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Cytomegalovirus encephalitis in acquired immunodeficiency syndrome (AIDS)
N R Holland1, C Power, V P Mathews
1Department of Neurology, Johns Hopkins University, Baltimore, MD 21287-7609.
Abstract:
Cytomegalovirus encephalitis (CMVE) is frequently diagnosed only at postmortem because its specific clinical features have not been fully identified. We have described the clinical, radiologic, and laboratory features of CMVE in a retrospective review of 14 autopsy-confirmed cases of CMVE and compared them with a control group of demented acquired immunodeficiency syndrome (AIDS) patients without CMVE. CMVE was more common among homosexual men, and a subacute onset was more typical (mean duration of presenting symptoms was 3.5 weeks versus 18 weeks in demented controls). Median survival times were 4.6 weeks for CMVE and 28 weeks for controls. CMVE was accompanied by prominent systemic CMV infection at autopsy, including CMV adrenalitis (92%), CMV pneumonitis (42%), systemic Mycobacterium avium intracellulare (MAI; 58%), and CMV retinitis (58%). Hyponatremia and MAI bacteremia were found in 58% of CMVE cases. Polymerase chain reaction (PCR) of CSF samples identified CMV genome in 33% of CMVE cases. CMVE was associated with periventricular enhancement on CTs and periventricular lesions with meningeal enhancement on MRI scans. CMVE should be particularly suspected in homosexual men presenting with subacute encephalopathy who have had AIDS for more than 1 year and have a history of systemic CMV infection. Other features supporting the diagnosis of CMVE include periventricular lesions, hyponatremia, and identification of CMV genome in CSF by PCR.
Insights
Cytomegalovirus encephalitis (CMVE) is difficult to diagnose during life. Key indicators include subacute encephalopathy in AIDS patients, systemic CMV, and specific brain imaging findings.
Area of Science:
- Neurology
- Infectious Diseases
- Virology
Background:
- Cytomegalovirus encephalitis (CMVE) is often diagnosed postmortem due to unclear clinical features.
- Acquired immunodeficiency syndrome (AIDS) patients are at risk for opportunistic infections like CMVE.
Purpose of the Study:
- To identify and describe the clinical, radiologic, and laboratory features of CMVE.
- To differentiate CMVE from other causes of dementia in AIDS patients.
Main Methods:
- Retrospective review of 14 autopsy-confirmed CMVE cases.
- Comparison with a control group of demented AIDS patients without CMVE.
- Analysis of clinical presentation, autopsy findings, and diagnostic tests including PCR of CSF and neuroimaging (CT/MRI).
Main Results:
- CMVE was more prevalent in homosexual men with a subacute onset (3.5 weeks vs. 18 weeks in controls) and shorter survival (4.6 weeks vs. 28 weeks).
- Common autopsy findings included systemic CMV infection (adrenalitis, pneumonitis) and Mycobacterium avium intracellulare (MAI) coinfection.
- Hyponatremia, MAI bacteremia, and CMV DNA in CSF (33%) were observed in CMVE cases.
- Neuroimaging showed periventricular enhancement on CT and periventricular lesions with meningeal enhancement on MRI.
Conclusions:
- CMVE should be suspected in homosexual men with AIDS (duration >1 year) presenting with subacute encephalopathy and a history of systemic CMV infection.
- Periventricular lesions on imaging, hyponatremia, and CMV detection in CSF support the diagnosis.
- Early diagnosis can be challenging but is crucial for patient management.