306
is protective against blood-bome and milkborne transmission of HTLV-1. The presence of virus-infected lymphocytes in cord blood, as detected by antigen expression or polymerase chain reaction,3’ does not necessarily point to infectious transmission of HTLV-1 from mother to child. The eventual outcome of perinatal infection of HTLV-1 will depend on the protective immunity of babies acquired through the placenta from seropositive mothers.
neutralising antibody
Kochi Medical School,
Kochi 783, Japan
ISAO MIYOSHI HIDENORI MUNEISHI YUJI TANAKA
R, Takehara N, Iwahara Y, et al. Transmission of HTLV-I by blood transfusion and its prevention by passive immunization in rabbits. Blood 1990; 76: 1657-61. 2. Sawada T, Iwahara Y, Ishii K, Taguchi H, Hoshino H, Miyoshi I Immunoglobulin prophylaxis against milkborne transmission of human T cell leukemia virus type I in rabbits J Infect Dis 1991; 164: 1193-96. 3. Saito S, Furuki K, Ando Y, et al. Identification of HTLV-I sequence in cord blood mononuclear cells of neonates born to HTLV-I antigen/antibody positive-mothers by polymerase chain reaction. Jpn J Cancer Res 1990; 81: 890-95. 4. Narita M, Shibata M, Togashi T, Koga Y Vertical transmission of human T cell leukemia virus type I. J Infect Dis 1991; 163: 204 1. Kataoka
Efficacy of cytarabine in progressive leucoencephalopathy in AIDS
multifocal
SIR,-Portegies et all reported three AIDS patients in whom progressive multifocal leucoencephalopathy (PML) developed and improved after long-term treatment with cytarabine (2 mg/kg intravenously daily for 5 days every month). Diagnosis was based only on clinical and neuroradiological criteria.2,3 We report two further cases of PML that improved with this treatment. Patient 1-(age 27 years, male, HIV-1-positive in February, 1991, with progressive right hemiparesis for 4 months.) On admission, motor deficiency was seen predominantly in the face and the right hand. Diminished pinprick sensation in these regions and dysarthria were also noted. Neuropsychological examination was normal. Magnetic resonance imaging (MRI) revealed focal areas of high signal intensity in the frontal white-matter of both hemispheres (figure) without a mass effect or contrast enhancing. A presumptive diagnosis of PML was confirmed by stereotactic brain biopsy of the left frontal region. Treatment with cytarabine was started on July 21, 1991, and was repeated monthly. Zidovudine was given between courses. After three courses, strength of the right hand increased, dysarthria regressed, and MRI picture improved (figure). Zidovudine was discontinued on Sept 27, 1991, because of bone-marrow toxicity. In December, 1991, improvement was continuing. Patient 2--(age 39, male, HIV-1 seropositive, presented May, 1991, with time disorientation, word-finding difficulties, some paraparesis, normal oral comprehension, confusion between his right and left sides, left homonymous hemianopia, and moderate neglect of his left legs.) He was taking zidovudine 600 mg daily.
MRI
scans
in
patient 1 (upper) and patient 2 (lower).
Upper left, after 1 month of treatment, nght, 2 months later Lower. left, after 1 month of treatment, nght, 4 months later. extinction of left
leg, and bilateral Babinski’s sign. Auditory comprehension was almost normal. As Portegies et al reported, improvement was noted after the third or fourth course of cytarabine. Aggravation of leucoencephalopathy during the first months of treatment does not mean that cytarabine is ineffective, as shown by patient 2. In view of the lack of specificity of MRI, bone-marrow toxicity of cytarabine, and delay of response, the diagnosis should be confirmed by stereotactic brain biopsy. Our results seem to confirm the efficacy of long-term treatment with cytarabine for PML in AIDS. Service of Neurology,
Hôpital Sainte-Marguerite, 13274 Marseille, France, and Service of Neurosurgery, Hôpital de la Timone, Marseille,
F. NICOLI B. CHAVE J. C. PERAGUT J. L. GASTAUT
MRI revealed bilateral
parieto-occipital white-matter lesions of high signal intensity, predominantly on the right hemisphere and without mass effect. Treatment for toxoplasmosis for 3 weeks was unsuccessful. During this period, the patient had comprehension deficit, many paraphasias, alexia, acalculia, constructional apraxia, left auditory extinction, left spatial neglect, and dense left hemihypo-aesthesia to light touch and pinprick, and impaired position sense. Treatment with cytarabine, for a presumptive diagnosis of PML, was started on June 6, 1991, and repeated monthly. During 2 months, aphasia, apraxia, and left spatial neglect became severe. Left hemiparesis of the face, arm, and leg, and frontal syndrome with uninhibited behaviour, tendency to joke, and lack of tact developed. MRI showed diffusion of lesions toward temporal and frontal regions bilaterally (figure). Zidovudine was discontinued in July, 1991, for one month because of leucopenia and thrombocytopenia. Clinical improvement began after the fourth course of cytarabine. After the fifth course, aphasia, apraxia, neglect syndrome, frontal syndrome, hemiparesis, and the MRI picture improved strikingly (figure). In December, 1991, the patient had only left homonymous hemianopia, moderate left visual neglect, rare paraphasias, moderate left lower facial paresis, sensory
1. Portegies P, Algra PR, Hollak CEM, et al. Response to cytarabine in progressive multifocal leucoencephalopathy in AIDS. Lancet 1991; 337: 680-81. 2. Krupp LB, Lipton RB, Swerdlow ML, Leeds NE, Llena J Progressive multifocal leukoencephalopathy clinical and radiographic features. Ann Neurol 1985, 17: 344-49
3.
