conflicting evidence indicates that HIV seropositivity may influence the outcome of patients with hepatocellular carcinoma (HCC), a leading cause of mortality in people with HIV. We aimed to verify whether HIV affected the overall survival (OS) of patients with HCC, independent of treatment and geographic origin. PATIENTS AND METHODS We designed an international multicohort study of patients with HCC accrued from four continents who did not receive any anticancer treatment. We estimated the effect of HIV seropositivity on patients’ OS while accounting for common prognostic factors and demographic characteristics in uni- and multivariable models. RESULTS A total of 1,588 patients were recruited, 132 of whom were HIV positive. Most patients clustered within Barcelona Clinic Liver Cancer (BCLC) C or D criteria (n = 1,168 [74%]) and Child-Turcotte-Pugh (CTP) class B (median score, 7; interquartile range [IQR], 3). At HCC diagnosis, the majority of patients who were HIV-positive (n = 65 [64%]) had been on antiretrovirals for a median duration of 8.3 years (IQR, 8.59 years) and had median CD4+ cell counts of 256 (IQR, 284) with undetectable HIV RNA (n = 68 [52%]). OS decreased significantly throughout BCLC stages 0 to D (16, 12, 7.5, 3.1, and 3 months, respectively; P < .001). Median OS of patients who were HIV-positive was one half that of their HIV-uninfected counterparts (2.2 months [bootstrap 95% CI, 1.2 to 3.1 months] v 4.1 months [95% CI, 3.6 to 4.4 months]). In adjusted analyses, HIV seropositivity increased the hazard of death by 24% ( P = .0333) independent of BCLC ( P < .0001), CTP ( P < .0001), α-fetoprotein ( P < .0001), geographical origin ( P < .0001), and male sex ( P = .0016). Predictors of worse OS in patients who were HIV-positive included CTP ( P = .0071) and α-fetoprotein ( P < .0001). CONCLUSION Despite adequate antiretroviral treatment, HIV seropositivity is associated with decreased survival in HCC, independent of stage, anticancer treatment, and geographical origin. Mechanistic studies investigating the immunobiology of HIV-associated HCC are urgently required.

scholarly journals Neurosyphilis Presenting As Status Epilepticus, Successively Hemiparesis And Aphasia

2021 ◽  
Author(s):  
Yunwen Qi ◽  
Zongze Jiang ◽  
Xiong Zhang ◽  
Daixin Xie ◽  
Zhiyou Cai
Keyword(s):  
Status Epilepticus ◽  
Brain Mri ◽  
Case Presentation ◽  
Fluid Analysis ◽  
Penicillin Therapy ◽  
History Of ◽  
No Gold Standard ◽  
Todd’S Paresis ◽  
The Brain ◽  
Better Than

Abstract Background: Neurosyphilis can occur anytime and present with a myriad of symptoms. Lissauer form of General Paresis Insane (GPI) is rare. We can learn more about this form of GPI through this case report.Case Presentation: The patient presented as status epilepticus, successively as hemiparesis and aphasia, which may be considered as the Todd's paresis or stroke. By performing the reactive serum rapid plasma reagent test and cerebrospinal fluid analysis, as well as the brain MRI results, we made the diagnosis as Lissauer form of GPI. The patient was started on intravenous penicillin for a total of 14 days. After that, the patient appeared with marked clinical improvement. Cognitive ability was better than before. Conclusions: GPI typically has a progressive course and normally presents 10 to 30 years after the initial infection. The manifestations of this patient and his suspicious history of Transient Ischemic Attacks (TIA) may mislead to the diagnosis of Todd's paresis or stroke. The prevalence of syphilis is rising again in recent years. To date, there is no gold standard for the diagnosis of neurosyphilis. Early diagnosis is of great importance as effective penicillin therapy is available.

scholarly journals 270. New Onset Seizure Presented as Neurosyphilis

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S241-S242
Author(s):  
Shwe S Phyo ◽  
Cho T Zin ◽  
Zeyar Thet
Keyword(s):  
Brain Mri ◽  
Venereal Disease ◽  
False Negative ◽  
Treponema Pallidum ◽  
Clonic Seizure ◽  
Penicillin G ◽  
Serological Tests ◽  
History Of ◽  
The Brain ◽  
New Onset

Abstract Background The term “neurosyphilis” refers to infection of the central nervous system (CNS) by Treponema pallidum. It can occur at any time after initial infection. Early in the course of syphilis, the most common forms of neurosyphilis involve the cerebrospinal fluid (CSF), meninges, and vasculature (asymptomatic meningitis, symptomatic meningitis, and meningovascular disease). Late in disease, the most common forms involve the brain and spinal cord parenchyma (general paralysis of the insane and tabes dorsalis). Methods A 31-year-old man who suddenly developed a new onset generalized tonic clonic seizure, was admitted to the emergency department. He had no history of epilepsy and denied any vision or gait problems. The brain MRI showed no abnormalities. He had a history of rapid plasma reagent (RPR) titer 1:32 and a positive fluorescent treponemal antibody absorption (FTA-ABS) test in 2017. However, the RPR result was non-reactive when he retested a week later and therefore was not diagnosed with syphilis and did not get treated at that time. His most recent RPR titer was 1:16. HIV serology and other STD tests were all negative. His wife and his 3 kids were negative for syphilis. Due to serological evidence of syphilis and neurological symptoms, we arranged him to get a lumbar puncture to rule out neurosyphilis. Results His CSF study showed positive venereal disease research laboratory (VDRL), WBC cell count 44 cells/ul (lymphocytes 80%, Neutrophil 20%), Glucose 50 mg/dl, Protein 75 mg/dl. Based on the CSF study, he was diagnosed with neurosyphilis and was treated with intravenous Penicillin G 3-4 million units every 4 hours for 14 days, followed by Benzathine Penicillin 2.4million units intramuscularly on day 21. Conclusion This is an unusual case because his false negative RPR result has hindered the prompt diagnosis and management of syphilis. RPR is a nontreponemal test and therefore it is not always reliable as a diagnostic criteria. False negatives in RPR may occur in certain conditions such as in early primary or in late stage syphilis and prozone phenomenon. This case illustrates the importance of using a reverse sequence algorithm in diagnosing syphilis. Thorough history taking is also crucial in conjunction with serological tests to determine the diagnosis and to ensure appropriate treatment. Disclosures All Authors: No reported disclosures

