Ammassari A, Scoppettuolo G, Murri R, Pezzotti P, Cingolani A, Del Borgo C, De Luca A, Antinori A, Ortona L
Department of Infectious Diseases, Catholic University, Rome, Italy.
J Acquir Immune Defic Syndr Hum Retrovirol. 1998 Aug 1;18(4):365-71. doi: 10.1097/00042560-199808010-00008.
To assess temporal trends of the different disorders causing focal brain lesions (FBL) in HIV-infected patients and to examine the reliability of the U.S. Centers for Disease Control and Prevention (CDC) criteria for presumptive diagnosis of toxoplasmic encephalitis (TE) for the years 1991 to 1996.
DESIGN/METHODS: A prospective, monocenter study. Percentages of occurrence of the different FBL-causing disorders for each year were calculated. Temporal trends were analyzed by chi2 test for linear trend and multivariate polytomous nonordinal logistic regression. The positive predictive value (PPV) of the CDC's presumptive criteria for the diagnosis of TE (recent onset of a focal neurologic abnormality consistent in intracranial disease or a reduced level of consciousness, evidence on brain imaging of a lesion having mass effect or the radiographic appearance of which is enhanced by injection of contrast medium, and serum antibody to toxoplasmosis) was calculated using contingency tables for each calendar year.
A highly significant decline of the risk of TE and an increase of the probability of patients to take anti-Toxoplasma prophylaxis were observed. A threefold but statistically not significant augmented risk of diagnosing both primary central nervous system lymphoma (PCNSL) and progressive multifocal leucoencephalopathy (PML) has been registered for 1996 compared with 1991. Among FBL showing contrast enhancement, the increased finding of PCNSL over the years studied was significant. The probability of other FBL-causing disorders, such as focal viral encephalitis sustained by cytomegalovirus or herpes simplex virus, increased significantly over the years studied. Multivariate analysis confirmed that the year of diagnosis of FBL had a significant effect on the risk reduction of TE. The PPV of the CDC's criteria for the presumptive diagnosis of TE dropped from 100% for the year 1991 to 39% in the year 1996. A similar result was obtained in calculating the PPV of presumptive criteria only among patients without previous primary prophylaxis.
Because of the significant decrease of TE and the increase of PCNSL empiric anti-Toxoplasma therapy no longer seems appropriate as a first-line approach to all HIV-positive patients with FBL. Especially in the case of a finding of FBL by contrast enhancement, new diagnostic strategies should be employed to identify the underlying disorder rapidly and accurately.
评估导致HIV感染患者局灶性脑损伤（FBL）的不同疾病的时间趋势，并检验美国疾病控制与预防中心（CDC）1991年至1996年期间弓形虫脑病（TE）推定诊断标准的可靠性。
设计/方法：一项前瞻性单中心研究。计算每年导致不同FBL的疾病的发生百分比。通过线性趋势的卡方检验和多变量多分类无序逻辑回归分析时间趋势。使用每个日历年的列联表计算CDC用于诊断TE的推定标准（近期出现与颅内疾病一致的局灶性神经功能异常或意识水平降低、脑部影像学显示有占位效应的病变或注射造影剂后影像学表现增强、以及弓形虫血清抗体）的阳性预测值（PPV）。
观察到TE风险显著下降，且患者接受抗弓形虫预防的概率增加。与1991年相比，1996年诊断原发性中枢神经系统淋巴瘤（PCNSL）和进行性多灶性白质脑病（PML）的风险增加了三倍，但在统计学上无显著差异。在显示有造影剂增强的FBL中，研究期间PCNSL的检出率增加显著。多年来，由巨细胞病毒或单纯疱疹病毒引起的其他导致FBL的疾病的概率显著增加。多变量分析证实，FBL的诊断年份对TE风险降低有显著影响。CDC用于TE推定诊断的标准的PPV从1991年的100%降至1996年的39%。仅在未接受过初级预防的患者中计算推定标准的PPV时也得到了类似结果。
由于TE显著减少且PCNSL增加，经验性抗弓形虫治疗似乎不再适合作为所有HIV阳性FBL患者的一线治疗方法。特别是在通过造影剂增强发现FBL的情况下，应采用新的诊断策略来快速、准确地识别潜在疾病。