Berger JR, Kaskovitz B, Donovan-Post JD, Dickinson G. Progressive multifocal leukoencephalopathy associated with human immunodeficiency virus infection, a review of the literature and report of sixteen cases. Ann Intern Med 1987, 107: 78-87.
Iohexol to monitor GFR SIR,-Your Jan 4 editorial about our paper on the use of iohexol marker for glomerular filtration rate (GFR)l expresses the view that in clinical practice extreme precision is seldom needed. In place of striving to find more convenient and accurate means of measuring renal function, you suggest that a simple measure such as detecting "gross abnormality (say, creatinine over 500 fU1101/1)" would be more appropriate in reducing renal morbidity. Since therapeutic effort should be directed towards the preservation of renal function, this seems a pessimistic view. By the time the serum
as a
creatinine concentrations start to rise above normal 50% or more of nephrons may have been 10st.2 Recognising deterioration in renal
is protective against blood-bome and milkborne transmission of HTLV-1. The presence of virus-infected lymphocytes in cord blood, as detected by antigen expression or polymerase chain reaction,3’ does not necessarily point to infectious transmission of HTLV-1 from mother to child. The eventual outcome of perinatal infection of HTLV-1 will depend on the protective immunity of babies acquired through the placenta from seropositive mothers.
neutralising antibody
Kochi Medical School,
Kochi 783, Japan
ISAO MIYOSHI HIDENORI MUNEISHI YUJI TANAKA
R, Takehara N, Iwahara Y, et al. Transmission of HTLV-I by blood transfusion and its prevention by passive immunization in rabbits. Blood 1990; 76: 1657-61. 2. Sawada T, Iwahara Y, Ishii K, Taguchi H, Hoshino H, Miyoshi I Immunoglobulin prophylaxis against milkborne transmission of human T cell leukemia virus type I in rabbits J Infect Dis 1991; 164: 1193-96. 3. Saito S, Furuki K, Ando Y, et al. Identification of HTLV-I sequence in cord blood mononuclear cells of neonates born to HTLV-I antigen/antibody positive-mothers by polymerase chain reaction. Jpn J Cancer Res 1990; 81: 890-95. 4. Narita M, Shibata M, Togashi T, Koga Y Vertical transmission of human T cell leukemia virus type I. J Infect Dis 1991; 163: 204 1. Kataoka
Efficacy of cytarabine in progressive leucoencephalopathy in AIDS
multifocal
SIR,-Portegies et all reported three AIDS patients in whom progressive multifocal leucoencephalopathy (PML) developed and improved after long-term treatment with cytarabine (2 mg/kg intravenously daily for 5 days every month). Diagnosis was based only on clinical and neuroradiological criteria.2,3 We report two further cases of PML that improved with this treatment. Patient 1-(age 27 years, male, HIV-1-positive in February, 1991, with progressive right hemiparesis for 4 months.) On admission, motor deficiency was seen predominantly in the face and the right hand. Diminished pinprick sensation in these regions and dysarthria were also noted. Neuropsychological examination was normal. Magnetic resonance imaging (MRI) revealed focal areas of high signal intensity in the frontal white-matter of both hemispheres (figure) without a mass effect or contrast enhancing. A presumptive diagnosis of PML was confirmed by stereotactic brain biopsy of the left frontal region. Treatment with cytarabine was started on July 21, 1991, and was repeated monthly. Zidovudine was given between courses. After three courses, strength of the right hand increased, dysarthria regressed, and MRI picture improved (figure). Zidovudine was discontinued on Sept 27, 1991, because of bone-marrow toxicity. In December, 1991, improvement was continuing. Patient 2--(age 39, male, HIV-1 seropositive, presented May, 1991, with time disorientation, word-finding difficulties, some paraparesis, normal oral comprehension, confusion between his right and left sides, left homonymous hemianopia, and moderate neglect of his left legs.) He was taking zidovudine 600 mg daily.
