ACQUIRED HUMAN IMMUNODEFICIENCY ASSOCIATED ILLNESS: THE FIRST REPORT OF THREE NEUROSURGICAL CASES IN IRAN
A. Amirjamshidi MD , S.M. Ramak Hashemi MD, I. Khalatbary MD
Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
Acquired immunodeficiency syndrome is a major health problem in every community. We recently encountered 3 such cases in our neurosurgical department who proved to be HIV positive after surgery took place. All 3 patients were operated upon by the authors and we hereby report our experiences and findings.
Keywords • Acquired Immunodeficiency Syndrome (AIDS) • Human Immunodeficiency Virus(HIV) • Toxoplasmosis
Introduction
Nearly half of the symptomatic AIDS patients have neuropathologic diseases, demanding the clinician to be aware of the different neurological manifestations of AIDS and possible effective methods of diagnosis and treatment of such illnesses. We recently encountered 3 such cases in our neurosurgical department who proved to be HIV positive after surgery. To our knowledge, this was the first report from neurosurgery departments in Iran, which is a low prevalence country for AIDS.
Case Reports
Case 1. A 53-year-old man had developed headache in the past 3 months and had experienced a few epileptic episodes during the last 2-3 weeks.
The patient was a divorcee, had lived abroad for some years, and had a history of heterosexual promiscuity.
In the physical examination, only bilateral papilledema and right hemianopia were the positive findings. Routine paraclinical studies including white cell count, sedimentation rate, and chest X-ray were all normal. MRI showed a hypo-intense lesion on T1-weighted image and a hyper-intense lesion in T2-weighted image, on the right parieto-occipital area, enhancing non homogenously after contrast material injection (Fig. 1).
The lesion was located subcortically, dark gray in color, and meaty in texture. There was no necrosis or cyst formation and it could be excised totally. The post-operative course was complicated by some abnormal behavior changes, which improved over the course of the first post-operative week. Histopathology confirmed the diagnosis of toxoplasmosis.
A serology test for HIV infection was performed at this time, which proved positive, but the patient left the hospital without any notification.
Case 2. A 19-year-old man was admitted to the emergency department in a confused state. Headache and behavior changes had been the major positive points during the previous 6 months. He had married in Iran and had lived in African countries for several years.
On admission he was disoriented in place and time, although there were no speech disturbances.
Cranial nerves were intact and severe papilledema was detectable bilaterally. The routine paraclinical data was within normal range.
A contrast CT-scan revealed an area of a homogeneously enhanced mass with marked peritumoral edema in the right temporal region (Fig. 2)
A right temporal craniotomy was performed and a meaty and partly necrotic intra-axially located tumor was removed feasibly. The tumor was a glioblastoma multiforme and the patient underwent whole cranial irradiation after the surgery. He died 6 months later with tumor recurrence, malaise and upper respiratory tract infection.
Case 3. A 32-year-old man complaining of headache, nausea and vomiting of 4 months duration, and recent mental change was admitted to the neurology department. Severe bilateral papilledema was the only clinical finding. Brain CT-scan (Fig. 3a) and MRI (Fig. 3b), both revealed a focus of edema involving the right frontoparietal region affecting at least two adjacent gyri. With the impression of a gliomatous tumor, a right frontoparietal craniotomy was performed and the least obvious tumoral tissue was found. There was a diffuse white matter edema.
Several biopsy specimens were taken and the dura was closed using a pericranial graft patch. The pathological examination revealed an edematous brain compatible with ischemic white and gray matter tissue, without any tumoral infiltration. The post-operative course became complicated with deterioration in the level of consciousness and the patient died after 5 days. The serodiagnostic test for HIV infection turned to be positive.
Discussion
The most common CNS disorders in HIV-positive patients include HIV-encephalopathy, cryptococcal meningitis, Toxoplasma abscess, non-HIV viral encephalitis, and primary CNS lymphoma. The less frequently occurring disorders are: progressive multifocal leukoencephalopathy (PML), candidal abscess, mycobacterial meningitis or abscess, Kaposi’s sacroma, and gliomatous tumor.
Intracranial space occupying lesions are found in approximately 10% of AIDS patients with CNS symptoms.1-4 Toxoplasmosis and primary CNS lymphomas are the most common pathological entities. 5,6 We encountered one case of Toxoplasmosis, a glioma, and one mass lesion which turned to be an ischemic vasculopathy.
Toxoplasma accounts for 50-70% of all mass lesions in this population. These mass lesions may produce acute focal or diffuse meningitis, encephalitis, and tissue destruction. 5,6
The usual clinical presentations include lethargy, cognitive impairment, seizure and other focal neurological deficits, as was seen in our cases. Certain CT- or MRI findings may be highly suggestive of Toxoplasma infection, i.e. multiple small uniformly ring-enhancing lesions with moderate to marked surrounding edema, in the basal ganglia and subcortical regions.7,8 However a solitary lesion may also be a Toxoplasma abscess or granuloma, as in our case (Fig 1). The vast majority of patients with Toxoplasmosis respond clinically to an empirical therapy with Pyrimethamine and Sulfadiazine, although life-long suppressive therapy is required to prevent reinfection.
If a HIV-patient develops intra-cerebral or brain stem symptoms, a contrast enhanced brain CT or MRI should be performed. If the findings are either normal, or show brain atrophy, meningeal enhancement and hydrocephalus, a CSF evaluation should be performed monthly. Further treatment depends on the results of CSF studies or progression of hydrocephalus. For a space- occupying lesion, the decision depends on whether the lesion is single or multiple and whether it has produced a "mass effect"or not. In the patients with mass lesion and good general condition, a three-week empirical therapy with Sulfadiazine and Pryimethamine for presumed Toxoplasmosis may resolve all or some of the lesions. If the lesion did not resolve, a stereotactic biopsy, or in the case of herniation, decompression and open biopsy should be performed. Further treatment will depend on the etiology of the space-occupying lesion.3,7,9-14
References