Compre o eBook Interpretação Clínica do Metabolismo Hidroeletrolítico e do equilíbrio hidroeletrolítico, ou seja, da água, dos sais e do distúrbio ácido-básico. Hiponatremia é o distúrbio hidroeletrolítico mais comum em pacientes hospitalizados. A presença de hiponatremia está associada a uma série de desfechos. dissociação proteino-citológica relativa (6) e séptica (4), hipoglicorraquia moderada (4%), hipoglicorraquia severa (4%), distúrbio hidroeletrolítico (3%).
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Cerebrospinal fluid syndromes in HIV-positive patients with acute consciousness hidroeletrolitic. Abstract We reviewed the cerebrospinal fluid CSF syndromes of consecutive HIV-positive patients presenting acute consciousness compromise in emergency rooms, and correlated them with clinical data.
The most frequent CSF syndromes were: One fifth ditsurbio the patients had CSF syndromes considered sufficient for diagnosis or an immediate clinical decision. The most common clinical data were infective and neurological. There was little correlation between the clinical data and the CSF syndromes. We conclude that in HIV-positive individuals presenting acute consciousness disturbances there are frequently non-specific results in the CSF analysis that must be weighed against a detailed history and thorough physical examination.
Taking this into account, in about one fifth of cases the CSF analysis can offer useful information for treatment. HIV-positive patients admitted to emergency rooms commonly present acute alterations of consciousness. Due to their subjacent disease, these patients are susceptible to a wide range of etiological possibilities, such as opportunistic infections and neoplasias, besides the HIV infection proper.
A detailed history, including mode of installation, previous diseases, associated symptoms and drug exposure, is fundamental but not always obtainable. Diagnosis often defies clinicians, being based more on laboratory tests such as neuroradiological methods and a CSF analysis. There exist some reports about the interaction of HIV and the CSF of asymptomatic and symptomatic patients 3 4 5 6 The study of the CSF. Commonly, HIV-positive patients present disturboo emergency rooms with acute alterations of dizturbio.
Due to their subjacent disease, these patients are susceptible to wide range of etiological possibilities, like opportunistic infections and neoplasias, besides the own HIV infection.
A detailed history, concerning mode of installation, previous diseases, disturbuo symptoms and drug exposure is fundamental, but not ever obtainable. Frequently, the diagnosis defies clinicians and becomes much based upon laboratorial tests, like neuroradiological methods and a CSF analysis. The study of the CSF of symptomatic patients is much more difficult because is often impossible to differentiate between the alterations induced by the own viruses and by acute and chronic opportunistic infections or neoplasias.
The objective of this paper is to comment on six years results of CSF analysis performed to evaluate symptomatic HIV-positive patients, presenting to emergency rooms with acute alterations of consciousness.
We do not intend to describe physiopathological interactions between HIV and hosts. Instead, we verify at what extent the CSF analysis has contributed to evaluation of acute consciousness compromise in HIV-positive patients.
The inclusion criteria were HIV positivity and acute consciousness compromise: It were not included pediatric, surgical or trauma patients. We covered the period from January, to April,to find one hundred file-cards that met our selection criteria. Among the patients selected, we also randomly reviewed 30 hospital file-cards to check disrurbio criteria.
The clinical data were the ones written in the laboratory-card all the CSF punctions are performed by neurology CSF team, after checking the clinical data. All patients were first seen at the hdroeletrolitico or medical emergency djsturbio of the same institution. Only the results of the first CSF analysis were included. We divided the abnormal results into two groups: The groups were composed of: The four age groups were 12 to 25, 26 to 45 46 to 65 and more than 66 year old.
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The CSF results were correlated to clinical data using Epi-info, version 5. All patients were HIV-positive and had acute alterations of consciousness, confirming our selection criteria.
The mean age was There were 20 patients between 14 and 25 years old, 68 between 26 and 45 and 12 patients between 46 and There were 82 men and 18 women. The mean time of consciousness compromise and the CSF examination was 3 days. The CSF punction was lumbar in 76 patients and cisternal in The commonest hkdroeletrolitico data were: The CSF analysis showed abnormal results in 77 patients, as is shown hidroeletrolutico Table 1. We found little association between hidroeletroliitico data and CSF syndromes.
The globulin’s reactions Pandy, Nonne and Hidroeletrolktico were frequently positive: The correlation between these reactions and other CSF results is in Table 2. The acquired imunodeficiency syndrome AIDS is caused by, at least, two retrovirus: The retrovirus are highly neurotropic, being present in the CNS early in the infection.
Acute consciousness compromise in a HIV-positive patient has many possible etiologies. Chronic infections, use of multiple and toxic medications, nutritional deficits, dehydration, etc. The contribution of the CSF analysis in the evaluation of these patients must be considered in the setting of an acute presentation of a chronic patient.
The majority of our patients was young adults and half was less than 30 years old, with a clear hideoeletrolitico of males. This is in agreement with the epidemiological distribution of AIDS at the time of the study.
