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Cytomegalovirus encephalitis in acquired immunodeficiency syndrome.

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Encephalitis in Acquired
Marc G. Reyes, M D
1 recently examined the brain of a 31-year-old white homosexual man with acquired immunodeficiency syndrome
(AIDS) who presented with right-sided Bell’s palsy and mild
spastic left hemiparesis two weeks before he died of a fulminating cytomegalovirus (CMV) pneumonia. Neuropathological examination showed a necrotizing CMV brainstem
encephalitis of the right ventral tegmentum and pyramid and
smaller areas in the midline, subependymal, and contralateral
tegmentum and pyramid of the rostra1 medulla (Fig, A) and
the tegmentum of the right lower pons. Cytomegalic cells
with large nuclear inclusions and occasional cytoplasmic inclusions abounded (Fig, B) in these necrotic foci with fatladen macrophages but other inflammatory cells were sparse.
In addition, cytomegalic cells with nuclear inclusions were
seen in the ependyma of the fourth, third, and lateral ventri-
(A) Myelin-stained section of the upper medulla shwing extensive necrosis ofthe right tegmentum and pyramid (arrows) and
smaller amounts of necrosis ofthe midline, lej9 pyramid, and
subependymal region. (B) Cytomegalic cells with nuclear inclusions (arrows) andfew fat-laden macrophages (arrowheads) in
necrotic tegmentum. (H6E; bar = 100 pm.)
cles and aqueduct of Sylvius and rarely in the subependymal
region. The gray and white matter of the cerebral hemispheres and cerebellum showed no microglial nodules or
multinucleated giant cells.
It is well known that CMV encephalitis presents in adults
with AIDS as microglial nodules of subcortical and cortical
gray matter and not as multifocal necrotizing encephalitis [ 11.
In the newborn and other immune suppressed patients including those with AIDS, CMV causes ventriculitis and subependymal necrosis that lead to calcifications [ 1, 21, but a
predominant distribution in the brainstem as in my patient
and the patient reported by Masdeu and co-workers [ 3 ] is
unusual even in AIDS. Thus, my patient supports Masdeu
and co-workers’ suggestion that the brainstem lesions seen in
the magnetic resonance scan of their patient were the result
of CMV, and demonstrates the atypical pathological manifestations of many infections in AIDS.
Division of Pathology
Cook County Hospital
Chicago, IL
1. Petito CK, Cho ES, Lemann W, et
al. Neuropathology of acquired immunodehciency syndrome (AIDS): an auropsy review.
J Neuropathol Exp Neurol 1986;45:635-646
2. Friede RL.Developmentalneuropathology.New York: SpringerVerlag, 1975
3. Masdeu JC, Small CB, Weiss L, et al. Multifocal cytomegalovirus
encephalitis in AIDS. Ann Neurol 1988;23:97-39
98 Copyright 0 1988 by the American Neurological Association
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immunodeficiency, encephalitis, acquire, syndrome, cytomegalovirus
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