Immune Reconstitution Inflammatory Syndrome (IRIS) Associated Multifocal Leukoencephalopathy (PML) in Patients with Human Immunodeficiency Virus (HIV) Infection: A Case Report
Abstract—Progressive Multifocal Leukoencephalopathy (PML) is seen mostly in advanced human immunodeficiency virus (HIV) infection. In some individuals, especially those with very low CD4+ counts, worsening of PML or new-onset PML can be observed after the initiation of highly active antiretroviral therapy (HAART). A case of IRIS associated PML is reported here which is much more rare as compared to PML in HIV patients unrelated to HAART. This is thought to be secondary to immune reconstitution inflammatory syndrome (IRIS). IRIS is defined as a paradoxical deterioration of a previously existing infection which is related to the immune system recovery. It is suggested to occur due to an imbalance of CD8+/CD4+ T cells. So in HIV cases with low CD4 counts and if one is on HAART then should be further investigated for IRIS and PML.
Neurological manifestations are common in COVID-19, occurring in around 80% of hospitalized patients. The document discusses several neurological effects such as smell and taste disorders, encephalopathy, cerebrovascular disease, neuromuscular disorders, seizures, sleep disorders, and various acute neurological manifestations. The pathogenesis is multifactorial, involving direct viral invasion, immune dysfunction, coagulopathies, and the renin-angiotensin system.
Cardiomyopathy in HIV patients has been shown to progress faster than idiopathic Dilated Cardiomyopathy in the HIV negative population. It is therefore important to recognize this condition early in this population and manage it appropriately. Studies need to be done to validate the current therapy for cardiomyopathy in this population since it is still unclear that LV dysfunction in this population responds in a similar fashion as in HIV negative patients with Dilated Cardiomyopathy
This document discusses coronary artery disease in HIV patients. It covers the relative magnitude of cardiovascular disease among HIV patients, current data on the association between HIV and coronary artery disease, known risk factors and how they may be modulated by HIV diagnosis, screening and prevention recommendations, and areas for future research. Key points include increased rates of myocardial infarction and atherosclerosis in HIV patients, traditional and HIV-specific risk factors, screening tools and their limitations, effects of antiretroviral therapy on risk, and lifestyle and medical interventions for prevention.
1. HIV was first described in 1981 and is caused by HIV-1 and HIV-2 viruses which deplete CD4 lymphocytes. As of 2000, 58 million people were infected globally and 21.8 million had died.
2. Cardiac manifestations are common in HIV/AIDS patients, occurring in 28-73% of patients. Prior to antiretroviral therapy, cardiac disease was usually only detected at autopsy.
3. Guidelines recommend regular echocardiograms to monitor cardiac dysfunction in HIV patients, with increased frequency if abnormalities are detected. Endocarditis prevalence is increased in HIV patients.
1) A study in Bangladesh assessed pain and disability in post-COVID patients and found that 100% reported pain and 46.66% reported increased disability after recovering from COVID-19.
2) The COVID-19 pandemic has overwhelmed healthcare systems around the world and most resources have focused on acute care, leaving less attention to long-term issues like post-COVID pain.
3) Many Asian countries are reporting high rates of post-COVID symptoms including pain, fatigue, and breathing difficulties. Further research is needed to better characterize and manage post-COVID pain in Asia.
Upsurge of chikungunya cases in Uttar Pradesh, IndiaAhmad Ozair
Background & objectives: Chikungunya (CHIK) re-emerged in India in 2006 after a gap of three decades. In Uttar Pradesh (UP), <100 confirmed cases per million were reported during this outbreak. Based on an upsurge of CHIK cases at UP, this retrospective study was conducted to investigate clinical and serological profile of CHIK cases in UP. Methods: A retrospective study was done on all clinically suspected CHIK cases that had been tested by ELISA for anti-CHIK virus IgM antibodies from September 2012 to December 2017. Based on clinical features, a subset of patients had earlier been tested serologically for dengue and Japanese encephalitis (JE). Results: Of the 3240 cases enrolled, 771 (23.8%) were seropositive. Patients had a range of clinical manifestations with seropositivity highest in those exhibiting arthralgia with fever (40%), followed by fever of unknown origin (FUO) (22%), encephalitis (13%) and fever with rash (12%). Cases (total, seropositive) increased over 20-fold in 2016 (1389, 412) and 2017 (1619, 341), compared to 2012-2015. Nearly a third of dengue serology-positive cases and a fifth of JE serology-positive cases were co-positive for CHIKV. Interpretation & conclusions: Archival data from 2006-2011 and data from this study (2012-2017) indicated that UP experienced first CHIK outbreak in the decade in 2016, as part of a large-scale upsurge across northern India. CHIK should be considered as a differential diagnosis in patients presenting with fever of unknown origin or fever with rash or acute encephalitis, in addition to classical arthralgia.
Neurological manifestations are common in COVID-19, occurring in around 80% of hospitalized patients. The document discusses several neurological effects such as smell and taste disorders, encephalopathy, cerebrovascular disease, neuromuscular disorders, seizures, sleep disorders, and various acute neurological manifestations. The pathogenesis is multifactorial, involving direct viral invasion, immune dysfunction, coagulopathies, and the renin-angiotensin system.
Cardiomyopathy in HIV patients has been shown to progress faster than idiopathic Dilated Cardiomyopathy in the HIV negative population. It is therefore important to recognize this condition early in this population and manage it appropriately. Studies need to be done to validate the current therapy for cardiomyopathy in this population since it is still unclear that LV dysfunction in this population responds in a similar fashion as in HIV negative patients with Dilated Cardiomyopathy
This document discusses coronary artery disease in HIV patients. It covers the relative magnitude of cardiovascular disease among HIV patients, current data on the association between HIV and coronary artery disease, known risk factors and how they may be modulated by HIV diagnosis, screening and prevention recommendations, and areas for future research. Key points include increased rates of myocardial infarction and atherosclerosis in HIV patients, traditional and HIV-specific risk factors, screening tools and their limitations, effects of antiretroviral therapy on risk, and lifestyle and medical interventions for prevention.
