CMV ventriculitis and polyradiculopathy



Varicella zoster virus

VZV encephalitis and zoster



Herpes simplex virus type 1

HSV encephalitis



Table 36.4. Medical therapy of selected HIV-associated CNS infections. Infection Therapy Dose and duration

Cryptococcal meningitis Amphotericin B 0.6-0.8 mg/kg/day IV for 14 days, or until headache, fever, nausea and vomiting resolved

And flucytosine (5-FC) then fluconazole

75-100 mg/kg/day PO

400 mg/day until CSF culture negative, then decrease to 200 mg/day and continue for life

Toxoplasma encephalitis

Pyrimethamine And folinic acid and sulfadiazine or clindamycin

100-200 mg load, then 75-100 mg/day PO 10-50 mg/day PO

4-8 g/day (100 mg/kg/day) PO divided into four doses 600-900 mg PO/IV qid


Initial therapy with fluconazole associated with delayed sterilization of CSF and more early deaths. For increased intracranial pressure, repeat lumbar punctures one to four times daily, with removal of 15-30 ml of CSF each time, until opening pressure consistently normal

Flucytosine should be used concurrently with amphotericin B; may cause marrow suppression or leukopenia

Lumbar puncture should be repeated after amphotericin B, then every 2-4 weeks, or sooner if clinical deterioration occurs. Once CSF culture negative, fluconazole should be started. CSF CrAg can persist positive, even if culture negative, and should not guide therapy. If CSF CrAg titer rises above initial titer, repeat treatment with amphotericin B

Alternatives to sulfadiazine:

1. Atovaquone: 750 mg PO qid

2. Clarithromycin: 1 g PO bid

3. Azithromycin: 1 g load, then 500 mg/day

Consider sulfa desensitization for sulfa-allergic people

Lifetime maintenance dose required:

1. Pyrimethamine: 25-50 mg/day

2. Folinic acid: 10-50 mg/day

3. Sulfadiazine: 1 g tid-qid, or clindamycin: 300-450 mg tid-qid

Table 36.4. continued

Infection Therapy

Primary CNS lymphoma Radiotherapy

Dose and duration

Whole-brain irradiation with 4,000 cGy with a "boost" of 1,000-2,000 cGy focused on the tumor bed

Progressive multi-focal leukoencephalo-pathy

Chemotherapy Methotrexate (intravenous and intrathecal), thiotepa and procarbazine

Antiretroviral therapy Potent antiretroviral therapy (previously called highly Cidofovir/Ara-C active antiretroviral therapy, or HAART)

Cytomegalovirus Gancydovir 5 mg/kg BID or TID for 2—4 weeks (induction) then ventriculitis or Or 5 mg/kg/day 5-7 times/week (maintenance)

polyradiculitis Foscarnet 60 mg/kg q8H for 2-3 weeks (induction), then

90-120 mg/kg/day IV 6-7 times/week (maintenance)


Radiation or combined modality treatments prolong life by several months (27 vs 119 days mean survival in persons receiving radiation therapy)

Steroids (dexamethasone) may reduce edema associated with tumor, thereby improving symptoms

Anecdotal reports of efficacy of cytosine arabinoside (Ara-C), and high-dose AZT (1,000 mg/day)

Spontaneous remissions and prolonged survival in 5-10%, but average life expectancy is usually months

There may be synergy if gancyclovir and foscarnet used together. Resistance to gancyclovir has occurred in patients with polyradiculopathy. Poor prognosis associated with prior treatment for CMV retinitis, Karnofsky score less than 70, persistently positive CSF CMV PCR, persistent hypoglycorrhachia. Average life expectancy for CMVE or polyradiculopathy is weeks to months

Recommended treatment for severely affected patients is induction with gancyclovir and foscarnet, then monotherapy after 2 weeks of therapy, if improvement in symptoms or lower quantitative CSF-CMV-PCR. Improvement of symptoms may take weeks or months

In the USA, government inspection usually identifies ten cases of cysticercosis in the 80 million hogs that are slaughtered each year [15]. During the first year of mandatory reporting of NCC in California, 134 cases were reported. The majority of infected people were immigrant Hispanics, but three people had never traveled outside the USA [16]. Neurocysticercosis has also been reported in Orthodox Jewish people with no travel outside the USA or exposure to pork products [17]. Presumptive infection through contact with infected immigrant food preparers illustrates that asymptomatic carriers of cysticercosis are an important factor in the development of NCC in developed countries.

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