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The microscopic recognition of typical rounded capsulated yeasts in centrifuged cerebrospinal fluid (CSF), stained with India ink, is a common, rapid and effective method for the diagnosis of cryptococcal meningitis among AIDS patients. The presence of atypical forms of Cryptococcus neoformans var. neoformans in samples of CSF of an AIDS patient with cryptococcosis treated at the University Hospital of Infectious Disease is presented. The India ink microscopy of three consecutive CSF samples revealed capsulated yeast with India ink particles in the deteriorated capsules and capsulated pseudohyophae. Clinically, the patient showed a subacute meningoencephalitis, with a clinical picture not particularly different from those commonly observed in patients with AIDS-associated cryptococcosis treated in our hospital. In all cases, the culture of the CSF showed colonies of C. neoformans with typical macro and micromorphology, and the in vitro susceptibility tests to amphotericin B, fluocitosine, itraconazole and fluconazole showed MIC values into the limits of sensitivity. The presence of atypical forms of C. neoformans, considered as an atypical finding, could be the consequence of an adaptive phenomenon of this fungal species to an impaired immunological status present in the host.

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Primary non-Hodgkin lymphoma of the central nervous system is rare in pediatric AIDS patients. We report a seven-year-old HIV-infected boy, in stage C3 of the disease, who developed non-Hodgkin lymphoma in the central nervous system with a leptomeningeal location. The patient started with signs and symptoms of increased intracranial pressure, impaired consciousness and then became blind. The diagnosis was based on brain biopsy, immunophenotypic studies of B cells, and Epstein-Barr virus serology of the cerebrospinal fluid. The boy was treated with intrathecal and systemic chemotherapy. Fifteen months after diagnosis he had clinically improved, but he then relapsed with a thalamic tumor. He was treated with radiotherapy and he died four months later. In the present article, we discuss diagnostic difficulties, evolution, treatment, and the association of this neoplasm with the Epstein-Barr virus.

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OBJECTIVE: To evaluate the presence of JC virus DNA in CSF samples from Brazilian AIDS patients with focal lesions of CNS white matter without mass effect compatible with progressive multifocal leukoencephalopathy (PML). METHODS: CSF samples from AIDS patients with neurological symptoms and a CT scan showing focal lesions of CNS white matter without mass effect suggestive of PML, and from AIDS and non-AIDS patients with non-PML neurological diseases were tested for JC virus DNA by PCR. The primers used to amplify the T antigen region of the JC virus resulted in a 173-bp fragment. The presence of the JC virus was confirmed by digestion of the PCR product using BamH1. RESULTS: The PCR for JCV DNA was negative in 119/120 non-PML CSF samples (specificity =99.2%). Of 56 CSF samples from AIDS patients with focal lesions of CNS white matter without mass effect, JCV DNA was positive in 48.2% (27/56). In 23/29 (79.3%) JCV DNA-negative cases, other causes for the encephalitic lesions were found. No JCV DNA-positive cases showed other diagnoses. CONCLUSIONS: The prevalence of JCV DNA by PCR in CSF samples from Brazilian AIDS patients with focal brain lesions, without mass effect was 48.2%. In these patients, a negative JCV PCR is highly suggestive of other neurological conditions.

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Cryptococcus neoformans causes meningitis in AIDS patients. In the Säo José Hospital, reference center for patients with AIDS in Fortaleza - Ceará State - Brazil, 54 samples of the cerebrospinal fluid were analyzed from January 1st through December 31st 2000. Direct examination with India ink and culture in Sabouraud's agar at 37°C were done. Of the specimens studied 5(9.25 percent) were positive

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Cryptococcus neoformans causes meningitis in AIDS patients. In the São José Hospital, reference center for patients with AIDS in Fortaleza--Ceará State--Brazil, 54 samples of the cerebrospinal fluid were analyzed from January 1st through December 31st 2000. Direct examination with India ink and culture in Sabouraud's agar at 37 degrees C were done. Of the specimens studied 5(9.25%) were positive.