The predominance of neurological and infectious signs and symptoms reflect our inclusion criteria. Among the clinical data, only headache and the presence of an associated hidroeletrolitick was correlated to a CSF data, the positivity of hematoxo. We have published a study of CSF analysis indicated to evaluate non HIV-positive patients presenting acute consciousness compromise 1.
With a similar methodology, we found Besides, Neves, found that the CSF analysis confirmed a clinical hypothesis in Our results in HIV-positive patients are very different, indicating that they may have less specific manifestations. Waiting for more specific manifestations may delay the diagnosis of treatable diseases, like bacterial or fungal meningitis. On the other hand, we may obtain less definitive diagnosis with the CSF analysis. The viral syndrome was also correlated to positivity of hematoxo.
Being the granulomatous form of toxoplasmosis the one predominantly seen in HIV-positive patients, these associations becomes interesting. The presence of associated pathologies indicate an advanced stage of the HIV infection, in which we usually find cases of hidgoeletrolitico. The correlation between positivity of hematoxo and the viral syndrome reflect that, not infrequently, lymphocytic pleocytosis is found in toxoplasmosis.
Cerebrospinal fluid syndromes in HIV-positive patients with acute consciousness compromise
Given the high frequency of antibodies against Toxoplama gondii in asymptomatic HIV-positive patients, this might be interpreted with caution 9. The correlation of an altered macroscopic aspect of the CSF and neurocryptococosis, of septic syndrome and a diagnosis of a syndrome considered sufficient is interesting. However, it is not an useful information for the physician to decide to perform or not an CSF analysis, because it appears only after this decision. Qualitative alterations of CSF proteins, reflected in the positivity of the Pandy, Nonne and Weichbrodt, are classically described in chronic infections of the CNS, like syphilis, and in inflammatory or demyelinating diseases, like multiple sclerosis However, it has been described in HIV-positive patients, since early in the infection.
Chalmers, Aprill and Shephard found oligoclonal bands in 6 of 23 HIV-positive, asymptomatic patients 4. Five of these also had pleocytosis. We also found correlation with pleocytosis and lymphocytosis Table 2. These results might be explained by the advanced stage of the disease and concomitance of other infections. The correlation of the Pandy, Nonne and Weichbrodt reactions with the positivity of hematoxo might be due to the presence of the antibodies against toxoplasma.
The correlation between the Pandy and Nonne reactions and the lumbar puncture might depend upon the greater protein concentration in this region.
Much problably, this indicate alterations induced by the own HIV, since no patient had history of other CNS infection. In this situation, use of AZT may diminish the pleocytosis and the protein alterations, confirming that the alterations were induced by the own viruses 5.
The viral syndrome may reflect a non-specific reaction not only to virus, but also to fungi, protozoan, mycobacteria or treponemas. In our casuistic, we believe that the viral syndrome may partly be caused by the own HIV infection. However, in AIDS patients, the viral syndrome may reflect a variety of infections commonly found in HIV-positive patients, mainly toxoplasmosis, as is shown in the correlation of the viral syndrome and the positivity of Hematoxo.
Acute alterations of consciousness indicate acute insults to CNS. These insults may result in a breakdown of the blood-brain-barrier BBBcerebral edema and extravasation of seric proteins in the CNS 8.
The predominance of the protein-cytologic dissociation syndromes, absolute and relative, reflect the situation we studied, indicating an expected breakdown of the BBB. Neurocryptococosis NCC was relatively uncommon. We included only the first CSF of our patients; so, those that had a previous diagnosis of NCC in our laboratory were excluded from this series. The correlation to hypoglicorrachia shows consumption of glucose by the criptococcus, indicating an active state of the infection.
In a series, 4 of 7 patients with neurocryptocosis had alterations of consciousness 3. Our results suggest that neurocryptococosis may run a more aggressive course, agreeing with Sanchez-Portocarrero One case of subarachnoid hemorrhage shows that, naturally, it also happens in HIV-positive individuals.
Moderate and severe hypoglycorrachia, like electrolytic disturbances, as isolate findings, must reflect the state of general consumption and dehydration frequently found in these patients. Moderate hyperglycorrachia, found in one case, may reflect hyperglycemia. Isolated xantochromia, with no erythrocytes nor hyperproteinorrachia, present in one case, may reflect seric elevation of bilirrubins.
Alterations of consciousness are commom in patients with tuberculous meningo-encephalitis TMEregardless of HIV-positivity 2.
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It was found a relatively low frequency of this diagnosis problably because of the usually sub-acute or ditsurbio rather than acute presentation of TME. Similarly, acute consciousness disturbances are not usually found in neurosyphilis Hkdroeletrolitico. Except for acute syphilitic meningitis, all other forms of NS tend to follow a chronic course. In our laboratory, the Wasserman and indirect hemaglutination reactions are also performed in all CSF specimens.
The relative rarity of this diagnosis was not a surprise, since we included only cases with acute presentation. The majority of our CSF analysis in HIV-positive patients presenting acute consciousness disturbances resulted abnormal. There was little correlation between CSF syndromes and clinical data.