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HIV-1 Associated Opportunistic Infections - Cytomegalovirus Encephalitis: Differential Diagnoses & Workup

Author: Niranjan N Singh, MD, DNB, Assistant Professor of Neurology, University of Missouri Columbia
Coauthor(s): Vitor Pacheco, MD, Staff Physician, Department of Neurology, St Louis University Hospital; Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Contributor Information and Disclosures

Updated: May 4, 2007

Differential Diagnoses

Herpes Simplex Encephalitis
HIV-1 Associated Opportunistic Neoplasms: CNS Lymphoma
HIV-1 Associated Cerebrovascular Complications
HIV-1 Encephalopathy and AIDS Dementia Complex
HIV-1 Associated Opportunistic Infections: CNS Cryptococcosis
HIV-1 Associated Opportunistic Infections: CNS Toxoplasmosis
HIV-1 Associated Opportunistic Infections: PML

Other Problems to Be Considered

Metabolic encephalopathies

Workup

Laboratory Studies

  • Cerebrospinal fluid (CSF) analysis not only can point to the correct diagnosis but also permits exclusion of other diagnostic considerations.
    • Typically, CSF has elevated protein and mononuclear leukocytosis levels.
    • CMV can be detected by culture, polymerase chain reaction (PCR), CMV antigen, or cytology. In patients without CMV infection, CMV is rarely detected by PCR in the CSF. CSF PCR may be of benefit in confirming the diagnosis.
  • Electrolyte disturbances (eg, hypernatremia) consistent with adrenal insufficiency may be observed.

Imaging Studies

  • Computed tomography (CT) scan and magnetic resonance imaging (MRI) can aid in the diagnosis and can exclude other diagnostic considerations (eg, absence of parenchymal enhancement, evidence of increased intracranial pressure).
  • Head CT and MRI findings include encephalitis involving the cerebral hemispheres and brainstem, ventriculitis, meningitis, and infarcts. Hydrocephalus, ring enhancing lesions, and cerebral atrophy have been reported. Periventricular calcification, a marker of congenital CMV infection, is not seen.
  • MRI may show discrete nonspecific abnormalities including ventriculitis, hydrocephalus, and atrophy. Mass lesions due to CMV have been reported but are rare.
    • T2-weighted MRI may show diffuse white matter hyperintensity similar to that seen in HIV encephalopathy and other HIV-associated CNS disorders.
    • Gadolinium contrast MRI may reveal meningeal and ependymal enhancement as well as ring enhancing lesions.

Histologic Findings

Histologic findings include ventriculoencephalitis, microglial nodules, focal parenchymal necrosis, isolated cytomegalic cells, and nuclear inclusions.

More on HIV-1 Associated Opportunistic Infections - Cytomegalovirus Encephalitis

Overview: HIV-1 Associated Opportunistic Infections - Cytomegalovirus Encephalitis
Differential Diagnoses & Workup: HIV-1 Associated Opportunistic Infections - Cytomegalovirus Encephalitis
Treatment & Medication: HIV-1 Associated Opportunistic Infections - Cytomegalovirus Encephalitis
Follow-up: HIV-1 Associated Opportunistic Infections - Cytomegalovirus Encephalitis
References
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References

  1. Anduze-Faris BM, Fillet AM, Gozlan J, et al. Induction and maintenance therapy of cytomegalovirus central nervous system infection in HIV-infected patients. AIDS. Mar 31 2000;14(5):517-24. [Medline].

  2. Bylsma SS, Achim CL, Wiley CA. The predictive value of cytomegalovirus retinitis for cytomegalovirusencephalitis in acquiredimmunodeficiency syndrome. Arch Ophthalmol. 1995;113:89-95. [Medline].

  3. Erice A. Resistance of human cytomegalovirus to antiviral drugs. Clin Microbiol Rev. Apr 1999;12(2):286-97. [Medline].

  4. Gendelman HE, Lipton SA, Epstein L. The Neurology of AIDS. New York, NY: Chapman & Hall; 1998.

  5. Griffiths P. Cytomegalovirus infection of the central nervous system. Herpes. Jun 2004;11 Suppl 2:95A-104A. [Medline].

  6. Klepser ME, Klepser TB. Drug treatment of HIV-related opportunistic infections. Drugs. Jan 1997;53(1):40-73. [Medline].

  7. Offiah CE, Turnbull IW. The imaging appearances of intracranial CNS infections in adult HIV and AIDS patients. Clin Radiol. May 2006;61(5):393-401. [Medline].

  8. Sadler M, Morris-Jones S, Nelson M, Gazzard BG. Successful treatment of cytomegalovirus encephalitis in an AIDS patient using cidofovir. AIDS. Aug 1997;11(10):1293-4. [Medline].

  9. Said G, Saimont AG, Lacroix C. Neurological complications of HIV and AIDS. Philadelphia, PA: WB Saunders; 1998.

  10. Springer KL, Weinberg A. Cytomegalovirus infection in the era of HAART: fewer reactivations and more immunity. J Antimicrob Chemother. Sep 2004;54(3):582-6. [Medline].

  11. Whitley RJ, Jacobson MA, Friedberg DN, et al. Guidelines for the treatment of cytomegalovirus diseases in patients with AIDS in the era of potent antiretroviral therapy: recommendations of an international panel. International AIDS Society-USA. Arch Intern Med. May 11 1998;158(9):957-69. [Medline].

  12. de Gans J, Portegies P. Neurological complications of infection with human immunodeficiency virus type 1. A review of literature and 241 cases. Clin Neurol Neurosurg. 1989;91(3):199-219. [Medline].

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Further Reading

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Keywords

acquired immunodeficiency syndrome, AIDS, CMV, HIV infection, encephalitis, ventriculitis, myelitis, retinitis, radiculoganglionitis, peripheral neuropathies, cytomegalovirus encephalitis, HIV-1 associated opportunistic infections

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Contributor Information and Disclosures

Author

Niranjan N Singh, MD, DNB, Assistant Professor of Neurology, University of Missouri Columbia
Niranjan N Singh, MD, DNB is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Coauthor(s)

Vitor Pacheco, MD, Staff Physician, Department of Neurology, St Louis University Hospital
Disclosure: Nothing to disclose.

Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Paraplegia Society, and National Multiple Sclerosis Society
Disclosure: Nothing to disclose.

Medical Editor

Ronald A Greenfield, MD, Professor, Department of Internal Medicine, Section of Infectious Diseases, University of Oklahoma College of Medicine
Ronald A Greenfield, MD is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious Diseases Society of America, Medical Mycology Society of the Americas, Phi Beta Kappa, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Pfizer Honoraria Speaking and teaching; Gilead Honoraria Speaking and teaching; Ortho McNeil Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubist  Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Richard J Caselli, MD, Professor, Department of Neurology, Mayo Medical School, Rochester, MN; Chair, Department of Neurology, Mayo Clinic of Scottsdale
Richard J Caselli, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, American Neurological Association, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

Matthew J Baker, MD, Consulting Staff, Collier Neurologic Specialists, Naples Community Hospital
Matthew J Baker, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

 
 
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