Sanders JW; International Conference on AIDS.
Int Conf AIDS. 1996 Jul 7-12; 11: 297 (abstract no. Tu.B.2187).
Medical University of South Carolina, Charleston, South Carolina, USA. Fax: 803-792-6680. E mail: John_W_Sanders@smtgpw.musc.edu.
Objective: CMVE in AIDS has a median survival of 5 weeks1. It is rarely diagnosed or treated due to its nonspecific clinical presentation and the lack of an accurate non-invasive diagnostic test. We report a case, developing during GCV induction therapy for CMV pneumonitis, diagnosed by gadolinium magnetic resonance imaging (MR) with a prolonged response (9 months) to Fosc alone. Methods: Case report, histologic and radiographic findings, literature review. Case Report: A 38 year old man with AIDS and a CD4 count of 4 /mm3 presented with cough, dyspnea, and fever of 38 degrees. A chest xray (CXR) showed increased interstitial markings. Bronchoalveolar lavage failed to show pneumocystis, fungi, or mycobacteria. Transbronchial biopsies (x5) showed many cytoplasmic and intranuclear inclusions in respiratory epithelial and vascular endothelial cells that stained immunocytochemically for CMV. GCV 5 mg/kg IV q 12 hrs. was begun. Dyspnea and CXR findings resolved in 14 days. At this time confusion, ataxia, apathy, diplopia, and a right intranuclear opthalmoplegia developed. No CMV retinitis was present. Computerized tomography (CT) showed "diffuse vague white matter and deep gray matter changes". Cerebrospinal fluid showed 6 lymphocytes per mm3, protein 137 mg/dl, and negative syphilis, cryptococcal antigen, and CMV polymerase chain reaction tests. An MR showed "extensive diffuse periventricular and aqueductal signal abnormalities with enhancement" consistent with prior reports of CMVE2. Brain biopsy was declined. Fosc 60 mg/kg IV q 8 hrs. was substituted for GCV. Confusion and diplopia improved on day 14 of Fosc. Normal mental status and minimal ataxia were present on day 19. MR 2 weeks later showed " significant decrease in the size of the previous lesions without enhancement". Nine months later he has a normal mental status, minimal ataxia, slight lateral gaze nystagmus and one stable CMV retinal lesion on Fosc 90 mg/kg/day. Conclusions: CMVE may have typical MR findings justifying empiric therapy, in the absence of other findings, with very low CD4 counts3. MR may be more accurate than CT for the presumptive diagnosis of CMVE4. GCV-refractory CMVE has responded to combined GCV and Fosc5, but this is the first report of prolonged response to Fosc alone. The response of CMV pneumonitis to GCV in this case suggests that the benefit of Fosc for CMVE may not be due to CMV resistance to GCV. A randomized trial of Fosc vs. GCV for CMVE is warranted.
Publication Types:
Keywords:
- Acquired Immunodeficiency Syndrome
- CD4 Lymphocyte Count
- Confusion
- Cytomegalovirus Infections
- Cytomegalovirus Retinitis
- Encephalitis, Viral
- Foscarnet
- Ganciclovir
- Humans
- Magnetic Resonance Imaging
- Magnetic Resonance Spectroscopy
- Male
- Polymerase Chain Reaction
- Tomography, X-Ray Computed
- radiography
Other ID:
UI: 102218291
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