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This paper analyzes the diagnosis aid of the dosage of lactate in the cerebrospinal fluid (CSF) in infectious diseases of the central nervous system (CNS). We analyzed prospectively 130 samples of CSF of 116 patients with diagnoses of infectious processes in the CNS. The 130 samples of CSF were divided into five groups: 28 samples of the control group, 40 of bacterial meningitis, 22 of viral meningitis, 16 of fungal meningitis and 24 of patients presenting acquired immune deficiency syndrome (AIDS). The concentration of lactate in the CSF was elevated in the group of patients with bacterial meningitis (average = 46.2 mg/dL), fungal meningitis (average = 27.3 mg/dL) and in the AIDS group (average = 23.5 mg/dL). In the control group and viral meningitis group the lactate content in the CSF presented the reference rates according to the employed method. The lactate dosage in the CSF presented a negative correlation with glycorrhachia and positive correlation with the cellularity and total proteins of the CSF. We conclude that the lactate dosage in the CSF, although unspecific, helps to distinguish the infectious processes of the CNS.

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This paper analyzes the diagnosis aid of the dosage of lactate in the cerebrospinal fluid (CSF) in infectious diseases of the central nervous system (CNS). We analyzed prospectively 130 samples of CSF of 116 patients with diagnoses of infectious processes in the CNS. The 130 samples of CSF were divided into five groups: 28 samples of the control group, 40 of bacterial meningitis, 22 of viral meningitis, 16 of fungal meningitis and 24 of patients presenting acquired immune deficiency syndrome (AIDS). The concentration of lactate in the CSF was elevated in the group of patients with bacterial meningitis (average = 46.2 mg/dL), fungal meningitis (average = 27.3 mg/dL) and in the AIDS group (average = 23.5 mg/dL). In the control group and viral meningitis group the lactate content in the CSF presented the reference rates according to the employed method. The lactate dosage in the CSF presented a negative correlation with glycorrhachia and positive correlation with the cellularity and total proteins of the CSF. We conclude that the lactate dosage in the CSF, although unspecific, helps to distinguish the infectious processes of the CNS

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Cryptococcosis is considered the most frequent fungal systemic opportunist infection in patients with AIDS. C. neoformans var. neoformans infects the patients with AIDS more often than C. neoformans var. gattii which has been rarely isolated from patients with AIDS. Even in endemic regions of C. neoformans var. gattii, the variety of neoformans is still the most common agent diagnosed in cryptococcosis of patients with AIDS. Cerebrospinal fluid (CSF) from fifty patients with neurocryptococcosis associated with AIDS were studied. The fungi were isolated in agar Sabouraud medium, and were identified by microscopic and macroscopic examination by agar Sabouraud, agar niger and Christensen's urea medium. The variety was determined based on a color characteristic reaction on glycine-L-canavanina-bromothymol blue agar. From all of the fifty patients' cerebrospinal fluid (CSF) we were able to recover C. neoformans. The isolates were identified as C. neoformans var. neoformans in 47 patients and as C. neoformans var. gattii. in the 3 remaining patients. These findings suggest that both varieties, gattii and neoformans, are agents of neurocryptococcosis in patients with AIDS.

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Foram estudadas 127 amostras de LCR de pacientes adultos com diagnóstico de síndrome de imunodeficiência adquirida (SIDA. Encontramos anormalidades em 105 (82,6 por cento) amostras, caracterizadas pelo aumentos das proteínas totais 56 (44 por cento), hipercitose 49 (38,6 por cento) e hipoglicorraquia em 23 (18 por cento). As reaçöes imunológicas mostraram-se positivas para toxoplasmose em 38 (29,9 por cento) amostras, sífilis 9 (7 por cento) e cisticercose em 3 (2,3 por cento). O diagnóstico de neurocriptococose foi constatado em 25 (19,8 por cento) do total, meningite bacteriana 2 (1,6 por cento), neurotuberculose 2 (1,6 por cento) e meningite asséptica em 20 (15,7 por cento). Associaçäo das diversas patologias infecciosas ocorreu em 16 (12,6 por cento)

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Mediante la utilización del medio de canavanina-glicina-azul de bromotimol (CGB), se estudiaron 50 cepas de Cryptococcus neoformans de origen clínico. El 56 % de las cepas se aisló de pacientes con sida y el 16 % pertenecía a pacientes sometidos a transplante renal. El 90 % de las cepas se obtuvo a partir de muestras de líquido cefalorraquídeo, lo que se corresponde con la forma clásica de presentación de la criptococosis. Todas las cepas se identificaron como C. neoformans var. neoformans, lo que coincide con reportes anteriores realizados en Cuba. Con el conocimiento de las variedades de C. neoformans se pueden hacer inferencias sobre la epidemiología, la clínica y la respuesta al tratamiento de la criptococosis.