1. HIV was first described in 1981 and is caused by HIV-1 and HIV-2 viruses which deplete CD4 lymphocytes. As of 2000, 58 million people were infected globally and 21.8 million had died.
2. Cardiac manifestations are common in HIV/AIDS patients, occurring in 28-73% of patients. Prior to antiretroviral therapy, cardiac disease was usually only detected at autopsy.
3. Guidelines recommend regular echocardiograms to monitor cardiac dysfunction in HIV patients, with increased frequency if abnormalities are detected. Endocarditis prevalence is increased in HIV patients.
1) A study in Bangladesh assessed pain and disability in post-COVID patients and found that 100% reported pain and 46.66% reported increased disability after recovering from COVID-19.
2) The COVID-19 pandemic has overwhelmed healthcare systems around the world and most resources have focused on acute care, leaving less attention to long-term issues like post-COVID pain.
3) Many Asian countries are reporting high rates of post-COVID symptoms including pain, fatigue, and breathing difficulties. Further research is needed to better characterize and manage post-COVID pain in Asia.
Upsurge of chikungunya cases in Uttar Pradesh, IndiaAhmad Ozair
Background & objectives: Chikungunya (CHIK) re-emerged in India in 2006 after a gap of three decades. In Uttar Pradesh (UP), <100 confirmed cases per million were reported during this outbreak. Based on an upsurge of CHIK cases at UP, this retrospective study was conducted to investigate clinical and serological profile of CHIK cases in UP. Methods: A retrospective study was done on all clinically suspected CHIK cases that had been tested by ELISA for anti-CHIK virus IgM antibodies from September 2012 to December 2017. Based on clinical features, a subset of patients had earlier been tested serologically for dengue and Japanese encephalitis (JE). Results: Of the 3240 cases enrolled, 771 (23.8%) were seropositive. Patients had a range of clinical manifestations with seropositivity highest in those exhibiting arthralgia with fever (40%), followed by fever of unknown origin (FUO) (22%), encephalitis (13%) and fever with rash (12%). Cases (total, seropositive) increased over 20-fold in 2016 (1389, 412) and 2017 (1619, 341), compared to 2012-2015. Nearly a third of dengue serology-positive cases and a fifth of JE serology-positive cases were co-positive for CHIKV. Interpretation & conclusions: Archival data from 2006-2011 and data from this study (2012-2017) indicated that UP experienced first CHIK outbreak in the decade in 2016, as part of a large-scale upsurge across northern India. CHIK should be considered as a differential diagnosis in patients presenting with fever of unknown origin or fever with rash or acute encephalitis, in addition to classical arthralgia.
Heart Disease In Pregnancy During The Pandemicahvc0858
Heart disease in pregnancy during the pandemic
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
The document discusses various types of heart disease that can occur in patients with HIV infection, including cardiomyopathy, conduction abnormalities, endocarditis, pericarditis, and aneurysms. It notes an interest in further understanding pericardial disease, HIV-associated cardiomyopathy, how HIV may modify the presentation and treatment of other heart conditions, and the impacts of antiretroviral therapies on cardiovascular risk factors. The document also addresses cardiac and non-cardiac surgical considerations for patients with HIV.
This document discusses cardiovascular diseases in HIV patients. It notes that cardiovascular disease is more common in HIV patients due to multiple potential factors, including traditional risk factors, HIV itself, antiretroviral therapy, and chronic inflammation. It also discusses specific cardiac complications in more detail, such as cardiomyopathy, pericardial effusion, endocarditis, pulmonary hypertension, vasculitis, and the possible association between viral infections and coronary artery disease.
- The study analyzed clinical features of 175 patients with neuromyelitis optica spectrum disorder (NMOSD) based on their aquaporin-4 antibody (AQP4-Ab) serostatus.
- Seropositive patients were more likely to be female, have severe myelitis with motor symptoms, and longer spinal cord lesions on MRI.
- Seronegative patients more often had simultaneous optic neuritis and myelitis at onset, bilateral optic nerve involvement, pure sensory myelitis, and a monophasic disease course.
- However, both groups had similar relapse rates, time between relapses, and long-term disability progression.
The document discusses Coronavirus (COVID-19) by providing details about what Coronaviruses are, how the current pandemic started in Wuhan China, risks factors like age and preexisting medical conditions, challenges in communicating with children, importance of filtering misinformation, potential drug treatments being tested, and how knowing facts about the virus can help people survive and stay aware.
TheNeuroSurgeons sponsored the presentation to the Zimbabwe Association of Neurological Surgeons.
we are learning more about the neurological manifestations of the novel coronavirus as we are frantically looking for solution to this formidable pandemic.
Neurological Manifestations of COVID-19 InfectionSudhir Kumar
COVID-19 primarily affects respiratory system, however, it can affect other systems too, including nervous system. This presentation offers details about neurological symptoms and disorders seen in patients with COVID-19.
Pediatric multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system that can affect children and adolescents under 18 years of age. While symptoms are similar to adult MS and include sensory deficits, optic neuritis, motor deficits and fatigue, diagnosis can be more challenging in children due to atypical presentations. The incidence is highest between 13-16 years of age and females are more commonly affected than males. Diagnosis involves evaluating clinical symptoms, MRI images showing lesions, and CSF analysis. Treatment involves disease-modifying drugs like interferons or corticosteroids for relapses.
