Objective To compare central nervous system (CNS) outcomes in participants treated during acute HIV infection with standard combination antiretroviral therapy (cART) vs. cART plus integrase inhibitor and CCR5 antagonist (cART+). Design 24-week randomized open-label prospective evaluation. Method Participants were evaluated then randomized to initiate cART (efavirenz, tenofovir, and either emtricitabine or lamivudine) vs. cART+ (cART plus raltegravir and maraviroc) during acute HIV and re-evaluated at 4, 12 and 24 weeks. We examined plasma and CSF cytokines, HIV RNA levels, neurological and neuropsychological findings, and brain MRS across groups and compared to healthy controls. Results At baseline, 62 participants were in Fiebig stages I-V. Randomized groups were similar for mean age (27 vs. 25, p = 0.137), gender (each 94% male), plasma log10 HIV RNA (5.4 vs. 5.6, p = 0.382), CSF log10 HIV RNA (2.35 vs. 3.31, p = 0.561), and estimated duration of HIV (18 vs. 17 days, p = 0.546). Randomized arms did not differ at 24 weeks by any CNS outcome. Combining arms, all measures concurrent with antiretroviral treatment improved, for example, neuropsychological testing (mean NPZ-4 of -0.408 vs. 0.245, p<0.001) and inflammatory markers by MRS (e.g. mean frontal white matter (FWM) choline of 2.92 vs. 2.84, p = 0.045) at baseline and week 24, respectively. Plasma neopterin (p<0.001) and interferon gamma-induced protein 10 (IP-10) (p = 0.007) remained elevated in participants compared to controls but no statistically significant differences were seen in CSF cytokines compared to controls, despite individual variability among the HIV-infected group. Conclusions A 24-week course of cART+ improved CNS related outcomes, but was not associated with measurable differences compared to standard cART.
A spontaneous intramural esophagogastric hematoma developed in a patient with hemophilia A. The hematoma did not resolve after antihemophiliac factor replacement but ruptured into the stomach causing massive gastrointestinal bleeding. The associated enlarged right tracheobronchial gland and the histopathological finding of fibrocaseating granuloma at the esophagogastric junction indicated that the primary disorder was esophageal tuberculosis. The whole process responded rapidly to antituberculous treatment.
Leiomyosarcomas of the central nervous system are extremely rare; however they are becoming more prevalent in immunocompromised patients. The authors present MRI (Magnetic Resonance Imaging) of six cases of pathological proved leiomyosarcomas of the central nervous system in patients infected with human immunodeficiency virus. MR images of 4 cases of intraspinal leiomyosarcoma showed lobulated masses expanding multilevel of neural foramina with extradural and intradural extension, giving dumbbell appearance which mimic neurofibroma. Two cases of intracranial leiomyosarcoma revealed a mass at the left cavernous sinus involving prepontine cistern in one case and two lesions in the other case showing masses with dural based appearance at the region of the planum sphenoidale and the posterior aspect of the falx cerebri which mimiced a meningioma. The leiomyosarcoma should be included in the differential diagnosis of extra-axial CNS lesions in HIV-infected patients.
Objective: To determine the incidence, timing, and severity of neurologic findings in acute HIV infection (pre-antibody seroconversion), as well as persistence with combination antiretroviral therapy (cART). Background: Although HIV can cross into the CNS within days of systemic infection, little is known about the vulnerable neuroanatomy or neurologic presentation of acute HIV infection. The current literature on early HIV is skewed towards cases of fulminant neurologic involvement, and does not include systematic evaluations of patients. Methods: Participants identified with acute HIV were enrolled, underwent structured neurologic interviews and examinations, immediately initiated cART, and were followed with neurologic evaluations at 4 and 12 weeks. Concurrent brain MRIs, and both viral and inflammatory markers in plasma and CSF were obtained. Results: Median estimated HIV infection duration was 19 days (range: 3-56) at study entry for the 139 participants evaluated. Seventy-three participants (53[percnt]) experienced one or more neurologic finding in the 12 weeks after diagnosis, with one developing a fulminant neurologic manifestation (Guillain-Barrè syndrome). A total of 245 neurologic findings were noted, reflecting cognitive symptoms (33[percnt]), motor findings (34[percnt]), and neuropathy (11[percnt]). Nearly half of the neurologic findings (n=121, 49[percnt]) occurred at diagnosis, prior to cART initiation, and most of these (n=110, 90[percnt]) remitted concurrent with one month on treatment. Only 9[percnt] of neurologic findings (n=22) persisted at 24 weeks on cART. Nearly all neurologic findings (n=236, 96[percnt]) were categorized as mild in severity. No structural neuroimaging abnormalities were observed. Participants with neurologic findings had a higher mean plasma log10 HIV RNA at diagnosis compared to those without neurologic findings (5.9 vs. 5.4; p=0.006). Conclusions: Acute HIV infection is commonly associated with mild neurologic findings that largely remit while on treatment, and may be mediated by direct viral factors. Severe neurologic manifestations are infrequent in treated acute HIV.
