Encephalitis in primary HIV infection: challenges in diagnosis and treatment

[First-episode psychosis as primary manifestation of medical disease: An update]

A huge variety of medical diseases may potentially present with isolated psychotic symptoms, and disease-specific treatment or management is available for a significant part of them. The initial medical work-up of a first-episode psychosis (FEP) is of crucial importance. This literature review aimed to identify medical conditions potentially revealed by FEP, to list the warning signs of secondary psychosis, and to discuss a screening strategy. Underlying organic conditions may be drugs and medications, neurologic diseases, infections, inflammatory and/or autoimmune pathologies, and metabolic disorders whether of hereditary origin. Each patient presenting with a first-episode psychosis should be evaluated with a precise anamnesis, a careful clinical examination, and routine laboratory tests. Brain imaging and tests (depending on the context) should be performed in the presence of atypical clinical features or "red flags", leading to suspect an organic disease.

Zika virus-induced neurological critical illness in Latin America: Severe Guillain-Barre Syndrome and encephalitis

Zika virus (ZIKAV) is classically described as causing minor symptoms in adult patients, however neurologic complications have been recognized. The recent outbreak in Central and South America has resulted in serious illness in some adult patients. We report adult patients in Latin America diagnosed with ZIKAV infection admitted to Intensive Care Units (ICUs).

METHODS

Multicenter, prospective case series of adult patients with laboratory diagnosis of ZIKAV in 16 ICUs in 8 countries.

RESULTS

Between December 1st 2015 and April 2nd 2016, 16 ICUs in 8 countries enrolled 49 critically ill patients with diagnosis of ZIKAV infection. We included 10 critically ill patients with ZIKAV infection, as diagnosed with RT-PCR, admitted to the ICU. Neurologic manifestations concordant with Guillain-Barre Syndrome (GBS) were present in all patients, although 2 evolved into an encephalitis-like picture. 2 cases died, one due to encephalitis, the other septic shock.

CONCLUSIONS

Differing from what was usually reported, ZIKAV infection can result in life-threatening neurologic illness in adults, including GBS and encephalitis. Collaborative reporting to identify severe illness from an emerging pathogen can provide valuable insights into disease epidemiology and clinical presentation, and inform public health authorities about acute care priorities.

CXCL13 as a diagnostic marker of neuroborreliosis and other neuroinflammatory disorders in an unselected group of patients

BACKGROUND

The C-X-C motif chemokine ligand 13 (CXCL13) and its receptor CXCR5 play an important role in the homing of B-lymphocytes. As a biomarker in the cerebrospinal fluid (CSF), CXCL13 has increasingly been used for the diagnosis of neuroborreliosis (NB). We evaluated the diagnostic and prognostic potential of CXCL13 for NB and other neuroinflammatory diseases in an unselected cohort, paying attention to those patients particularly who might benefit from newly emerging CXCL13-directed therapies.

METHODS

We report the CSF CXCL13 concentrations and other relevant baseline characteristics for an unselected cohort of 459 patients. We compare different diagnostic groups and analyse the sensitivity and specificity of CSF CXCL13 as a marker of NB. The course of the CXCL13 concentrations is reported in a subgroup of 19 patients.

RESULTS

We confirm the high diagnostic yield of CXCL13 for NB in this unselected cohort. The optimal cut-off for the reliable diagnosis of NB was 93.83 pg/ml, resulting in a sensitivity and specificity of 95 and 97%, respectively (positive predictive value 55.9%, negative predictive value 99.8%), surpassing the sensitivity of both serological testing and PCR. CSF CXCL13 concentration showed a swift response to therapy. Non-NB patients with high CSF CXCL13 concentrations suffered from meningeosis neoplastica or infectious encephalitis.

CONCLUSIONS

CXCL13 is a valuable tool for the diagnosis and assessment of therapeutic response in NB. Furthermore, our data point towards an emerging role of CXCL13 in the diagnosis and prognosis of viral encephalitis and meningeosis neoplastica. These results are of particular interest in the light of recently developed approaches to CXCL13-directed therapeutic interventions.

