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In this paper we have reviewed the main clinico-pathologic disease groups of neurocandidiasis: the microabscesses, the macroabscesses, and the meningitis. Special attention has been paid to the predisposing conditions for the appearance of neurocandidiasis, the neuroimaging techniques, and the study of the cerebrospinal fluid, needed for diagnosis. We have also discussed the differential diagnosis with other illnesses. Treatment should be given with amphotericin-B and 5-fluorocytosine. The use of other antifungal drugs for neurocandidiasis is also discussed.

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Neurologic complications of HIV infection are numerous. This review focuses on the clinical presentation, diagnostic particularities and therapeutic issues of neurotuberculosis. The pertinent literature describing this important infection is succinctly summarized with a particular emphasis on the discussion of differences in clinical presentation between HIV-infected and -uninfected patients.

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The frequency of intracerebral mass lesions (ICML) in patients with human immunodeficiency virus (HIV) infection and cryptococcal meningitis (CM) is not well established. Cryptococcoma seems to be a rare affliction. The objective of this study was to analyze the etiology of ICML in patients with HIV infection and CM. The methodology was a retrospective review of cases diagnosed in two Spanish hospitals between September 1988 and April 1995. Eighteen cases of CM were identified. Computed tomography was performed on presentation in 17 cases. Only one patient had ICML, which progressed while on antifungal treatment and regressed when anti-Toxoplasma treatment was established. During follow-up, two additional patients developed ICML and were successfully treated as toxoplasmosis. Overall, 3 out of 17 patients (18%) developed ICML and all three were cured when anti-Toxoplasma treatment was implemented. In our study, cerebral toxoplasmosis was the only presumed cause of ICML. In areas of high prevalence of toxoplasmosis, ICML in patients with CM may not be cryptococcomas. Consequently, in these areas of high prevalence, a trial of toxo-therapy should be strongly considered for patients with CM and ICML.

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OBJECTIVE: To determine the prevalence and causes of meningitis in patients with human immunodeficiency virus (HIV) infection. DESIGN: A prospective study of HIV-associated neurologic complications carried out from 1988 to 1992. SETTING: A tertiary care university hospital in Madrid, Spain. PATIENTS. A total of 142 patients, 65% of whom were injecting drug users. RESULTS: Thirty-six episodes of meningitis were diagnosed in 33 patients (23%). Of these, 17 cases (47%) were tuberculous meningitis (5 definite and 12 probable) and 7 (19%) corresponded to cryptococcal meningitis. Comparative studies of the tuberculous and cryptococcal meningitis cases showed injecting drug use as the most common form of HIV transmission in the tuberculous meningitis (P = .03) and a lower mean CD4+ cell count in the cryptococcal meningitis group (P = .02). CONCLUSIONS: Tuberculous meningitis was the prime type of meningitis, which was associated with HIV transmission by injecting drug use. Cryptococcal meningitis appears in more advanced stages of HIV infection, which determines its characteristic presentation.

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This study aimed to determine the incidence of AIDS dementia complex (ADC), the clinical data which distinguish it from other neurological complications of HIV infection, and the impact of zidovudine (AZT) therapy on the appearance and course of this condition. Data on the neurological complications of HIV patients treated at a community hospital from 1988 to 1992 were collected prospectively. Out of 500 AIDS patients treated at the hospital, there were 142 patients with neurological complications, with an average of 1.42 complications/patient There were 23 patients diagnosed as having ADC; with an estimated incidence of 4.6%, it was the most frequent neurological complication, after cerebral toxoplasmosis. Age was higher in patients with ADC as first manifestation of AIDS with respect to ADC patients with previous AIDS diagnosed. Compared with the group of patients suffering from other neurological complications, patients with ADC showed significant differences in several biological markers of progression to AIDS, such as hemoglobin, hematocrit, global lymphocyte count, serum ß2-microglobulin and serum IgA. CD4 count was similar in both groups. Ten ADC patients had been treated previously with AZT. Dementia continued progressing in seven of these patients and remained stable in three. Of the other 13 cases not treated previously with the drug, eight received AZT therapy, and a favourable response was obtained in three patients (p = 0.068). ADC represents a major neurological complication in AIDS patients. AZT therapy may delay the appearance of ADC, but not prevent it. A trend towards a favourable response to AZT was observed in ADC patients who had not been treated with it previously.

