Vіsnik Naukovih Doslіdžen' (Jan 2018)
CHARACTERISTICS OF CEREBRAL TOXLOPLASMOSIS IN HIV PATIENTS: RETROSPECTIVE ANALYSIS OF 135 CASES IN DNIPROPETROVSK REGION
Abstract
From 40 to 70 % of patients with HIV have neurological disorders. Toxoplasmosis is one of the most common causes of brain damage in patients with HIV, which often leads to mortality. The aim of the study – to determine and compare the main characteristics of the central nervous system toxoplasmosis in HIV-positive patients who had different outcome of the disease (survived or died as a result of the disease). Materials and Methods. A retrospective cohort analysis of 135 cases of cerebral toxoplasmosis in HIV-positive patients in the Dnipropetrovsk region (Ukraine) from 2010 to 2017 was conducted. The presence of toxoplasmosis was confirmed by the detection of DNA of Toxoplasma gondii in the cerebrospinal fluid, and in the dead patients, the study of autopsy material was performed. Statistical processing of the results of the study was conducted using STAT IST ICA v.6.1® and SPSS programs. In order to compare the indicators in the groups of patients who died and those who survived, odds ratios (OR s) were calculated with confidence intervals (95 % CI). Results and Discussion. Toxoplasmosis was diagnosed in 30 % of HIV-positive patients with CNS disordrers. Most of the patients were males – 71 (52.6 %), the average age was 37.79±0.64. The number of fatal cases was 29 (21.5 %). The groups of patients who survived or died did not differ significantly in age ((37.47±0.72) versus (38.93±1.46) years)) (p>0.05) and gender composition (male 53.8 % vs. 48.3 % of women). Sexually transmitted infections occurred in 40.0 % of cases, because of injecting drug use (IDU s) – 34.8 %, the infection route was uncertain in 25.2 %. In the dead, the uncertain route of infection was 51.7 % versus 17.9 % (p<0.001) of surviving patients. In 43 patients (31.9 %) with cerebral toxoplasmosis, the HIV status was determined in the same year or at the same time as the development of toxoplasmosis. The frequency of late detection of HIV (less than a year before the manifestation of CNS toxoplasmosis) in patients who died was 6.49 times higher (95 % CI 2.64–15.95) compared survivors. 76 (56.3 %) of patients had CD4 levels of less than 50 cells/mm3, including those in deaths, this figure was 1.5 times higher – 75.9 % vs. 50.9 % (p<0.05) in survivors. Median CD4 in the period of development of neurological diseases in patients with toxoplasmosis of the central nervous system was 44.5 (IQR 21–100) cells/mm3, of which in patients who died – 33 (IQR 15–44) cells/mm3 vs. 52 (IQR 25–106) cells/mm3 in survivors (p<0.05). The median of viral load (lg VL ) in the period of development of neurological symptoms was 4.96 (IQR 1.60–5.80) copies/ml, and in patients who died, it was 6.20 (IQR 6.05–6.31) copies/ml and significantly exceeded the same rate in those who were discharged with improvement status – 4.89 (IQR 1.60–5.72) copies/ml (p<0.05). Among clinical symptoms, the most common in patients with toxoplasmosis of the central nervous system were: headache – 86 (63.7 %) patients, dizziness and coordination disorders – 81 (60.0 %), convulsions 43 (31.9 %), mono- and hemiparesis – 57 (42.2 %), disorders of cranial nerves – 37 (27.4 %), dysarthria – 27 (20.0 %), cognitive impairment – 29 (21.5 %), disturbed consciousness – 14 (10.4 % ), visual impairment – 7 (5.2 %) cases. In 30 (22.2 %) patients there was a combination of toxoplasmosis and other diseases of the central nervous system. The development of co-infection of toxoplasmosis with tuberculosis in patients with fatal outcome of the disease was observed 4.5 times more often (95 % CI 1.42–14.29) than in survivors (p<0.05). The spread of Epstein-Barr viral infection among the deceased was 4.21 times higher (95 % CI 1.11–15.90) (p<0.05). Conclusions. Cerebral toxoplasmosis accounts for 30.0 % of all HIV-associated infectious disorders of the central nervous system in patients in Dnipropetrovsk region; in 56.3 % of patients, toxoplasmosis is diagnosed at the background of severe immunosuppression, in 21.5 % the primary diagnosed toxoplasmosis has lethal outcome. The chances of lethal outcome of the disease do not depend on gender, age, but significantly increase in the absence of ART , the number of CD4 cells/mm3 less than 50 and the presence of coinfections of the central nervous system, the most important of which is the risk of tuberculosis of the central nervous system. The obtained results are important for predicting the course of the disease and identifying possible risks, for the improvement of preventive measures.
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