This document discusses stroke in HIV infection. It begins by providing background on HIV/AIDS classifications and prevalence statistics. It then describes the CDC classification system for HIV infection and lists conditions under categories B and C. It discusses the epidemiology of stroke in HIV patients, noting rates vary from 0.5-5% in studies. Potential causes of ischemic and hemorrhagic stroke are outlined. Treatment focuses on underlying infections or disorders. While HAART reduced some complications, protease inhibitors may increase atherosclerosis risk. In conclusion, strokes in HIV patients tend to occur in severe immunosuppression and various infectious etiologies can cause ischemic or hemorrhagic strokes.
This document discusses highly active multiple sclerosis (MS). It defines several subtypes of aggressive MS including malignant, fulminant, and highly active MS. Predictors of highly active MS are discussed from a 2016 study. The case vignette describes a 34-year-old male physician's MS course from 2006 to 2017, showing recurrent attacks and progression. The timing of therapy is key to preventing disability, with an emphasis on early treatment to preserve brain reserve. Treatment algorithms recommend escalating therapy for aggressive MS to effectively treat within a narrow therapeutic window.
The Prevalence and Prognostic Value of Neuroimaging Abnormalities in the Acut...CrimsonPublishersTNN
The Prevalence and Prognostic Value of Neuroimaging Abnormalities in the Acute Phase of Sepsis-Associated Encephalopathy by Keenan A Walker in Techniques in Neurosurgery & Neurology
This document discusses hypothyroidism. It defines hypothyroidism as a hormonal deficiency caused by dysfunction of the thyroid gland that interrupts the synthesis and secretion of T4 and TSH. It discusses the epidemiology, risk factors, classifications, clinical manifestations, diagnosis, screening, and treatment of hypothyroidism. It notes that the prevalence is estimated to be 1-7% of the population and is more common in women and older adults. Diagnosis is based on elevated TSH and low free T4 levels. Treatment goals are to normalize TSH levels and improve symptoms.
MS Disease modifying agents for multiple sclerosisHossam Sayed
This document summarizes disease modifying drugs for multiple sclerosis. It discusses established agents like interferon beta, glatiramer acetate, natalizumab, and mitoxantrone that have been proven to reduce relapse rates and disability progression in clinical trials. Side effects and administration methods are provided for each. Other potential agents are mentioned, including immunosuppressants like azathioprine, cyclophosphamide, and immune modulators like methotrexate and intravenous immunoglobulin, but they have not been conclusively proven to benefit MS through phase III trials.
A 38-year-old man with uncontrolled diabetes was admitted with 1 week of fevers, chills, and cough. He was diagnosed with infective endocarditis of the tricuspid valve caused by Staphylococcus aureus based on positive blood cultures, echocardiogram findings, and Duke criteria. He received IV antibiotic therapy and was monitored closely in the hospital. Nursing care involved administering antibiotics, monitoring for signs of heart failure, and providing patient education on preventing future infections and managing his diabetes.
Septic encephalopathy is characterized by diffuse brain dysfunction that occurs in patients with sepsis without direct evidence of intracranial infection or metabolic causes unrelated to the infectious process. It is a common complication among critically ill patients, occurring in 9-71% of cases. Diagnosis involves assessing for altered mental status in the setting of sepsis through EEG, biomarkers of brain injury, and neuroimaging while excluding other potential causes. Management focuses on early treatment of the underlying sepsis through organ support and intensive care, with adjunctive therapies like EEG monitoring and antipsychotics potentially helping to guide care and symptoms.
This document summarizes the London experience with autologous hematopoietic stem cell transplantation (AHSCT) for multiple sclerosis (MS). It provides data on 54 patients who underwent AHSCT, with a median follow up time of 23 months. Complications included admissions to the intensive care unit and re-admissions post-transplant, with no treatment related deaths in this group. Outcomes included low rates of relapses, disability progression, and new MRI lesions post-transplant. The results were consistent with prior studies and support further investigation of AHSCT as a treatment for highly active relapsing MS and progressive MS with disease activity. Ongoing trials are exploring whether AHSCT may be superior to
Acute disseminated encephalomyelitis (ADEM) is a monophasic demyelinating disease of central nervous system (CNS) which is most frequently associated with an antecedent infection (identified in ~ 50-77%). 5% of ADEM cases follow immunization. Post infectious autoimmune events associated with Japanese encephalitis (JE) have been limited to Guillian Barre Syndrome (GBS) and JE virus vaccine related ADEM. We hereby report a case of 18 year boy who presented to us with fever, urinary retention, bilateral diminution of vision and acute onset paraparesis. Japanese encephalitis was diagnosed by elevated IgM titres against JE virus in cerebrospinal fluid (CSF). ADEM was confirmed by MRI brain and spinal cord. Our patient also developed bilateral eye optic neuritis presenting clinically as sudden onset blurring of vision in both eye one day after admission and confirmed by visual evoked potential (VEP) study. His symptoms improved after giving high dose intravenous methylprednisolone.
This document discusses the management of treatment-naive HIV patients. It presents scenarios for two patients - ST and RW - who are being evaluated for initiation of antiretroviral therapy (ART). It addresses factors to consider in recommending ART, choosing initial regimens, and indications for starting treatment.
Dr. Rahul VC Tiwari - Fellowship In Orthognathic Surgery - Jubilee Mission Medical College Hospital and Research Center, Thrissur, Kerala - 29th publication iosr jdms 3rd name
Herpes Simplex Encephalitis in Medulloblastoma Patients: Case Report and Revi...clinicsoncology
Encephalitis caused by Herpes Simplex Virus (HSV) and medulloblastoma are both fairly rare disorders with relatively poor prognoses. We experienced a case of HSV encephalitis (HSE) in which the patient presented 1 year after surgical resection and radiation therapy and 1 month after chemotherapy....
