Sensibilidade e especificidade do diagnóstico clínico, sorológico e tomográfico da encefalite por Toxoplasma gondii na Síndrome da Imunodeficiência Adquirida (SIDA)

Wainstein, Marco V.; Wolffenbuttel, Luciano; Lopes, Demetrius K.; González, Helena E.; Golbspan, Liane; Ferreira, Lisiane; Sprinz, Eduardo; Kronfeld, Matias; Edelweiss, Maria I.

doi:10.1590/S0037-86821993000200001

Resumos

A encefalite por Toxoplasma gondii (ET) é a principal causa de massa no sistema nervoso central (SNC) em pacientes com a síndrome da imunodeficiência adquirida (SIDA). Com o objetivo de determinar a prevalência dessa afecção e da presença de anticorpos específicos no soro e no líquor, bem como a sensibilidade (S) e a especificidade (E) da tomografia computadorizada (TC), dos achados clínicos e dos testes específicos foram revisados todos os prontuários de 516 pacientes com SIDA, internados no HCPA entre maio/85 e dezembro/91. A prevalência através de TC foi de 13% (diagnóstico presuntivo). A pesquisa de anticorpos específicos para toxoplasmose por imunofluorescência indireta no sangue (SS) foi positiva em 65% e no líquor (SL) em 49% dos pacientes em que foi realizada. Necrópsias de 125 pacientes foram revisadas encontrando-se uma prevalência de ET em 27 (22%) casos, em que o diagnóstico foi considerado definitivo. A sensibilidade da TC foi de 65% e a especificidade de 82%. A SS apresentou S de 95% e E de 30%, enquanto a SL apresentou uma S de 77% e E de 56%. Os seguintes achados clínicos foram pesquisados: febre (S=92%; E=56%); sinais neurológicos focais (S=59%; E=82%) e cefaléia (S=41 %; E=69%). Concluímos que é alta a prevalência da ET na SIDA e que a TC e a pesquisa de anticorpos específicos no soro e no líquor, devido à alta especificidade da primeira e a alta sensibilidade da segunda, constituem-se em métodos adequados para o diagnóstico da ET, sendo discutível a necessidade de realizar biópsia cerebral nesses casos.

SIDA; Encefalite por Toxoplasma gondii; Prevalência

Toxoplasmic encephalitis (TE) is among the most common neurologic affections and it is the most prevalent cause of intracerebral mass lesions in AIDS patients. All patients with AIDS hospitalized at the Hospital de Clinicas de Porto Alegre between May/85 and December/91 (516 cases) had their files revised to determinate TE prevalence, serology, sensivity and specificity of the computed tomography (CT) brain scan, clinical findings and serology to make its diagnosis. The prevalence on CT was 13% (presumptive diagnosis). Blood serology and cerebrospinal (CSF) serology to toxoplasma werepositive respectiveiy in 65% and 49%. Autopsies of 125 patients were also revised with a prevalence of 22% (definite diagnosis). CT scan had 65% of sensivity and 82% of specificity. Sensivity and specificity of serology on blood was respectively 95% and 30%, while the cerebrospinal fluid (CSF) serology had 77% of sensivity and 56% of specificity. The following clinical findings were considered: fever (sensivity = 92%; specificity = 56%), neurological focal signs (sensivity = 59% ; specificity = 82%) and headache (sensivity =41 %; specificity = 69%). We conclude that, based on the high serology sensivity and high CT scan specificity, they constitute an useful approach to make TE diagnosis.

Toxoplasmic encephalitis; AIDS; Prevalence

ARTIGOS

Sensibilidade e especificidade do diagnóstico clínico, sorológico e tomográfico da encefalite por Toxoplasma gondii na Síndrome da Imunodeficiência Adquirida (SIDA)

Marco V. Wainstein; Luciano Wolffenbuttel; Demetrius K. Lopes; Helena E. González; Liane Golbspan; Lisiane Ferreira; Eduardo Sprinz; Matias Kronfeld; Maria I. Edelweiss

^{Endereço para correspondência} Endereço para correspondência: Dra. Maria I. Edelweiss. Serviço de Anatomia Patológica/HCPA. R. Ramiro Barcelos 2350 subsolo 93054-490 Porto Alegre, RS, Brasil.