MR imaging of adult acute infectious encephalitis

BACKGROUND

Imaging is a key tool for the diagnosis of acute encephalitis. Brain CT scan must be urgently performed to rule out a brain lesion with mass effect that would contraindicate lumbar puncture. Brain MRI is less accessible than CT scan, but can provide crucial information with patients presenting with acute encephalitis.

METHOD

We performed a literature review on PubMed on April 1, 2015 with the search terms "MRI" and "encephalitis".

RESULTS

We first described the various brain MRI abnormalities associated with each pathogen of acute encephalitis (HSV, VZV, other viral agents targeting immunocompromised patients or travelers; tuberculosis, listeriosis, other less frequent bacterial agents). Then, we identified specific patterns of brain MRI abnomalies that may suggest a particular pathogen. Limbic encephalitis is highly suggestive of HSV; it also occurs less frequently in encephalitis due to HHV6, syphillis, Whipple's disease and HIV primary infection. Rhombencephalitis is suggestive of tuberculosis and listeriosis. Acute ischemic lesions can occur in patients presenting with severe bacterial encephalitis, tuberculosis, VZV encephalitis, syphilis, and fungal infections.

CONCLUSION

Brain MRI plays a crucial role in the diagnosis of acute encephalitis. It detects brain signal changes that reinforce the clinical suspicion of encephalitis, especially when the causative agent is not identified by lumbar puncture; it can suggest a particular pathogen based on the pattern of brain abnormalities and it rules out important differential diagnosis (vascular, tumoral or inflammatory causes).

Associations between HIV and schizophrenia and their effect on HIV treatment outcomes: a nationwide population-based cohort study in Denmark

BACKGROUND

Associations between HIV and schizophrenia in people with and without substance use disorders and the effect on timeliness of HIV diagnosis, antiretroviral therapy (ART), and treatment outcomes are poorly understood. We aimed to assess the association between HIV and schizophrenia and the effect on HIV treatment outcomes in people with and without substance use disorders.

METHODS

We did a population-based cohort study with data from nationwide registries in Denmark to investigate the risk of schizophrenia after a diagnosis of HIV and the risk of HIV after a diagnosis of schizophrenia, accounting for substance misuse, timeliness of HIV diagnosis, and treatment success in relation to schizophrenia. We selected the cohort from people born in Denmark between Jan 1, 1955, and Dec 31, 1995, who we followed up from their 16th birthday or Jan 1, 1995 (whichever occurred last) until their death, emigration from Denmark, onset of schizophrenia, or Dec 31, 2011 (whichever came first). We estimated incidence rate ratios (IRRs) with Poisson and Cox regression, with adjustment for calendar period, and age and its interaction with sex.

FINDINGS

We identified 2,786,286 individuals, of whom we included 2,646,154 people in analyses of risk of schizophrenia diagnosis and 2,658,662 people in analyses of risk of HIV diagnosis. In 35,353,633 person-years of follow up, HIV was associated with an increased risk of schizophrenia (IRR 4·09, 95% CI 2·73-5·83) and acute psychosis (7·15, 4·45-10·8); the IRR was highest within the first year of HIV diagnosis for both disorders (8·24, 2·95-17·7 and 12·7, 3·15-32·9, respectively). Schizophrenia was not associated with an increased risk of HIV in individuals without substance misuse disorders (IRR 1·42, 95% CI 0·81-2·27). The risk of schizophrenia in individuals with HIV decreased after ART (IRR 0·53, 0·32-0·87). The risk of acute psychosis did not differ between HIV-infected individuals receiving antiretroviral regimens with and without efavirenz (IRR 0·70, 95% CI 0·32-1·54). We recorded no differences in CD4 cell counts, time to ART, or viral suppression between individuals with schizophrenia with HIV and those without schizophrenia when substance use was taken into account. Between 1999 and 2011, the mortality rate ratio comparing HIV-infected individuals with schizophrenia with HIV-negative individuals without schizophrenia was 25·8 (95% CI 18·8-34·3).

INTERPRETATION

Our findings emphasise the need for interventions to prevent HIV in people with schizophrenia, especially for those with substance use disorders, and for accessible mental health services for individuals with HIV.

FUNDING

Stanley Medical Research Institute, Lundbeck Foundation, Preben and Anna Simonsen Fund, Novo Nordisk Foundation, The Danish AIDS Foundation, and the Augustinus Foundation.