50 strains of Cryptococcus neoformans of clinical origin were studied by using the canavanine-glycine-bromothymol blue (CGB) medium. 56 % of the strains were isolated from AIDS patients, and 16 % belonmged to patients with kidney transplantation. 90 % of the samples were obtained from the samples of cerebrospinal fluid, which corresponded to the classical form of presentation of cryptococcosis. All the strains were identified as C. neoformans var. neoformans, coincidings with previous reports made in Cuba. Knowing the varieties of C. neoformans, inferences can be drawn on the epidemiology, clinics and response to the treatment of criptococcosis.

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50 strains of Cryptococcus neoformans of clinical origin were studied by using the canavanine-glycine-bromothymol blue (CGB) medium. 56% of the strains were isolated from AIDS patients, and 16% belonged to patients with kidney transplantation. 90% of the samples were obtained from the samples of cerebrospinal fluid, which corresponded to the classical form of presentation of cryptococcosis. All the strains were identified as C. neoformans var. neoformans, coinciding with previous reports made in Cuba. Knowing the varieties of C. neoformans, inferences can be drawn on the epidemiology, clinics and response to the treatment of cryptococcosis.

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Se utilizó la técnica de reacción en cadena de la polimerasa (RCP) múltiple para detectar, en un solo tubo de reacción, la presencia del virus de herpes simple (VHS), citomegalovirus (CMV), virus de Epstein Barr (VEB), virus de la varicela zóster (VVZ) y/o el virus del herpes humano 6 (VHH6). Cincuenta líquidos cefalorraquídeos de pacientes con el síndrome de inmunodeficiencia adquirida y con sospecha clínica de meningoencefalitis por el VHS, recibidos en el Laboratorio de Enfermedades de Transmisión Sexual del Departamento de Virología del Instituto de Medicina Tropical "Pedro Kourí" entre los años 1993 y 1996 fueron analizados; de estos,4 resultaron positivos al VHS, 3 a CMV, 2 al VVZ y 1 al VHH6, para 20 por ciento de positividad. Se correlacionaron los resultados de la RCP con los hallazgos clínicos que presentaban los pacientes en el momento que se les realizó la punción lumbar. La introducción de esta técnica en el laboratorio permite contar con una herramienta útil, por su sencillez y rapidez para el diagnóstico de las meningoencefalitis por herpesvirus

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A criptococose e uma das infeccoes fungicas mais comuns do sistema nervoso central (SNC) em pacientes com Sindrome da Imunodeficiencia Adquirida (SIDA), sendo meningoencefalite ou meningite manifestacoes frequentemente observadas. Apesar disso, poucos sao os estudos sistematicos sobre a composicao do liquido cefalo-raquidiano (LCR) de pacientes com SIDA e neurocriptococose. No presente estudo, foram analisadas amostras de LCR de 114 pacientes soropositivos para HIV, com queixa clinica sugestiva de envolvimento do SNC, sendo 32 com neurocriptococose (Grupo 1) e 82 sem doenca neurologica identificada (Grupo 2). Considerando os resultados citologicos e bioquimicos, dois perfis liquoricos foram observados...

