Manzardo Christian, Del Mar Ortega María, Sued Omar, García Felipe, Moreno Asunción, Miró José M
Infectious Diseases Service, Hospital Clinic, Institut d'Investigacions Biomediques August Pi i Sunyer, University of Barcelona, Barcelona, Spain.
J Neurovirol. 2005;11 Suppl 3:72-82. doi: 10.1080/13550280500513846.
A marked decrease in incidence has been observed for most central nervous system (CNS) opportunistic infections (OIs) after the use of highly active antiretroviral therapy (HAART) in developed countries. However, the spectrum of these OIs in acquired immunodeficiency syndrome (AIDS) patients has remained almost unchanged. CNS toxoplasmosis, cryptococcosis, tuberculosis, and progressive multifocal leukoencephalopathy (PML) remain the most frequent ones. Primary CNS lymphoma should be included in the differential diagnosis of all cases with focal lesions. Final diagnosis is currently made by combining neuroimaging techniques (single-photon emission computed tomography [SPECT], positron emission tomography [PET], magnetic resonance imaging [MRI] and/or computed tomography [CT] scan) and molecular studies of cerebrospinal fluid (CSF) and therapeutical response. Stereotactic biopsy should only be performed in the case of atypical lesions or nonresponse to recommended treatments. After treatment of the acute phase, lifelong maintenance therapy is necessary to prevent OI recurrences. Once HAART is initiated, some patients can develop a clinical worsening of some CNS OIs with or without atypical neuroimaging manifestations. This paradoxical worsening is known as the immune reconstitution inflammatory syndrome (IRIS) and it results from reconstitution of the immune system's ability to recognize pathogens/antigens in patients with prior OIs and low CD4+ T-cell counts. In this context, IRIS can be seen in patients with CNS cryptococcosis, tuberculosis, or PML. On the other hand, HAART-induced immune reconstitution can improve the prognosis of some untreatable diseases such as PML, and can allow maintenance therapy of some CNS OI to be safely discontinued in patients with high and sustained CD4+ T-cell response.
在发达国家，使用高效抗逆转录病毒疗法（HAART）后，大多数中枢神经系统（CNS）机会性感染（OI）的发病率已显著下降。然而，获得性免疫缺陷综合征（AIDS）患者中这些OI的谱几乎保持不变。CNS弓形虫病、隐球菌病、结核病和进行性多灶性白质脑病（PML）仍然是最常见的。所有有局灶性病变的病例的鉴别诊断都应包括原发性CNS淋巴瘤。目前通过结合神经影像学技术（单光子发射计算机断层扫描[SPECT]、正电子发射断层扫描[PET]、磁共振成像[MRI]和/或计算机断层扫描[CT]）以及脑脊液（CSF）的分子研究和治疗反应来做出最终诊断。立体定向活检仅在病变不典型或对推荐治疗无反应的情况下进行。急性期治疗后，需要终身维持治疗以预防OI复发。一旦开始HAART，一些患者可能会出现一些CNS OI的临床恶化，伴有或不伴有非典型神经影像学表现。这种矛盾的恶化被称为免疫重建炎症综合征（IRIS），它是由于免疫系统识别先前有OI且CD4 + T细胞计数低的患者中的病原体/抗原的能力重建所致。在这种情况下，IRIS可见于患有CNS隐球菌病、结核病或PML的患者。另一方面，HAART诱导的免疫重建可以改善一些不可治疗疾病如PML的预后，并且可以使一些CNS OI的维持治疗在CD4 + T细胞反应高且持续的患者中安全停药。