Heart Disease In Pregnancy During The Pandemicahvc0858
Heart disease in pregnancy during the pandemic
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
The document discusses various types of heart disease that can occur in patients with HIV infection, including cardiomyopathy, conduction abnormalities, endocarditis, pericarditis, and aneurysms. It notes an interest in further understanding pericardial disease, HIV-associated cardiomyopathy, how HIV may modify the presentation and treatment of other heart conditions, and the impacts of antiretroviral therapies on cardiovascular risk factors. The document also addresses cardiac and non-cardiac surgical considerations for patients with HIV.
This document discusses cardiovascular diseases in HIV patients. It notes that cardiovascular disease is more common in HIV patients due to multiple potential factors, including traditional risk factors, HIV itself, antiretroviral therapy, and chronic inflammation. It also discusses specific cardiac complications in more detail, such as cardiomyopathy, pericardial effusion, endocarditis, pulmonary hypertension, vasculitis, and the possible association between viral infections and coronary artery disease.
- The study analyzed clinical features of 175 patients with neuromyelitis optica spectrum disorder (NMOSD) based on their aquaporin-4 antibody (AQP4-Ab) serostatus.
- Seropositive patients were more likely to be female, have severe myelitis with motor symptoms, and longer spinal cord lesions on MRI.
- Seronegative patients more often had simultaneous optic neuritis and myelitis at onset, bilateral optic nerve involvement, pure sensory myelitis, and a monophasic disease course.
- However, both groups had similar relapse rates, time between relapses, and long-term disability progression.
The document discusses Coronavirus (COVID-19) by providing details about what Coronaviruses are, how the current pandemic started in Wuhan China, risks factors like age and preexisting medical conditions, challenges in communicating with children, importance of filtering misinformation, potential drug treatments being tested, and how knowing facts about the virus can help people survive and stay aware.
TheNeuroSurgeons sponsored the presentation to the Zimbabwe Association of Neurological Surgeons.
we are learning more about the neurological manifestations of the novel coronavirus as we are frantically looking for solution to this formidable pandemic.
Neurological Manifestations of COVID-19 InfectionSudhir Kumar
COVID-19 primarily affects respiratory system, however, it can affect other systems too, including nervous system. This presentation offers details about neurological symptoms and disorders seen in patients with COVID-19.
Pediatric multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system that can affect children and adolescents under 18 years of age. While symptoms are similar to adult MS and include sensory deficits, optic neuritis, motor deficits and fatigue, diagnosis can be more challenging in children due to atypical presentations. The incidence is highest between 13-16 years of age and females are more commonly affected than males. Diagnosis involves evaluating clinical symptoms, MRI images showing lesions, and CSF analysis. Treatment involves disease-modifying drugs like interferons or corticosteroids for relapses.
This document discusses stroke in HIV infection. It begins by providing background on HIV/AIDS classifications and prevalence statistics. It then describes the CDC classification system for HIV infection and lists conditions under categories B and C. It discusses the epidemiology of stroke in HIV patients, noting rates vary from 0.5-5% in studies. Potential causes of ischemic and hemorrhagic stroke are outlined. Treatment focuses on underlying infections or disorders. While HAART reduced some complications, protease inhibitors may increase atherosclerosis risk. In conclusion, strokes in HIV patients tend to occur in severe immunosuppression and various infectious etiologies can cause ischemic or hemorrhagic strokes.
This document discusses highly active multiple sclerosis (MS). It defines several subtypes of aggressive MS including malignant, fulminant, and highly active MS. Predictors of highly active MS are discussed from a 2016 study. The case vignette describes a 34-year-old male physician's MS course from 2006 to 2017, showing recurrent attacks and progression. The timing of therapy is key to preventing disability, with an emphasis on early treatment to preserve brain reserve. Treatment algorithms recommend escalating therapy for aggressive MS to effectively treat within a narrow therapeutic window.
The Prevalence and Prognostic Value of Neuroimaging Abnormalities in the Acut...CrimsonPublishersTNN
The Prevalence and Prognostic Value of Neuroimaging Abnormalities in the Acute Phase of Sepsis-Associated Encephalopathy by Keenan A Walker in Techniques in Neurosurgery & Neurology
This document discusses hypothyroidism. It defines hypothyroidism as a hormonal deficiency caused by dysfunction of the thyroid gland that interrupts the synthesis and secretion of T4 and TSH. It discusses the epidemiology, risk factors, classifications, clinical manifestations, diagnosis, screening, and treatment of hypothyroidism. It notes that the prevalence is estimated to be 1-7% of the population and is more common in women and older adults. Diagnosis is based on elevated TSH and low free T4 levels. Treatment goals are to normalize TSH levels and improve symptoms.
MS Disease modifying agents for multiple sclerosisHossam Sayed
This document summarizes disease modifying drugs for multiple sclerosis. It discusses established agents like interferon beta, glatiramer acetate, natalizumab, and mitoxantrone that have been proven to reduce relapse rates and disability progression in clinical trials. Side effects and administration methods are provided for each. Other potential agents are mentioned, including immunosuppressants like azathioprine, cyclophosphamide, and immune modulators like methotrexate and intravenous immunoglobulin, but they have not been conclusively proven to benefit MS through phase III trials.
A 38-year-old man with uncontrolled diabetes was admitted with 1 week of fevers, chills, and cough. He was diagnosed with infective endocarditis of the tricuspid valve caused by Staphylococcus aureus based on positive blood cultures, echocardiogram findings, and Duke criteria. He received IV antibiotic therapy and was monitored closely in the hospital. Nursing care involved administering antibiotics, monitoring for signs of heart failure, and providing patient education on preventing future infections and managing his diabetes.
