Encephalitis associated with cytomegalovirus is rare in individuals with normal immune systems. In patients with iatrogenic immunosuppression (e.g. organ transplant recipients), cytomegalovirus may cause an acute and frequently fatal meningoencephalitis with a generalized inflammation of the brain. In patients with AIDS, cytomegalovirus may cause a more subtle encephalitic illness, pathologically focal or multifocal, with uncertain clinical correlates and natural history. A more aggressive subacute cytomegalovirus encephalitis seen in as many as 10 per cent of AIDS patients typically strikes the subependymal lining, causing a non-focal encephalitis associated with prominent mental status changes and cranial nerve abnormalities. Without intervention, progression to death in a matter of a few months is frequent. This syndrome may be mistaken for AIDS dementia complex, but it is more aggressive and is associated with high levels of cytomegalovirus DNA in the cerebrospinal fluid. Prognosis is poor and reflects the advanced state of AIDS-associated immunodepression typically present at the time of diagnosis. Therapeutic trials involving the nucleoside analog ganciclovir and the pyrophosphate analog foscarnet are under way.
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