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The central nervous system is considered an early and common target for the human immunodeficiency virus type 1 (HIV-1). Serum and cerebrospinal fluid (CSF) from 20 HIV positive patients, including 14 with AIDS-dementia complex (CDC stage IV) and 6 asymptomatic individuals (CDC stage II) were analyzed by enzyme immunoassay for detection of antibodies to native myelin basic protein (MBP) and for the amino acid sequence 68-84 exposed after partial degradation of native MBP. Control groups included HIV-1 negative patients with degenerative and/or vascular dementia, chronic multiple sclerosis (MS) and individuals without any sign of neurological or cognitive disturbances. As opposed to control groups, serum and CSF samples from MS and HIV-1 infected patients showed several oligoclonal bands running in the gamma region. AIDS-dementia complex (ADC) patients had increasingly high intrathecal IgG specific antibody titers for the amino acid sequence 68-84 of MBP. Marked intrathecal antibody production for myelin components was also detected in the majority of HIV-1 infected asymptomatic individuals. Such alteration paralleled development of cognitive deficits, neurological abnormalities and appearance of CNS demyelinating plaques. Preferential immune recognition of this myelin epitope within the CSF during early stages of HIV-1 infection might point to an ongoing process of active demyelination and ultimately indicate subclinical CNS involvement.

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A meningite neutrofílica persistente é raramente diagnosticada e é caracterizada pelo predomínio neutrofílico na contagem diferencial do número de leucócitos nas amostras de líquido cefalorraquidiano retiradas após sete dias de tratamento adequado. O paciente aqui descrito é soropositivo para o HIV, apresentou febre e confusão mental durante 4 meses e pleocitose neutrofílica na análise liquórica por mais 5 meses. Foi tratado desde o início com tuberculostáticos. Durante três meses as reações imunológicas, as culturas e as pesquisas diretas foram negativas. No sexagésimo dia de internação, a pesquisa de bacilo álcool-ácido resistente (BAAR) no líquor foi positiva e a cultura confirmou a presença de Mycobacterium tuberculosis resistente à isoniazida. Vários fatores podem provocar esta evolução incomum. O comprometimento da imunidade celular, principalmente na liberação de citocinas pró-inflamatórias como a IL 8 e o FNT. O uso concomitante de medicações que poderiam alterar a concentração liquórica dos tuberculostáticos e o aparecimento crescente de cepas multirresistentes foram discutidos.

Persistent neutrophilic meningitis is rarely found and it is characterized by predominance of the number of neutrophils in samples of C SF (cerebrospinal fluid) from the patient after seven days of treatment. The above patient in HIV positive; he has developed fever and mental disorder for 4 months and has presented neutrophilic pleocytosis in analysis of CSF for more than 5 months. Since the beginning or the treatment he has taken antituberculous drugs and corticosteroids. For 3 months, the serologic evaluation, smears and cultures were negative. On the 60th day in hospital, the investigation of acid-fast bacilli in CSF was positive and culture confirmed the presence of Mycobacterium tuberculosis resistant to isoniazid. Several factors that may have caused this uncommon development were discussed: the disturbance of cell-mediated immunity, mainly in release of IL 8 and TNF, the simultaneous use of medicines that could alter the CSF concentration of antituberculous drugs, and the increasing number of multiresistant strains.

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Persistent neutrophilic meningitis is rarely found and it is characterized by predominance of the number of neutrophils in samples of C SF (cerebrospinal fluid) from the patient after seven days of treatment. The above patient in HIV positive; he has developed fever and mental disorder for 4 months and has presented neutrophilic pleocytosis in analysis of CSF for more than 5 months. Since the beginning or the treatment he has taken antituberculous drugs and corticosteroids. For 3 months, the serologic evaluation, smears and cultures were negative. On the 60th day in hospital, the investigation of acid-fast bacilli in CSF was positive and culture confirmed the presence of Mycobacterium tuberculosis resistant to isoniazid. Several factors that may have caused this uncommon development were discussed: the disturbance of cell-mediated immunity, mainly in release of IL 8 and TNF, the simultaneous use of medicines that could alter the CSF concentration of antituberculous drugs, and the increasing number of multiresistant strains.