Septic encephalopathy is characterized by diffuse brain dysfunction that occurs in patients with sepsis without direct evidence of intracranial infection or metabolic causes unrelated to the infectious process. It is a common complication among critically ill patients, occurring in 9-71% of cases. Diagnosis involves assessing for altered mental status in the setting of sepsis through EEG, biomarkers of brain injury, and neuroimaging while excluding other potential causes. Management focuses on early treatment of the underlying sepsis through organ support and intensive care, with adjunctive therapies like EEG monitoring and antipsychotics potentially helping to guide care and symptoms.
This document summarizes the London experience with autologous hematopoietic stem cell transplantation (AHSCT) for multiple sclerosis (MS). It provides data on 54 patients who underwent AHSCT, with a median follow up time of 23 months. Complications included admissions to the intensive care unit and re-admissions post-transplant, with no treatment related deaths in this group. Outcomes included low rates of relapses, disability progression, and new MRI lesions post-transplant. The results were consistent with prior studies and support further investigation of AHSCT as a treatment for highly active relapsing MS and progressive MS with disease activity. Ongoing trials are exploring whether AHSCT may be superior to
Acute disseminated encephalomyelitis (ADEM) is a monophasic demyelinating disease of central nervous system (CNS) which is most frequently associated with an antecedent infection (identified in ~ 50-77%). 5% of ADEM cases follow immunization. Post infectious autoimmune events associated with Japanese encephalitis (JE) have been limited to Guillian Barre Syndrome (GBS) and JE virus vaccine related ADEM. We hereby report a case of 18 year boy who presented to us with fever, urinary retention, bilateral diminution of vision and acute onset paraparesis. Japanese encephalitis was diagnosed by elevated IgM titres against JE virus in cerebrospinal fluid (CSF). ADEM was confirmed by MRI brain and spinal cord. Our patient also developed bilateral eye optic neuritis presenting clinically as sudden onset blurring of vision in both eye one day after admission and confirmed by visual evoked potential (VEP) study. His symptoms improved after giving high dose intravenous methylprednisolone.
This document discusses the management of treatment-naive HIV patients. It presents scenarios for two patients - ST and RW - who are being evaluated for initiation of antiretroviral therapy (ART). It addresses factors to consider in recommending ART, choosing initial regimens, and indications for starting treatment.
Similar to Immune Reconstitution Inflammatory Syndrome (IRIS) Associated Multifocal Leukoencephalopathy (PML) in Patients with Human Immunodeficiency Virus (HIV) Infection: A Case Report
Dr. Rahul VC Tiwari - Fellowship In Orthognathic Surgery - Jubilee Mission Medical College Hospital and Research Center, Thrissur, Kerala - 29th publication iosr jdms 3rd name
Herpes Simplex Encephalitis in Medulloblastoma Patients: Case Report and Revi...clinicsoncology
Encephalitis caused by Herpes Simplex Virus (HSV) and medulloblastoma are both fairly rare disorders with relatively poor prognoses. We experienced a case of HSV encephalitis (HSE) in which the patient presented 1 year after surgical resection and radiation therapy and 1 month after chemotherapy....
Herpes Simplex Encephalitis in Medulloblastoma Patients: Case Report and Revi...SarkarRenon
Encephalitis caused by Herpes Simplex Virus (HSV) and medulloblastoma are both fairly rare disorders with relatively poor prognoses. We experienced a case of HSV encephalitis (HSE) in which the patient presented 1 year after surgical resection and radiation therapy and 1 month after chemotherapy....
Herpes Simplex Encephalitis in Medulloblastoma Patients: Case Report and Revi...pateldrona
Encephalitis caused by Herpes Simplex Virus (HSV) and medulloblastoma are both fairly rare disorders with relatively poor prognoses. We experienced a case of HSV encephalitis (HSE) in which the patient presented 1 year after surgical resection and radiation therapy and 1 month after chemotherapy..
Herpes Simplex Encephalitis in Medulloblastoma Patients: Case Report and Revi...komalicarol
Medulloblastoma is the most common malignant solid tumor
in childhood, with the highest frequency among other brain tumors accounting for 30% of pediatric brain tumors and 7% to 8%
of all brain tumors. According to the World Health Organization
(WHO), medulloblastoma is classified as a grade IV tumor and
defined as “a malignant, invasive embryonal tumor of the cerebellum with preferential manifestation in children, predominantly
neuronal differentiation and an inherent tendency to metastasize
via cerebrospinal (CSF) pathways
Herpes Simplex Encephalitis in Medulloblastoma Patients: Case Report and Revi...georgemarini
Encephalitis caused by Herpes Simplex Virus (HSV) and medulloblastoma are both fairly rare disorders with relatively poor prognoses. We experienced a case of HSV encephalitis (HSE) in which the patient presented 1 year after surgical resection and radiation therapy and 1 month after chemotherapy....
Herpes Simplex Encephalitis in Medulloblastoma Patients: Case Report and Revi...AnonIshanvi
Encephalitis caused by Herpes Simplex Virus (HSV) and medulloblastoma are both fairly rare disorders with relatively poor prognoses. We experienced a case of HSV encephalitis (HSE) in which the patient presented 1 year after surgical resection and radiation therapy and 1 month after chemotherapy....
This document discusses potential neuromuscular complications of COVID-19 infection. It may cause Guillain-Barre syndrome through molecular mimicry. Critical illness myopathy and mononeuropathies have also been reported. COVID-19 could potentially cause or exacerbate myasthenia gravis and other neuromuscular junction disorders. Patients with pre-existing neuromuscular disorders, especially those on immunosuppression, may be at higher risk. Neurologists should monitor high-risk patients closely and consider temporarily adjusting treatments.