RESUMO

A encefalite por Toxoplasma gondii (ET) é a principal causa de massa no sistema nervoso central (SNC) em pacientes com a síndrome da imunodeficiência adquirida (SIDA). Com o objetivo de determinar a prevalência dessa afecção e da presença de anticorpos específicos no soro e no líquor, bem como a sensibilidade (S) e a especificidade (E) da tomografia computadorizada (TC), dos achados clínicos e dos testes específicos foram revisados todos os prontuários de 516 pacientes com SIDA, internados no HCPA entre maio/85 e dezembro/91. A prevalência através de TC foi de 13% (diagnóstico presuntivo). A pesquisa de anticorpos específicos para toxoplasmose por imunofluorescência indireta no sangue (SS) foi positiva em 65% e no líquor (SL) em 49% dos pacientes em que foi realizada. Necrópsias de 125 pacientes foram revisadas encontrando-se uma prevalência de ET em 27 (22%) casos, em que o diagnóstico foi considerado definitivo. A sensibilidade da TC foi de 65% e a especificidade de 82%. A SS apresentou S de 95% e E de 30%, enquanto a SL apresentou uma S de 77% e E de 56%. Os seguintes achados clínicos foram pesquisados: febre (S=92%; E=56%); sinais neurológicos focais (S=59%; E=82%) e cefaléia (S=41 %; E=69%). Concluímos que é alta a prevalência da ET na SIDA e que a TC e a pesquisa de anticorpos específicos no soro e no líquor, devido à alta especificidade da primeira e a alta sensibilidade da segunda, constituem-se em métodos adequados para o diagnóstico da ET, sendo discutível a necessidade de realizar biópsia cerebral nesses casos.

Palavras-chave: SIDA. Encefalite por Toxoplasma gondii. Prevalência.

ABSTRACT

Toxoplasmic encephalitis (TE) is among the most common neurologic affections and it is the most prevalent cause of intracerebral mass lesions in AIDS patients. All patients with AIDS hospitalized at the Hospital de Clinicas de Porto Alegre between May/85 and December/91 (516 cases) had their files revised to determinate TE prevalence, serology, sensivity and specificity of the computed tomography (CT) brain scan, clinical findings and serology to make its diagnosis. The prevalence on CT was 13% (presumptive diagnosis). Blood serology and cerebrospinal (CSF) serology to toxoplasma were positive respectively in 65% and 49%. Autopsies of 125 patients were also revised with a prevalence of 22% (definite diagnosis). CT scan had 65% of sensivity and 82% of specificity. Sensivity and specificity of serology on blood was respectiveiy 95% and 30%, while the cerebrospinal fluid (CSF) serology had 77% of sensivity and 56% of specificity. The following clinical findings were considered: fever (sensivity = 92%; specificity = 56%), neurological focal signs (sensivity = 59% ; specificity =82%) and headache (sensivity = 41 %; specificity = 69%). We conclude that, based on the high serology sensivity and high CT scan specificity, they constitute an useful approach to make TE diagnosis.

Keywords: Toxoplasmic encephalitis. AIDS. Prevalence.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Recebido para publicação em 30/12/92.

Trabalho realizado na Unidade de Doenças Infecciosas e Serviço de Anatomia Patológica do Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS.

