Three acquired immunodeficiency syndrome patients with central nervous system infection: diagnostic approach and outcome of treatment

Three acquired immunodeficiency syndrome patients with central nervous system infection: diagnostic approach and outcome of treatment

For people living with AIDS, a weakened immune system makes them vulnerable to opportunistic infections—including those that target the brain and spinal cord (the central nervous system, or CNS). Here’s a critical fact: 10% of AIDS patients first notice symptoms like slurred speech, numbness, or limb weakness because of CNS issues, and over 40% of untreated patients will develop CNS diseases. Diagnosing these infections is challenging—symptoms and routine tests often don’t provide clear answers. To shed light on this, doctors at Peking Union Medical College Hospital in Beijing analyzed three AIDS patients with CNS infections where standard treatments failed, turning to brain biopsies for clearer diagnoses.

Study Background

Between 1985 and 2017, 442 patients with AIDS were admitted to Peking Union Medical College Hospital. Of these, three had CNS infections confirmed by cerebrospinal fluid (CSF—the fluid surrounding the brain and spinal cord) tests and brain biopsies. Routine antiretroviral therapy (HAART, a combination of drugs that suppress HIV) and empirical treatments didn’t improve their symptoms, so the team used biopsies to get specific diagnoses. The study followed ethical guidelines set by the Declaration of Helsinki and was approved by the hospital’s ethics committee.

The Three Cases

All three patients had focal neurological symptoms (problems in specific parts of the nervous system), like trouble speaking, numbness, or weakness. Their brain MRIs showed abnormal signals, and biopsies targeted areas identified by imaging (frontal lobe in two cases, frontal-temporal lobe in one). Here’s what happened:

Case 1: 47-Year-Old Woman with Dual Infections

Diagnosed with AIDS in 2006 after unexplained weight loss, she developed worsening neurological symptoms. A brain biopsy revealed two infections: progressive multifocal leukoencephalopathy (PML) (a viral disease that damages brain white matter) and toxoplasmosis (a parasitic infection). Special stains (Hexamine silver and Periodic Acid-Schiff, or PAS) confirmed Toxoplasma gondii, the parasite causing toxoplasmosis. She received HAART (Lamivudine + Stavudine + Nevirapine) and anti-toxoplasmosis drugs (TMP + Clindamycin + Azithromycin + SMZco). Unfortunately, her symptoms didn’t improve—likely because of the dual infections and how HIV damages the brain even with treatment.

Case 2: 25-Year-Old Man with Bacterial Infection

He had trouble speaking and moving his right limb for three months. A biopsy smear showed gram-positive cocci and gram-negative bacilli (types of bacteria). He received HAART (Efavirenz + Lamivudine + Stavudine) and antibiotics (Ceftazidime + Norvancomycin). His symptoms improved, and he was discharged in better condition.

Case 3: 37-Year-Old Man with Tuberculous Meningitis

Admitted with fever and headaches in 2013, his sputum tested positive for acid-fast bacteria (a key sign of tuberculosis). A second CSF sample also tested positive, and his CSF culture grew Staphylococcus hominis. The biopsy was non-specific, but he improved dramatically with HAART (Lamivudine + Stavudine + Nevirapine) and 4-drug anti-tuberculosis therapy (Isoniazid + Rifampin + Pyrazinamide + Ethambutol). This confirmed tuberculous meningitis—a rare but severe infection in AIDS patients, where the tuberculosis bacteria attack the membranes surrounding the brain.

Why Brain Biopsies Matter

Brain biopsies are a game-changer when standard treatments fail. Studies back this up:

• Rosenow et al. found 92.3% of biopsies in AIDS patients with CNS lesions gave a clear diagnosis.
• Zibly et al. reported a 93.75% diagnostic rate.

But biopsies aren’t perfect—some only show “infection” without naming the cause. For Case 1, special stains helped, but the team noted that adding tests like immunohistochemistry (using antibodies to detect specific proteins) or PCR (a technique to amplify DNA) could make diagnoses even stronger. For Cases 2 and 3, additional tests (biopsy smears, repeated CSF stains) filled in the gaps.

Treatment Insights

HAART is life-saving for AIDS patients—it controls HIV, reduces mortality, and slows the virus’s spread. But for CNS infections, the blood-brain barrier (a protective layer that blocks harmful substances from entering the brain) can stop antiretrovirals from working. Case 1’s lack of improvement shows that even early HAART might not reverse brain damage from multiple infections.

For Case 3, the 4-drug TB therapy worked because most non-TB bacteria resist standard anti-mycobacterial drugs—his improvement strongly supported the diagnosis of tuberculous meningitis.

Key Takeaways

Diagnosing CNS infections in AIDS requires a combination of tools: CSF tests, imaging, and sometimes biopsies. When empirical treatments (tries based on common causes) don’t work, a biopsy can be life-changing—like in Cases 2 and 3. But biopsies aren’t a replacement for other tests.

The biggest lesson? Multidisciplinary care (working with neurosurgeons, infectious disease experts, and pathologists) and early, targeted treatment are essential for better outcomes.

This study was conducted by Yi-Hao Chen, Jian-Bo Chang, Jun-Ji Wei, Wei Lyu, Shuang-Ni Yu, Bai-Tao Ma, Hao Wu, Xiao Zhang, Wei Lian, Wen-Bin Ma, Ting-Ting Wang, Tai-Sheng Li, and Ren-Zhi Wang from the Department of Neurosurgery, Department of Infectious Disease, Department of Pathology, and Central Research Laboratory at Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College in Beijing, China. It was published in the Chinese Medical Journal in 2019.

doi.org/10.1097/CM9.0000000000000507

Was this helpful?

YesNo

0 / 0