Cytomegalovirus ventriculoencephalitis in AIDS patients

We report 4 autopsy-proven cases of cytomegalovirus ventriculoencephalitis (CMV-VE) and a further case with dramatic clinical and radiological response to ganciclovir therapy. The diagnoses were based upon clinical features, cerebrospinal fluid (CSF) examination and either brain computerized tomography (CT) or magnetic resonance imaging (MRI), and confirmed by autopsy findings in 4 cases. All patients had previously had an AIDS-defining condition. CMV retinitis was diagnosed in 3 patients, 2 of them before the onset of encephalitis. CMV viremia was present in 4 patients. Examination of CSF demonstrated elevated protein and hypoglycorachia in all cases. CSF culture was negative for CMV in 3 of 3 patients. Periventricular enhancement was detected by MRI in 2 of 3 patients, but in only 1 of 5 patients by CT. Three patients received ganciclovir and 2 patients foscarnet therapy. All 4 patients died. Pathologic examination revealed periventriculitis with ependymal necrosis and CMV intranuclear inclusion bodies all 4 patients. One showed a marked neurological improvement and radiological resolution by MRI after 4 weeks of ganciclovir therapy. We conclude that CMV-VE should be suspected in HIV-infected patients who present with altered neurological status, CMV viremia or retinitis, hypoglycorachia and ventriculitis as demonstrated by MRI. Although more effective therapy is needed, ganciclovir may be beneficial, as shown in one of our patients.