Auxílio: CNPq

1. Anders KH, Guerra WF, Tomiyasu U, Verity MA, Vinters HV. The neuropathology of AIDS: UCLA experience and review. American Journal of Pathology 124:537-558, 1986.
2. Bishburg E, Slim J, Johnson ES, Kapita R, Eng RHK. The need for tissue diagnosis of central nervous system lesions with the acquired immunodeficiency syndrome. In: Abstract of Proceedings of the Third International Conference on AIDS, Washington, DC p.36, 1987.
3. Cimino C, LiptonRB, Williams A, Feraru E, Harris C, Hirschfeld A. The evaluation of patients with human immuno-deficiency virus-related disorders andbrain mass lesions. Archives oflnternal Medicine 151:1381-1384, 1991.
4. Cohn JA, McMeeking A, Cohen W, Jacobs J, Holzman RS. Evaluation of the policy of empiric treatment of suspected Toxoplasma encephalitis in patients with the acquired immunodeficiency syndrome. American Journal of Medicine 86:521- 527, 1989.
5. Grant IH, Gold JW, Rosenblum M, Niedzwiecki D, Armstrong D. Toxoplasma gondii serology in HIV- infected patients: the development of central nervo us system toxoplasmosis in AIDS. AIDS 4:519-521, 1990.
6. Israelski DM, Dannemann BR, Remington JS. Toxoplasmic encephalitis in patients with AIDS. In: Sande MA, Volverding PA (eds) The medical management of AIDS, WB Saunders, Philadelphia p.241-266, 1990.
7. Levy RM, Bredsen DE, Rosenblum ML. Neurological manifestations of the acquired immunodeficiency syndrome (AIDS): experienceat UCSF and review of the literature. Journal of Neurosurgery 621:475-495, 1985.
8. Levy RM, Pons VG, Rosenblum ML. Central nervous system mass lesions in acquired immunodeficiency syndrome (AIDS). Journal of Neurosurgery 61:9-16, 1984.
9. Luft BJ, Brooks RG, Conley FK, McCabe RE, Remington JS. Toxoplasmic encephalitis in patients with acquired immunodeficiency syndrome. Journal of the American Medical Association 252:913-917, 1984.
10. Luft BJ, Conley F, Remington JS, Laverdiere M, Levine JF, Strandberg DA, Wagner KF, Craven PC, File TM, Rice N, Carpentier FM. Outbreak of central-nervous-system toxoplasmosis in western Europe and North America. New England Journal of Medicine 1:781-783, 1983.
11. Luft BJ, Remington JS. AIDS commentary: toxoplasmic encephalitis. Journal of Infectious Diseases 157:1-6, 1988.
12. Luft BJ, Remington JS. Toxoplasmosis of the central nervous system. In: Remington JS,Swartz MN (eds) Current clinical topics in infectious diseases. McGraw-Hill, New York p.315-358, 1985.
13. Navia BA, Petito CK, Gold JW, Cho ES, Jordan BD, PriceRW. Cerebral toxoplasmosis complicating the acquired immunodeficiency syndrome: clinical and neurophatological findings in 27 patients. Annals of Neurology 19:224-238, 1986.
14. Post MJD, Kursunoglu SJ, Hensley GT, Chan JC, Moskowitz LB, HoffmanTA. Cranial CT in acquired immunodeficiency syndrome: spectrum of diseases and optimal contrast enhancement technique. American Journal ofRadiology 145:929-940,1985.
15. Snider WD, Simpson DM, Nielsen S, Gold JW, Metroka CE, Posner JB. Neurologicalcomplications of acquired immunodeficiency syndrome: analysis of 50 patients. Annals of Neurology 14:403-418, 1983.
16. Wainstein MV, Ferreira L, Wolffenbuttel L, Golbspan L, Sprinz E, Kronfeld M, Edelweiss MI. Achados neuropatológicos na síndrome da imunodeficiência adquirida (SIDA): revisão de 138 casos. Revista da Sociedade Brasileira de Medicina Tropical 25:95-99, 1992.
17. Whelan MA, Kricheff II, Handler M. Acquired immunodeficiency deficiency syndrome: cerebral computed tomographic manifestations. Radiology 149:477-484, 1983.
18. Wijdicks EM, Borleffs JC, Hoepelman AM, Jansen GH. Fatal disseminated hemorrhagic toxoplasmic encephalitis as the initial manifestation of AIDS. Annals of Neurology 29:683-686, 1991.
19. Wolffenbuttel L, Wainstein MV, Ferreira L, Lubianca JF, Petrillo VF, Kronfeld M. Prevalência da encefalite por toxoplasma em pacientes com SIDA no Hospital de Clínicas de Porto Alegre. Revista da Associação Médica do Rio Grande do Sul 35:23-26, 1991.
20. Wong B, Gold JW, Brown AE, Lange M, Fried R, Grieco M, Mildvan D, Giron J, Tapper ML, Lemer CW, Armstrong D. Central-nervous-system toxoplasmosis in homosexual men and parenteral drugabusers. Annals oflnternal Medicine 100:36- 42, 1984.

Endereço para correspondência:

Dra. Maria I. Edelweiss.

Serviço de Anatomia Patológica/HCPA.

R. Ramiro Barcelos 2350 subsolo

93054-490

Porto Alegre, RS, Brasil.

Datas de Publicação

Publicação nesta coleção
10 Abr 2013
Data do Fascículo
Jun 1993

Histórico

Aceito
30 Dez 1992
Recebido
30 Dez 1992

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Anders KH, Guerra WF, Tomiyasu U, Verity MA, Vinters HV. The neuropathology of AIDS: UCLA experience and review. American Journal of Pathology 124:537-558, 1986.

