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CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

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Page 1: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

CPC #2: 38 year old woman with HIV/AIDS and altered mental status

October 9, 2007

Page 2: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

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

Page 3: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

Pulmonary edema

Page 4: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

Necrotizing nodules – no AFB or fungi ID’d

CD20 – B-cells

CD3 – T-cells

Page 5: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

Bronchopneumonia

Page 6: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

Bronchopneumonia – and CMV infection

Page 7: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

CMV in alveoli and around necrotizing masses

Page 8: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

Disseminated CMV

Kidney Adrenal Pancreas

Page 9: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

Disseminated CMV

Spleen Ovary

Page 10: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

Brain: multiple poorly defined massesRight frontal lobe

Left striatum *

Right striatum *

Left insula

Left cerebellum

Page 11: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

Primary CNS lymphoma

Page 12: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

Primary CNS lymphoma

Tumor cells in vessel walls Diffuse parenchymal invasion

Page 13: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

Primary CNS lymphoma - EBV

CD20 – B-cells CD3 – T-cells EBV

Page 14: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

Cause of death

Part I

a) B-cell lymphoma, brain

b) Acquired immunodeficiency syndrome

Part II

a) Disseminated CMV infection

Page 15: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

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  

Page 16: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

CNS infections in AIDS Fungi

Cryptococcus AspergillusCoccidioides

http://www.vfce.arizona.edu/VFCE%20OLD/jpg/2330034.jpg

http://www.vfce.arizona.edu/
Page 17: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

CNS infections in AIDS

FungiCryptococcus

Aspergillus

Coccidioides

ParasitesToxoplasma

Page 18: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

CNS infections in AIDS Fungi

Cryptococcus AspergillusCoccidioides

ParasitesToxoplasma

Viruses (encephalitis)Cytomegalovirus (CMV)HIV

Ellison & Love: Neuropathology 2e © 2004 Elsevier Ltd.

Page 19: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

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

Page 20: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

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

Page 21: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

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

Page 22: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

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

Page 23: CPC #2: 38 year old woman with HIV/AIDS and altered mental status October 9, 2007

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