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The aim of the present study is to evaluate the relationship between the alpha tumor necrosis factor (TNF-alpha), interleukin 1 beta (IL-1 beta) and the neurological disease associated to the HIV-1 infection and different neurological manifestations (15 infections of the CNS and 11 AIDS-dementia complexes) and 14 from a control group. The mean value of TNF-alpha in CSF of patients with HIV-1 infection and AIDS-dementia complex was 19.8 +/- 30.6 pg/ml, superior to that of the control group (p < 0.05). The group of patients with HIV-1 and opportunistic CNS infection has a TNF-alpha value of 28.5 +/- 37.8 pg/ml, that is superior to that of the patients with the AIDS-dementia complex (TNF-alpha = 7.9 +/- 9.4 pg ml; p < 0.05). Within the group of patients with a CNS infection, the value of TNF-alpha was greater in those in the acute phase (44.2 +/- 42.4 pg/ml) than in those in the chronic phase (6.8 +/- 7.6 pg/ml; p < 0.05). The TNF-alpha in the CSF is a good marker of infection of the CNS in the HIV-1 infection.

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In this case report, we describe two patients with Candida shunt infection and review 22 cases from the previous literature. All of them had ventriculoperitoneal shunts, except one who had an external ventricular drain. The more outstanding predisposing factors were recent bacterial meningitis and/or neurosurgery (different from the shunt placement) and abdominal complications (intestinal perforation in three cases, and gastrostomy and lengthening of the distal catheter in one each). The clinical manifestations were hydrocephalus in 36%, fever in 31%, meningoencephalitis in 21%, and abdominal symptoms in 10%. The mean cerebrospinal fluid count was 78 cells/mm3 (with 77% lymphocytic predominance). Two patients died (9%); one of them was the only case in which the catheter was not removed. The recommended treatment is the replacement of the shunt and antifungal therapy with intravenous amphotericin B; in cases of poor clinical condition, the latter should also be given intraventricularly.

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Boutonneuse fever (BF) is usually considered to be a benign rickettsiosis. However, severe presentations, resembling Rocky Mountain spotted fever, have been reported. There are few neurological complications, except in serious forms of the disease. We present a case of meningoencephalitis in a male adult suffering from BF, and we review the clinical, etiopathogenic and diagnostic aspects among the cases previously reported. We conclude that BF encephalitis would have the following characteristics: a) they mostly affect elderly males; b) they cause altered consciousness level, headaches and low rate of meningeal signs; c) absence of "tâche noir"; d) cerebrospinal fluid with slight pleocytosis and/or increased level of proteins, and normal glucose values; e) computerized tomography without significative changes, and f) high rate of morbidity and mortality. We emphasize that we should consider BF in the differential diagnosis of our environmental encephalitis.

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BACKGROUND: HIV infection and parenteral drug abuse (PDA) are frequently associated conditions. Both are at increased risk of developing specific types of Candida infections. Localized CNS infection is an exceptional finding. METHODS: We report two cases of meningitis in PDA due to Candida albicans--one of them HIV positive, and review the literature emphasizing the characteristics of 8 HIV positive patients 4 of them PDA. RESULTS: Most frequent presentation symptoms were fever and headache for more than two weeks. Three patients were found normal on neurologic examination. In two cases CT scan showed hydrocephalus. In one case CNS infarcts were demonstrated on MRI. Median CSF cell counts were 109, mostly lymphocytic. Two cases had elevated adenosine deaminase levels in CSF. Two cases were treated with fluconazole, one improved and the other was cured. Four patients died due to the infection, one of them received no specific treatment. CONCLUSIONS: Candida meningitis can be a manifestation of HIV related immunosuppression. Clinical and CSF findings are mild. Mortality is high. Probably a maintenance therapy is required.

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The association between migraine and stroke is well known. It is assumed that 15% of strokes in patients below 45 years are due to migraine. To evaluate the features of this association, we have reviewed seven cases of patients with migraine and established neurological deficits. All patients fulfilled the following criteria: 1) past history of migraine, defined on the basis of the classification by the International Committee for the Classification of Headache; 2) temporal association between a migraine episode, similar to previous ones, and the ischemic episode, and 3) absence of other concomitant diseases that might result in stroke. We evaluated the age at the onset of migraine, its type, familial history of migraine (particularly of migrainous accompaniments), vascular risk factors, mode of onset, and type and duration of neurological deficit. In all cases, cranial CT, EEG, echocardiogram, serologic tests for syphilis, autoantibody investigation, routine laboratory tests and nuclear magnetic resonance (in four patients). In five cases cerebral arteriography was carried out, and arterial occlusion was demonstrated in one. We conclude that, in spite of its low frequency, migraine may result in cerebral ischemic episodes, although the relevant pathogenetic mechanisms are not yet well understood.

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