MRI
scans
in
patient 1 (upper) and patient 2 (lower).
Upper left, after 1 month of treatment, nght, 2 months later Lower. left, after 1 month of treatment, nght, 4 months later. extinction of left
leg, and bilateral Babinski’s sign. Auditory comprehension was almost normal. As Portegies et al reported, improvement was noted after the third or fourth course of cytarabine. Aggravation of leucoencephalopathy during the first months of treatment does not mean that cytarabine is ineffective, as shown by patient 2. In view of the lack of specificity of MRI, bone-marrow toxicity of cytarabine, and delay of response, the diagnosis should be confirmed by stereotactic brain biopsy. Our results seem to confirm the efficacy of long-term treatment with cytarabine for PML in AIDS. Service of Neurology,
Hôpital Sainte-Marguerite, 13274 Marseille, France, and Service of Neurosurgery, Hôpital de la Timone, Marseille,
F. NICOLI B. CHAVE J. C. PERAGUT J. L. GASTAUT
MRI revealed bilateral
parieto-occipital white-matter lesions of high signal intensity, predominantly on the right hemisphere and without mass effect. Treatment for toxoplasmosis for 3 weeks was unsuccessful. During this period, the patient had comprehension deficit, many paraphasias, alexia, acalculia, constructional apraxia, left auditory extinction, left spatial neglect, and dense left hemihypo-aesthesia to light touch and pinprick, and impaired position sense. Treatment with cytarabine, for a presumptive diagnosis of PML, was started on June 6, 1991, and repeated monthly. During 2 months, aphasia, apraxia, and left spatial neglect became severe. Left hemiparesis of the face, arm, and leg, and frontal syndrome with uninhibited behaviour, tendency to joke, and lack of tact developed. MRI showed diffusion of lesions toward temporal and frontal regions bilaterally (figure). Zidovudine was discontinued in July, 1991, for one month because of leucopenia and thrombocytopenia. Clinical improvement began after the fourth course of cytarabine. After the fifth course, aphasia, apraxia, neglect syndrome, frontal syndrome, hemiparesis, and the MRI picture improved strikingly (figure). In December, 1991, the patient had only left homonymous hemianopia, moderate left visual neglect, rare paraphasias, moderate left lower facial paresis, sensory
1. Portegies P, Algra PR, Hollak CEM, et al. Response to cytarabine in progressive multifocal leucoencephalopathy in AIDS. Lancet 1991; 337: 680-81. 2. Krupp LB, Lipton RB, Swerdlow ML, Leeds NE, Llena J Progressive multifocal leukoencephalopathy clinical and radiographic features. Ann Neurol 1985, 17: 344-49
3.
Berger JR, Kaskovitz B, Donovan-Post JD, Dickinson G. Progressive multifocal leukoencephalopathy associated with human immunodeficiency virus infection, a review of the literature and report of sixteen cases. Ann Intern Med 1987, 107: 78-87.
Iohexol to monitor GFR SIR,-Your Jan 4 editorial about our paper on the use of iohexol marker for glomerular filtration rate (GFR)l expresses the view that in clinical practice extreme precision is seldom needed. In place of striving to find more convenient and accurate means of measuring renal function, you suggest that a simple measure such as detecting "gross abnormality (say, creatinine over 500 fU1101/1)" would be more appropriate in reducing renal morbidity. Since therapeutic effort should be directed towards the preservation of renal function, this seems a pessimistic view. By the time the serum
as a
creatinine concentrations start to rise above normal 50% or more of nephrons may have been 10st.2 Recognising deterioration in renal
