cpc #2: 38 year old woman with hiv/aids and altered mental status october 9, 2007
TRANSCRIPT
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CPC #2: 38 year old woman with HIV/AIDS and altered mental status
October 9, 2007
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Lungs
Combined weight 2,200 gm (normal 685-1,050) Most of weight increase due to pulmonary edema Multiple discrete nodules with necrotic centers Bronchopneumonia CMV infection
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Pulmonary edema
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Necrotizing nodules – no AFB or fungi ID’d
CD20 – B-cells
CD3 – T-cells
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Bronchopneumonia
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Bronchopneumonia – and CMV infection
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CMV in alveoli and around necrotizing masses
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Disseminated CMV
Kidney Adrenal Pancreas
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Disseminated CMV
Spleen Ovary
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Brain: multiple poorly defined massesRight frontal lobe
Left striatum *
Right striatum *
Left insula
Left cerebellum
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Primary CNS lymphoma
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Primary CNS lymphoma
Tumor cells in vessel walls Diffuse parenchymal invasion
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Primary CNS lymphoma - EBV
CD20 – B-cells CD3 – T-cells EBV
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Cause of death
Part I
a) B-cell lymphoma, brain
b) Acquired immunodeficiency syndrome
Part II
a) Disseminated CMV infection
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HIV neuroinvasion: “Trojan Horse hypothesis”
Viral entrance into CNSInfected monocytes enter, differentiate into perivascular
macrophagesInfected CD4+ T cellsDirect entrance of virusTranscytosis of virus across endothelial cells
Productive infection of macrophages and microgliaRestricted infection of astrocytesInfection of oligodendrocytes and especially neurons is
questionable
Ghafouri et al. Retrovirology 2006; 3:28
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CNS infections in AIDS Fungi
Cryptococcus AspergillusCoccidioides
http://www.vfce.arizona.edu/VFCE%20OLD/jpg/2330034.jpg
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CNS infections in AIDS
FungiCryptococcus
Aspergillus
Coccidioides
ParasitesToxoplasma
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CNS infections in AIDS Fungi
Cryptococcus AspergillusCoccidioides
ParasitesToxoplasma
Viruses (encephalitis)Cytomegalovirus (CMV)HIV
Ellison & Love: Neuropathology 2e © 2004 Elsevier Ltd.
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CNS infections in AIDS Fungi
Cryptococcus AspergillusCoccidioides
ParasitesToxoplasma
Viruses (encephalitis)Cytomegalovirus (CMV)HIV
Viruses (other pathology)JC virus (PML, demyelination)Epstein-Barr virus (EBV) - lymphoma
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Primary CNS lymphoma (PCNSL)
More frequent in both immunocompromised and immunocompetent patients (especially elderly) over last 20 years6-20% of AIDS patients
EBV implicated in most immunocompromised and some immunocompetent individuals (nearly all AIDS patients)
Usually diffuse large B-cell tumors Occur anywhere in brain
Incidence proportional to volume (i.e., most common in frontal lobe)
Often multifocal in AIDS patients
Symptoms reflect location
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Primary CNS lymphoma (PCNSL)
Imaging (without AIDS): homogeneous enhancement Imaging (with AIDS): “ring-enhancing”, often multifocal Histology:
Solid sheets of tumor cells (often necrotic) blending into less cellular zones
Angiocentric and angioinvasive
Positive for B-cell markers, EBV (immunocompromised)
Treatment: radiation and / or chemotherapy Prognosis:
Immunocompetent: median survival 18 months
Immunocompromised: median survival 4 months
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References
Burger et al. Surgical Pathology of the Nervous System and Its Coverings. Fourth Edition. 2002. Churchill Livingston.
Ellison et al. Neuropathology. A reference text of CNS pathology. Second Edition. 2004.
http://www.emedicine.com/neuro/topic519.htm
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