This document discusses potential neuromuscular complications of COVID-19 infection. It may cause Guillain-Barre syndrome through molecular mimicry. Critical illness myopathy and mononeuropathies have also been reported. COVID-19 could potentially cause or exacerbate myasthenia gravis and other neuromuscular junction disorders. Patients with pre-existing neuromuscular disorders, especially those on immunosuppression, may be at higher risk. Neurologists should monitor high-risk patients closely and consider temporarily adjusting treatments.
Evan Syndrome A Case Report by Parimala L | P Anjaneyuluijtsrd
Evan syndrome is an autoimmune disorder in which auto antibodies are directed against antigens specific to red blood cells, platelets, and neutrophils. Also known as Immune mediated thrombocytopenia ITP , Autoimmune hemolytic anemia AIHA , or immune pancytopenia. Clinical symptoms are thrombocytopenia, hemolysis, and severe anemia. The first line treatment for Evan syndrome intravenous corticosteroids or intravenous immunoglobulins and the second line treatment with rituximab or mycophenolate mofetil or splenectomy for those who are refractory to steroids. We report the case of a 35 year old female who presented with high grade fever with chills and rigors associated with hematuria and she has undergone a diagnosis of Evan Syndrome. Parimala L | P Anjaneyulu "Evan Syndrome: A Case Report" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-8 | Issue-1 , February 2024, URL: https://www.ijtsrd.com/papers/ijtsrd62406.pdf Paper Url: https://www.ijtsrd.com/medicine/other/62406/evan-syndrome-a-case-report/parimala-l
Introduction: malignant syphilis is an uncommon form of secondary syphilis.This presentation usually occurs in immunocompromised patients, especially in those ones infected by human immunodeficiency virus (HIV). However, it is known that it might exceptionally affect individuals with normal immune response.
This case report describes an immunocompetent 30-year-old male patient who presented with widespread painful skin lesions and uveitis of the right eye. Laboratory tests initially were negative for syphilis but later tested positive, confirming the diagnosis of early malignant syphilis. Malignant syphilis is an uncommon form of secondary syphilis typically seen in immunocompromised individuals. However, this report describes the second known case of an immunocompetent patient presenting with both skin and ocular involvement. The patient was treated with intravenous ceftriaxone for 14 days and experienced an excellent clinical response.
- Early treatment initiation is most effective for MS, especially for those with recent disease activity or clinically isolated syndrome. A diagnosis of relapsing-remitting MS requires evidence of more than one inflammatory episode.
- Management of clinically isolated syndrome and early MS is complex, involving education, lifestyle management, and usually discussing disease-modifying therapy. Treatment selection involves considering the patient's risks and preferences.
- Common approaches to treatment include escalation therapy, starting with low-risk treatments, or an induction approach starting with an aggressive therapy. Recent evidence suggests avoiding delays in initiating or escalating treatment.
Relapse of Herpes Simplex Encephalomyelitis Presenting As Guillain Barre Synd...iosrjce
This document describes a case study of a 70-year-old man who presented with symptoms of herpes simplex encephalomyelitis (HSE) including headache, vomiting, fever, confusion and weakness. He was treated with acyclovir and showed improvement, but later developed Guillain-Barré syndrome (GBS) with progressive weakness. Testing found positive antibodies for herpes simplex virus type 1, indicating either a current or past infection. Despite treatment, his condition deteriorated and he ultimately died. The authors conclude this is a rare case of HSE relapse presenting as GBS, likely due to viral reactivation rather than a new infection.
Immune reconstitution inflammatory syndrome (IRIS) describes paradoxical worsening of preexisting infections after initiating antiretroviral therapy in HIV patients. It occurs as a result of the rapid recovery of CD4+ T cells, which mount inflammatory responses against pathogens. Common types of IRIS include TB, cryptococcosis, and CMV. Symptoms vary by pathogen but may include fever, lymphadenitis, and worsening pulmonary infiltrates. While usually self-limiting, corticosteroids may be used for severe cases. Prevention strategies include earlier HIV diagnosis and optimizing treatment of opportunistic infections prior to initiating ART.
Rheumatological diseases can affect any organ system and cause life-threatening complications requiring intensive care. The document discusses several key rheumatological conditions that intensivists should be aware of including:
1) Macrophage activation syndrome, a potentially lethal complication seen in rheumatological diseases characterized by uncontrolled inflammation.
2) Scleroderma renal crisis, a rheumatological emergency caused by thickening of renal arteries leading to hypertension and kidney failure.
3) Catastrophic antiphospholipid syndrome, a rare but severe form of antiphospholipid antibody syndrome involving rapid multi-organ failure.
Early recognition and management of these rheumatological conditions is important to prevent poor outcomes for patients in intensive care
A 34-year-old woman presented with fever, headache, and fatigue for 2 weeks. She was diagnosed with HIV 6 months ago and started on antiretroviral therapy. Examination found fever and neck stiffness. Tests found cryptococcal meningitis. She was diagnosed with advanced HIV and an opportunistic cryptococcal meningitis infection, possibly an immune reconstitution inflammatory syndrome reaction. Treatment included antifungals and monitoring for IRIS as her immunity improved with antiretroviral therapy.
Viruses are obligate intracellular parasites.Our arsenal of antivirals is dangerously small.Currently available antivirals are mainly against Herpes,Hepatitis and AIDS viruses.The treatment of HCV has shifted away from the use of Peg-IFN towards oral antivirals.Preventive vaccination is the key to global control of viral infections.
