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Two key things to ALWAYS remember in the management of HIV infected patients
HIV infection does not prevent the development of a non-HIV related problem Opportunistic problems are related to the CD4 (+) cell count.
If the count is > 200-300, the problem is probably not related to the HIV infection.
Toxoplasmosis
The most common in the west of the CNS space occupying lesions in a person with a CD4 count <200 (usually < 100)
Prevalence of toxoplasma CNS disease is unknown in Botswana Seroprevalence is low
Reactivation disease
Cat feces Meat
Toxoplasmosis
Other than a biopsy there is no good diagnostic test
Antibody testing is very non-specific and occasionally insensitive Usual diagnostic test is response to Rx
Toxoplasmosis
Things that make toxo unlikely
Negative toxo serology Patient taking Co-trimoxazole prophylaxis CD4 count > 100
Treatment
Pyrimethamine (50-100 mg QD) plus leucovorin and Sulfadiazine (1 gm QID) Alternatives
Fansidar 2-3 daily Atovoquone 750 mg QID Azithromycin 1200 mg QD Clindamycin 600 QID Co-trimoxazole 10mg/kg/day of trimethoprim Dapsone 100 mg QD
TOXOPLASMOSIS
Diagnosis by biopsy
Tuberculoma
Presents like any other mass lesion CT appearance
Looks like an abscess or a tumor
Nothing characteristic about CT appearance May be ring enhancing
CSF
Non-specifically abnormal or completely normal
Diagnosis: brain biopsy Treatment: standard drugs though the duration has not been studied
Many people treat longer than pulmonary TB
CT
Ring enhancing lesion(s)
CSF
Non-specifically abnormal
Anti-microbiol management
If known single bacterium: treat the bug If mixed or presumed mixed focus
Chloramphenicol 50 mg/kg/day in 4 divided doses OR Cefotaxime 2 gm Q4H and metronidazole 500 mg Q6H
Nocardia
Nocardia brain abscess
Presents like other brain abscesses, but some predisposition to involve the brain stem Can only be diagnosed by biopsy
Often diagnosed presumptively by finding nocardia elsewhere
Treatment
Initial
Cefotaxime 2 gm Q6H and Amikacin 7.5mg/kg Q12H or Co-trimoxazole15 mg/kg/day IV x 3-6 weeks
Continuation
Co-trimoxazole 480/2400 BD PO x 6-12 months
Syphilis (gumma)
Rare manifestation Presents as a mass
Looks like a brain tumor
Cryptococcal Meningitis
Clinical Presentations
Typical
Subacute onset of fever and headache Photophobia and/or meningeal signs in only 25%
Less typical
Seizures Confusion Progressive dementia Visual or hearing impairment FUO
Diagnosis
Very rare if CD 4 (+) cell count is > 100 CSF: may be deceptively normal Serum CRAG: > 99% sensitive in AIDS patients
Cryptococcal Meningitis
In 2003 there were 193 (+) CSF cultures for cryptococcus from PMH *
Leucocytes
No leucocytes in 31% Only 1-10 leucocytes in 23% 7% had > 250 leucocytes
30% of these had predominately PMNs
*Bisson et al
CRYPTOCOCCUS
Consolidation
Fluconazole 400 mg/day x 6-10 weeks then
Suppression
Fluconazole 200 mg/day x ?
Steroids: ?
Encephalitis
Needs to be considered in the differential diagnosis of acute encephalitis
Remember as with other manifestations of the acute infection HIV antibody may be negative. So consider:
Seroconversion PCR P24 antigen
HIV Dementia
Diagnosis of exclusion that is supported by
Atrophy on CT scan CSF normal or elevated protein
Typical feature is withdrawn appearance but can be anything Can have a dramatic response to ARVs
Tuberculous Meningitis
Similar presentation to cryptococcal meningitis, though can be a bit more acute Diagnosis made by CSF, but insensitive
Typically lymphocytic predominance, but may have PMNs early Moderate low glucose AFB smear (+) in 5% Culture (+) in 50%
Usually diagnosed by finding a sub-acute onset lymphocytic meningitis that is cryptococus and cytology negative. Treatment the same as pulmonary TB
CNS Syphilis
Secondary
Aseptic meningitis
Tertiary
Meningovascular General Paresis Tabes Dorsalis Asymptomatic neurosyphilis
Toxoplasma encephalitis
Toxoplasma may occasionally present as diffuse CNS disease rather than an abscess
CMV encephalitis
Relatively rare Diagnosed by PCR on CSF, NOT BY SEROLOGY
CD 4 > 200
Glucose Calcium
CD 4 < 200
If Focal Signs
If No Focal Signs
Image
Lumbar Puncture
India Ink
Imaging Negative
Cryptococcal Ag
Cytology
Imaging Positive
Response
No Response
Continue Treatment
Treat for TB
Response
No Response
Continue Treatment
Brain Biopsy
Recurring Themes
As with all problems in HIV patients the differential diagnosis is CD 4 count dependent As with all problems in HIV patients we must never forget to consider non-HIV related explanations for the symptoms CSF results are generally not helpful
Cryptococcus is an exception