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AIDS-associated cytomegalovirus infection mimicking central nervous system tumors: a diagnostic challenge
A Moulignier1, J Mikol, G Gonzalez-Canali
1Services des Maladies Infectieuses et tropicales, Hôpital de l'Institut Pasteur, Paris.
Abstract:
We reviewed cases of cytomegalovirus (CMV) infection of the central nervous system (CNS) that initially masqueraded as tumors in 37 of 543 consecutive patients infected with human immunodeficiency virus (HIV) and CMV who were seen at the Pasteur Institute Hospital and Saint-Louis Hospital (Paris) between 1992 and 1994. We detail the clinical features of three patients who presented with ring-enhanced space-occupying lesions mimicking CNS tumors. They were all profoundly immunodepressed (mean CD4 cell count, 13/mm3). Magnetic resonance imaging (MRI) showed enlargement of the spinal cord in one case, consistent with a space-occupying lesion and showing gadolinium enhancement; in the other two cases, ring-enhanced mass lesions were seen in the cerebral hemispheres. In all three cases marked edema and a mass effect were present. Image-guided stereotactic biopsies confirmed the diagnosis of CMV infection. The three patients' conditions improved with specific therapy. MRI showed enhanced focal intraparenchymal lesions consistent with marked focal necrosis, probably related to the severity of immunodepression, as HIV infection had been diagnosed several years previously. CMV infection should be considered as a cause of ring-enhanced space-occupying mass lesions in patients with HIV-1 infection. Earlier identification of these unusual tumorlike forms of CMV infection by means of MRI should result in improved outcome.
Insights
Cytomegalovirus (CMV) central nervous system (CNS) infections can mimic tumors in patients with human immunodeficiency virus (HIV). Early MRI identification of these unusual CMV lesions can improve patient outcomes.
Area of Science:
- Neurology
- Infectious Diseases
- Oncology
Background:
- Cytomegalovirus (CMV) infection is a significant opportunistic infection in individuals with human immunodeficiency virus (HIV).
- Central nervous system (CNS) involvement by CMV can present with diverse and atypical clinical manifestations.
Observation:
- This study reviewed 37 cases of CMV CNS infection mimicking tumors in HIV-positive patients.
- Three patients presented with ring-enhanced, space-occupying lesions on MRI, suggestive of CNS tumors.
- These patients were severely immunocompromised with low CD4 cell counts.
Findings:
- MRI revealed mass lesions with edema and mass effect, including spinal cord enlargement and cerebral hemisphere lesions.
- Image-guided stereotactic biopsies confirmed CMV infection as the cause of these tumor-like lesions.
- Specific anti-CMV therapy led to clinical improvement in all three patients.
Implications:
- CMV infection should be considered in the differential diagnosis of ring-enhanced space-occupying lesions in HIV-1 infected individuals.
- Magnetic resonance imaging (MRI) plays a crucial role in the early identification of these unusual, tumor-like CMV presentations.
- Timely diagnosis and treatment of CNS CMV infections can lead to better patient outcomes and potentially prevent misdiagnosis as primary CNS tumors.