Similar to Immune Reconstitution Inflammatory Syndrome (IRIS) Associated Multifocal Leukoencephalopathy (PML) in Patients with Human Immunodeficiency Virus (HIV) Infection: A Case Report (20)
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Immune Reconstitution Inflammatory Syndrome (IRIS) Associated Multifocal Leukoencephalopathy (PML) in Patients with Human Immunodeficiency Virus (HIV) Infection: A Case Report
1. International Multispecialty Journal of Health (IMJH) ISSN: [2395-6291] [Vol-3, Issue-4, April- 2017]
Page | 85
Immune Reconstitution Inflammatory Syndrome (IRIS)
Associated Multifocal Leukoencephalopathy (PML) in Patients
with Human Immunodeficiency Virus (HIV) Infection: A Case
Report
Dr. Mayank Gupta1*
, Dr. Jasraj B. Panwar2
, Dr. Ishwar Chouhan3
, Dr. Gaurav Chauhan4
,
Dr. Sunil Mahavar5
1,3,4,5
Ex Resident Doctor, Department of Medicine, SMS Medical College, Jaipur (Rajasthan) India.
2
Senior Resident Doctor, Department of Medicine, Rajindra Hospital, GMC, Patiala (Panjab) India
Abstract—Progressive Multifocal Leukoencephalopathy (PML) is seen mostly in advanced human
immunodeficiency virus (HIV) infection. In some individuals, especially those with very low
CD4+
counts, worsening of PML or new-onset PML can be observed after the initiation of highly active
antiretroviral therapy (HAART). A case of IRIS associated PML is reported here which is much more
rare as compared to PML in HIV patients unrelated to HAART. This is thought to be secondary to
immune reconstitution inflammatory syndrome (IRIS). IRIS is defined as a paradoxical deterioration of
a previously existing infection which is related to the immune system recovery. It is suggested to occur
due to an imbalance of CD8+
/CD4+
T cells. So in HIV cases with low CD4 counts and if one is on
HAART then should be further investigated for IRIS and PML.
Keywords: PML, HIV, HAART, IRIS
I. INTRODUCTION
Subclinical hypothyroidism (SCH) can be best defined as a high serum thyroid stimulating hormone
(TSH) and normal serum total/free thyroxine (T4), triiodothyronine (T3) concentrations associated with
few or no symptoms/signs of hypothyroidism. It is referred to as a state of mild thyroid failure and is
essentially a laboratory diagnosis.1,2
Subclinical hypothyroidism is much more common than overt
hypothyroidism3,4
with a world-wide prevalence of about 7.5% to 8.5% in women and 2.8% to 4.4% in
men. 5
In the era of combined antiretroviral therapy, despite a dramatic fall in the incidence of most
opportunistic infections, progressive multifocal leukoencephalopathy (PML) continues to occur at a
similar frequency in HIV infected patients. PML occurs in up to 5% of patients with Acquired
Immunodeficiency Syndrome (AIDS). 1
PML-IRIS may account for up to 18% of HIV-infected patients with PML. Rest 82% PML in HIV is
unrelated to HAART treatment. Reactivation of JC virus (JCV), a polyoma virus, leads to PML. JCV
infects oligodendrocytes and astrocytes in the CNS and induces a non-inflammatory lytic reaction which
leads to demyelination, necrosis, and cell death. In some individuals, especially those with very low
CD4+
counts, after the initiation of highly active antiretroviral therapy (HAART) worsening of PML or
new-onset PML can be observed. This is thought to be secondary to immune reconstitution
2. International Multispecialty Journal of Health (IMJH) ISSN: [2395-6291] [Vol-3, Issue-4, April- 2017]
Page | 86
inflammatory syndrome (IRIS). Immune reconstitution inflammatory syndrome (IRIS) is a paradoxical
deterioration of a previously existing infection following the initiation of HAART in patients with HIV
infection. 2,3
II. METHODOLOGY
A typical case of HIV with IRIS and PML attended in Medicine OPD of SMS Hospital, Jaipur. So case
study was done thoroughly and case report was prepared to publish this rare case.
III. CASE REPORT
A 52-year-old north Indian male with a past medical history of hypertension and diabetes mellitus was
presented with noncompliance with medication, who also presented with insidious onset, gradually
progressive weakness of left side of the body and progressive dysarthria over a 20-day period that had
worsened in the previous 3-4 days along with vertigo, vomiting, imbalance of gait, swaying of left side
of the body, ataxia and weakness of left side with cerebellar hypotonia. The patient denied any other
neurological symptoms.
On neurological examination, the patient was found to have difficulties with speech, nystagmus, left
sided cerebellar signs and hypotonia. The rest of the neurological examination was normal.
During the hospital stay, an MRI of the brain was performed for the suspicion of stroke or
demyelination etiology. A contrast enhanced MRI brain showed scalloped, high signal lesion in the left
fronto-parietal white matter and left cerebellar hemisphere in the axial T2- weighted fast spin-echo
(FSE) image (Figure 1). The lesion is better seen on axial FLAIR-FSE image (Figure 3). There is no
mass effect. No enhancement is seen in the contrast enhanced T1-weighted SE (spin echo), which was
not typical for ischemic infarction or demyelination (Figure 1 to 5). This subsequently broadened the
differential to include sarcoidosis, PML, CMV (Cytomegalo virus) encephalitis. The PCR for JC virus
in the CSF was positive; on that basis diagnosis of PML was made.
Figure: 1 Figure: 2
MRI Brain- diffuse increased T2 weighted signal
throughout the left cerebellar hemisphere
MRI Brain- increased T2 weighted signal in left
frontal lobe
3. International Multispecialty Journal of Health (IMJH) ISSN: [2395-6291] [Vol-3, Issue-4, April- 2017]
Page | 87
Figure: 3 Figure: 4
MRI Brain- increased axial FLAIR signal in pons
MRI Brain- increased coronal FLAIR signal in left
frontal lobe
Figure: 5
MRI Brain- increased axial FLAIR signal in left
temporal lobe
The patient was HIV positive with CD4 count of 26. The CD4 count had increased diminutively from
26 to 77 during last 2 months after starting HAART. The patient was assessed to have possible immune
reconstitution inflammatory syndrome (IRIS) given the new-onset weakness and dysarthria.