Establish criteria for the diameters of normal extraocular muscles using computerized tomography in a Thai population.Diameters of extraocular muscles (medial, lateral, superior complex, and inferior rectus) were calculated for 200 patients on coronal direction of screening paranasal sinuses. The effects of age and sex were also analyzed.Normal ranges for the diameters (mean +/- 2 SDs) of extraocular muscles were 3.7 +/- 0.9 mm for medial rectus, 3.6 +/- 1.2 mm for lateral rectus, 4.0 +/- 1.4 mm for inferior rectus and 3.8 +/- 1.4 mm for the superior group. The mean diameter of the extraocular muscles in male patients was not significantly larger than in female patients (p > 0.05). There was also no statistically significant correlation between age, diameter of each extramuscular muscle and the sum of all four muscles.The present result may help radiologists and ophthalmologists to accurately assess enlargement of the extraocular muscles, particularly in Oriental populations.
Objective: Combination antiretroviral therapy (cART) can suppress plasma HIV RNA to undetectable levels; yet reports indicate persistent HIV-associated neurocognitive disorders (HAND) among treated individuals. We sought to investigate imaging correlates of incomplete cognitive recovery among individuals with chronic HIV. Methods: We used single voxel proton magnetic resonance spectroscopy in 4 regions of the brain to measure changes in neuronal and glia biomarkers in cART-naive subjects before (n = 59, 27 with HAND) and after 12 months of cART. Results: At baseline, we observed elevated total choline (CHO) in the basal ganglia (BG, P = 0.002) and in the posterior cingulate gyrus (PCG, P = 0.022) associated with HIV infection. Myo-inositol (MI) was elevated in the frontal white matter (FWM, P = 0.040). N-acetylaspartate was elevated in the BG (P = 0.047). Using a mixed model approach among all HIV-infected individuals, at 6 months, we observed decreased n- acetylaspartate in FWM (P = 0.031), decreased creatine in PCG (P = 0.026) and increased MI in frontal gray matter (FGM, P = 0.023). At 12 months, we observed an increase in BG MI (P = 0.038) and in FGM (P = 0.021). Compared to those with normal cognition, HAND cases had higher FGM MI (P = 0.014) at baseline. At 12 months, individuals that remained cognitively impaired compared with those without HAND exhibited elevated CHO in the PCG (P = 0.018) and decreased glutamate in both FWM (P = 0.027) and BG (P = 0.013). Conclusions: cART started during chronic HIV is associated with reduced neuronal-glia and inflammatory markers. Alterations in CHO are noted among individuals who remain impaired after 12 months of cART.
Human immunodeficiency virus (HIV) RNA and DNA have been isolated from patient monocytes, an immune cell population that is quite different in several aspects from the canonical T-cell viral target. Because monocytes are migratory and resilient to both natural and synthetic antiviral defenses, knowledge of the contribution of monocyte infection to ongoing viral evolution and spread \textit{in vivo} is of significant interest for drug development and treatment strategies. Using single viral genome sequencing from different peripheral blood compartments and phyloanatomic statistical inference, we demonstrate that productively infected monocytes follow an evolutionary trajectory that is distinct from peripheral T cells during multiple stages of disease progression. Gene flow and selection analysis reveal plasticity in the source of monocyte infection and in the region of the HIV envelope glycoprotein that experiences selection pressure across individuals. The findings, thus, point to a potential reservoir showing a range of infection and transmission dynamics, for which the current universal, T cell-targeted treatment strategies would be inadequate.
Objective: To compare the accuracy of Limited CT with the Full CT as the standard evaluation for inflammatory disease of PNS and the identification of anatomical variations. Methods: From Full CT of PNS, Limited CT were retrieved. Computerized tomographic scans were performed for the preoperative planning of endoscopic sinus surgery (ESS) in 3 tertiary care university hospitals in Thailand. The two types of examinations were reviewed independently and in random order by two experienced radiologists. Using Full CT as the standard, the accuracy of Limited CT were evaluated for 1) the radiologic staging of rhinosinusitis (Lund-Mckay scoring system) and 2) the anatomic variations which are an important landmark for surgical operations in rhinosinusitis. Results: Totally 132 patients were included. Two hundred and sixty four half-faces were reviewed. Lund-McKay radiographic sinus staging system showed 97-99% specificity except for the ostiomeatal complex region. Regarding anatomic variation, Limited CT was able to yield accurate results for the frontal cell type II-IV, Haller cell, Agger nasi cell, paradoxical middle turbinate, concha bullosa and the protrusion of the optic nerve. Conclusion: Limited CT can be used as a surgical roadmap for the cases with the anterior group of sinus involvement. It may be utilized for surgical planning of chronic CRS involving the anterior group of sinuses. For the posterior group of sinuses, it may not yield enough accuracy and the standard Full CT should be requested to prevent erroneous estimation.