scholarly journals Spinal Syphilitic Gumma: A Rare Presentation of an Old Disease

2021 ◽  
Vol 2021 ◽  
pp. 1-6
Author(s):  
Dominic Worku ◽  
Angela Houston ◽  
Catherine Cosgrove ◽  
Laura Byrne
Keyword(s):  
White Cell Count ◽  
Treponema Pallidum ◽  
Hiv Positive ◽  
High Dose ◽  
Molecular Testing ◽  
Rare Presentation ◽  
Csf Analysis ◽  
Positive Individual ◽  
History Of ◽  
Magnetic Resonance Imaging Mri

Syphilis is an ancient condition which still is of global concern today. Despite better awareness amongst clinicians and improving diagnostics, it remains likely underdiagnosed in part because of its namesake the ‘great imitator.’ While many patients suffer primary or secondary disease, tertiary syphilis characterised by gumma is rare, especially in the context of neurosyphilis. Here, we report a rare case of a well-controlled human immunodeficiency virus- (HIV-) positive gentleman with a history of previous syphilis and epilepsy who presented with progressive left leg weakness leading to immobility and altered bowels and, on neurological examination, Brown-Sequard syndrome. Magnetic resonance imaging (MRI) of the spine revealed two peripherally enhancing cavitating lesions at T4-T5 with associated meningeal thickening and cord oedema. Cerebrospinal fluid (CSF) analysis revealed high protein (3.07 g/dL) and white cell count (7 × 109/L) with negative cryptococcal antigen, tuberculosis molecular testing (GeneXpert), microscopy and culture, and viral polymerase chain reaction (PCR). CSF serology was positive for Treponema pallidum particle agglutination (TPPA) 10240 and RPR 1 in 2 suggesting active disease. While TB treatment had been started prior to these investigations on day 11, 14-day high-dose benzylpenicillin therapy commenced. Repeat MRI of the spine at days 12 and 22 showed incremental improvements in all parameters which correlated with improving functionality and neurology. According to our literature search, this represents the 13th case recorded for spinal syphilitic gumma and the only case recorded in a HIV-positive individual and adds to the evidence that, in the absence of rapidly changing neurology, medical management can lead to good clinical outcomes.

Pretemporal transcavernous transtentorial approach for left pontine glioma

2019 ◽  
Vol 1 (2) ◽  
pp. V22
Author(s):  
Chih-Hsiang Liao ◽  
Chun-Fu Lin ◽  
Wei-Hsin Wang ◽  
Jui-To Wang ◽  
Shao-Ching Chen ◽  
...  
Keyword(s):  
Brain Mri ◽  
Myxopapillary Ependymoma ◽  
Pontine Glioma ◽  
Tumor Removal ◽  
Unsteady Gait ◽  
History Of ◽  
Surgical Corridor ◽  
Pathological Report ◽  
The Brain ◽  
Transtentorial Approach

A 39-year-old man, who had a history of spinal myxopapillary ependymoma with cerebrospinal seeding status post twice operations and radiation therapy, presented with aggravating headaches, diplopia, dysphagia, and unsteady gait for 2 weeks. The brain MRI revealed a parenchymal lesion at the left aspect of the pons, about 2.8 × 2.3 × 3.2 cm3. The patient underwent a pretemporal transcavernous transtentorial approach for tumor removal. The pathological report showed an anaplastic astrocytoma. In this approach, a wider surgical corridor was obtained by opening the Meckel’s cave and cutting the tentorium, via which a safe entry point into the pons could be determined with neuromonitoring. In the authors’ opinion, this approach is safe and effective in selected ventrolateral pontine gliomas.The video can be found here: https://youtu.be/sUt-9QFGgCI.

A rare presentation of plasmablastic lymphoma as cutaneous nodules in an immunocompromised patient

2016 ◽  
Vol 28 (6) ◽  
pp. 623-625 ◽  
Author(s):  
Selvin Sundar Raj Mani ◽  
Thomas Kodiatte ◽  
Manjeera Jagannati
Keyword(s):  
Gastrointestinal Tract ◽  
Oral Cavity ◽  
Hospital Stay ◽  
Immunocompromised Patient ◽  
The Body ◽  
Plasmablastic Lymphoma ◽  
Hiv Positive ◽  
Rare Entity ◽  
Tumour Burden ◽  
Rare Presentation

Plasmablastic lymphoma is a rare entity accounting for around 2.7% of all AIDS-related lymphomas. The oral cavity and gastrointestinal tract are the most common sites involved. We report a case of a 34-year-old HIV-positive woman with a rare presentation of cutaneous nodules all over the body. Due to overwhelming tumour burden, she developed tumour lysis syndrome during her hospital stay and succumbed to the illness.

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