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Cryptococcosis is one of the most common fungal infections of the central nervous system (CNS) in AIDS patients and meningoencephalitis or meningitis is a frequently observed manifestation. However, systematic studies of cerebrospinal fluid (CSF) composition from AIDS patients with CNS cryptococcosis have been few. CSF samples from 114 HIV seropositive patients whose clinical complaint suggested CNS involvement, were analyzed; 32 samples from patients diagnosed as having neurocryptococcosis (Group 1) and 82 samples from patients with no identified neurological disfunction (Group 2). Based on cytological and biochemical results, two distinct profiles were observed: Normal (Group 1 = 31%, Group 2 = 39%); Abnormal (Group 1 = 69%, Group 2 = 61%). Lymphocytes were the most frequent cells in both groups. Our CSF cytological and biochemical findings showed that in AIDS patients liquoric abnormalities are quite frequent, non-specific and difficult to interpret. In these circumstances a systematic search to identify the etiologic agent using microbiological and/or immunological assays must be routinely performed.

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Fifty AIDS patients were studied. All patients had anti-HIV antibodies (ELISA) present and met OPAS/Caracas punctuation criteria for AIDS cases in adults. Cerebrospinal fluid (CSF) analysis included pressure, cytology (number of cytomorphological aspects), total protein and electrophoresis, glucose and chloride concentration. Bacteriological and mycological investigations were performed as well as agglutination tests for Cryptococcus. Complement fixation, indirect immunoflorescence, passive hemagglutination and/or ELISA tests were performed for syphilis, toxoplasmosis, viral and fungal infections. All CSF analysis were made in the same laboratory following the same methodology. CSF was altered in 45 cases (90.0%) of the 50 patients studied. The most important alterations observed were: gammaglobulin (55.5%) and total protein (51.1%) increase, hypercytosis (48.9%) and decrease of chloride concentration (40.0%). HIV antibodies were detected in 42 patients (93.3%). Toxomoplamosis, isolated or associated to other agents, was the most frequent opportunistic infection (57.7%). Cerebrospinal fluid should always be examined in AIDS patients with or without neurological symptoms.

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Foram estudados 50 pacientes com AIDS, todos estes pacientes apresentavam anticorpos ant-HIV1 (ELISA) e preenchiam os critérios de pontuaçao OPAS/Caracas de definiçao de casos de AIDS em adultos. A análise do liquido cefalorraqueano (LCR) incluiu: pressao; citologia (número de células e aspectos citomorfológicos); proteína total e eletroforese; concentraçoes de glicose, cloretos e testes imunológicos para sífilis, toxoplasmose e infecçoes virais (citomegalovírus, varicela-zoster, Herpes simplex, e HIV1). Investigaçoes bacteriológicas e micológicas (pesquisa direta e cultura), além de teste de aglutinaçao (látex) paracryptococcus foram também realizados. Os testes imunológicos usados foram fixaçao do complemento, imunofluorescência indireta, hemaglutinaçao passiva e/ou ELISA. Todos os LCR foram analisados no mesmo laboratório seguindo sempre a mesma metodologia. O LCR esteve alterado em 45 pacientes (90,0 por cento) dos 50 pacientes estudados. As principais alteraçoes encontradas no LCR foram: aumento de gamaglobulina em 25 casos (55,5 por cento); aumento da proteína total em 23 (51,1 por cento); hipercitose em 22 (48,9 por cento) e diminuiçao dos cloretos em 18(40,0 por cento). A detecçao de anticorpos anti- HIV1 estiveram presentes em 42 pacientes (93,3 por cento). Toxoplasmose isolada ou associada a outros agentes foi a infecçao oportunista mais frequente, detectada em 26 casos (57,7 por cento). O LCR deverá ser sempre analisado em todos os pacientes com AIDS, com ou sem sintomas neurológicos.

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The adenosine-deaminase (ADA) activity was evaluated in CSF samples from 263 patients with AIDS. An elevated ADA activity in CSF was found in patients with: antibodies to toxoplasmosis, syphilis or cytomegalovirus; Cryptococcus neoformans or their antigens; tuberculous meningitis; lymphoma. There was no statistical difference among all these groups in respect to ADA activity. However, the ADA activity in CSF from AIDS patients without CSF changes other than HIV antibodies, even unspecific changes, was not elevated. This may suggest that ADA is related to AIDS associated pathologies activity rather than to HIV infection itself.

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