The patient was continued on HAART and started intravenous dexamethasone, antiepileptic
medications and Pneumocystis carinii prophylaxis.
On follow up in next visit, patient showed improvement in his neurological deficit along with
radiological improvement.
IV. DISCUSSION
PML-IRIS develops between 1 week and 26 months after initiation of antiretroviral therapy. There is
sparse literature on HIV/AIDS with PML from developing countries including India. Progressive
multifocal leukoencephalopathy (PML) is a CNS (central nervous system) demyelinating disease. It is
caused by JC polyoma virus (JCV). Acquired immunodeficiency syndrome (AIDS), after the advent of
4. International Multispecialty Journal of Health (IMJH) ISSN: [2395-6291] [Vol-3, Issue-4, April- 2017]
Page | 88
the HIV epidemic, became the most common predisposing factor for the occurrence of PML.4
The
incidence of PML has fallen less dramatically when compared to other CNS diseases after the advent of
HAART.5
The use of combined antiretroviral therapy markedly improves immune function and
prognosis in HIV-infected patients; however, PML may develop or worsen with antiretroviral therapy,
despite an immunological recovery. Immune reconstitution inflammatory syndrome (IRIS) is
responsible for this manifestation.6
IRIS, by definition, comprises of an inflammatory component which occurs in the setting of
reconstitution of the immune system that cannot be elaborated or justified by toxicity of the drug, a new
opportunistic infection (OI), or the expected course of a previously diagnosed OI. The clinical features
of IRIS are the result of dysregulated and enhanced cellular immune responses and are linked to the site
and type of pre-existing infections. Wide range of pre-existing infections which include Pneumocystis
carinii, mycobacterial and cryptococcal infections, Kaposi’s sarcoma, cytomegalovirus, non-Hodgkin
lymphoma and PML.7
In this case, PML-IRIS was defined by the following clinical criteria: 1) Patient with HIV infection; 2)
The diagnosis of PML was established by detection of JCV DNA in the CSF 3) By the presence of
characteristic clinical and neuro-radiological features with exclusion of other opportunistic infections
(tuberculosis, toxoplasmosis, cryptococcosis, other viral infections) and CNS lymphoma; 4) Symptoms
could not be explained by a newly acquired infection, the expected course of a newly diagnosed
opportunistic infection, or drug toxicity.
Risk factors for the development of IRIS in HIV-infected individuals include antiretroviral naive, using
a boosted protease inhibitor, low CD4 lymphocyte counts (<100 cells/mm3
), higher level of viraemia at
baseline, rapid decrease in HIV load, rapid immune recovery following the initiation of HAART, and
the presence of active or subclinical opportunistic infections at the time of initiation of HAART.8
This patient is antiretroviral naive, CD4 count <50, and no active opportunistic infection at the time of
initiation of HAART. Risk factors for the development of IRIS in this patient is antiretroviral naive, and
CD4 count 22 with no history suggestive of opportunistic infection.
For the prevention or treatment of PML-IRIS, till date, there are no evidence-based guidelines. Some
cases of IRIS are mild and resolve with continuation of combined antiretroviral therapy. Others result in
significant morbidity and sometimes death. Anti-inflammatory agents such as steroids have been used
and may be effective in the treatment of IRIS following other AIDS-related CNS infections.9
There are no effective drugs that inhibit or cure the virus infection without toxicity. Therefore treatment
aims at reversing the immune deficiency to slow or stop the disease progression. In patients on
immunosuppressant which means stopping the drugs or using plasma exchange to accelerate the
removal of the biologic agents like rituximab and natalizumab may put the person at risk for PML.10
In
HIV infected people, starting highly active antiretroviral therapy (HAART) may lead to PML. AIDS
patients starting HAART after being diagnosed with PML tend to have a slightly longer survival time
than patients who were already on HAART and then develop PML. 11
In patients with PML-IRIS, the standard treatment is continuation of HAART therapy in addition to
high-dose glucocorticoid therapy (e.g., dexamethasone). However, the efficacy and safety of using
steroids in PML-IRIS remain largely unknown due to limited data. A combination of neurologic
deterioration and radiologic evidence of brain swelling is a relative indication for steroid usage.12,13
5. International Multispecialty Journal of Health (IMJH) ISSN: [2395-6291] [Vol-3, Issue-4, April- 2017]
Page | 89
In three separate case reports, HAART was discontinued for 2-3 weeks following diagnosis of PML-
IRIS, and the patients did well on the followup. However, the practice of discontinuing HAART is not
currently advocated.14
Following the diagnosis of PML-IRIS in our patient, HAART was continued, and dexamethasone was
added in an attempt to counteract the cerebral edema. This corresponds to the standard treatment of
PML-IRIS. In this case, we examine the effects of steroid use in HIV-infected patients with PML-IRIS.
Cidofovir, Cytarabine (also known as ARA-C), a chemotherapy drug and antimalarial drug Mefloquine
with activity against the JC virus were studied as possible treatment for PML15,16,17
and has been used on
a case by case basis, working in some but not others.
V. CONCLUSION
It can be concluded from this study that subjects with HIV, following the initiation of HAART,
reconstitution of immune system may lead to activation of an inflammatory response which may leads
to detectable or latent JC virus infection. Early and prolonged treatment with steroids may be useful in
patients with PML-IRIS but requires further investigation.
CONFLICT OF INTEREST
None declared till now.
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