[2] 2. Bishburg E, Slim J, Johnson ES, Kapita R, Eng RHK. The need for tissue diagnosis of central nervous system lesions with the acquired immunodeficiency syndrome. In: Abstract of Proceedings of the Third International Conference on AIDS, Washington, DC p.36, 1987.

[3] 3. Cimino C, LiptonRB, Williams A, Feraru E, Harris C, Hirschfeld A. The evaluation of patients with human immuno-deficiency virus-related disorders andbrain mass lesions. Archives oflnternal Medicine 151:1381-1384, 1991.

[4] 4. Cohn JA, McMeeking A, Cohen W, Jacobs J, Holzman RS. Evaluation of the policy of empiric treatment of suspected Toxoplasma encephalitis in patients with the acquired immunodeficiency syndrome. American Journal of Medicine 86:521- 527, 1989.

[5] 5. Grant IH, Gold JW, Rosenblum M, Niedzwiecki D, Armstrong D. Toxoplasma gondii serology in HIV- infected patients: the development of central nervo us system toxoplasmosis in AIDS. AIDS 4:519-521, 1990.

[6] 6. Israelski DM, Dannemann BR, Remington JS. Toxoplasmic encephalitis in patients with AIDS. In: Sande MA, Volverding PA (eds) The medical management of AIDS, WB Saunders, Philadelphia p.241-266, 1990.

[7] 7. Levy RM, Bredsen DE, Rosenblum ML. Neurological manifestations of the acquired immunodeficiency syndrome (AIDS): experienceat UCSF and review of the literature. Journal of Neurosurgery 621:475-495, 1985.

[8] 8. Levy RM, Pons VG, Rosenblum ML. Central nervous system mass lesions in acquired immunodeficiency syndrome (AIDS). Journal of Neurosurgery 61:9-16, 1984.

[9] 9. Luft BJ, Brooks RG, Conley FK, McCabe RE, Remington JS. Toxoplasmic encephalitis in patients with acquired immunodeficiency syndrome. Journal of the American Medical Association 252:913-917, 1984.

[10] 10. Luft BJ, Conley F, Remington JS, Laverdiere M, Levine JF, Strandberg DA, Wagner KF, Craven PC, File TM, Rice N, Carpentier FM. Outbreak of central-nervous-system toxoplasmosis in western Europe and North America. New England Journal of Medicine 1:781-783, 1983.

[11] 11. Luft BJ, Remington JS. AIDS commentary: toxoplasmic encephalitis. Journal of Infectious Diseases 157:1-6, 1988.

[12] 12. Luft BJ, Remington JS. Toxoplasmosis of the central nervous system. In: Remington JS,Swartz MN (eds) Current clinical topics in infectious diseases. McGraw-Hill, New York p.315-358, 1985.

[13] 13. Navia BA, Petito CK, Gold JW, Cho ES, Jordan BD, PriceRW. Cerebral toxoplasmosis complicating the acquired immunodeficiency syndrome: clinical and neurophatological findings in 27 patients. Annals of Neurology 19:224-238, 1986.

[14] 14. Post MJD, Kursunoglu SJ, Hensley GT, Chan JC, Moskowitz LB, HoffmanTA. Cranial CT in acquired immunodeficiency syndrome: spectrum of diseases and optimal contrast enhancement technique. American Journal ofRadiology 145:929-940,1985.

[15] 15. Snider WD, Simpson DM, Nielsen S, Gold JW, Metroka CE, Posner JB. Neurologicalcomplications of acquired immunodeficiency syndrome: analysis of 50 patients. Annals of Neurology 14:403-418, 1983.

[16] 16. Wainstein MV, Ferreira L, Wolffenbuttel L, Golbspan L, Sprinz E, Kronfeld M, Edelweiss MI. Achados neuropatológicos na síndrome da imunodeficiência adquirida (SIDA): revisão de 138 casos. Revista da Sociedade Brasileira de Medicina Tropical 25:95-99, 1992.

[17] 17. Whelan MA, Kricheff II, Handler M. Acquired immunodeficiency deficiency syndrome: cerebral computed tomographic manifestations. Radiology 149:477-484, 1983.

[18] 18. Wijdicks EM, Borleffs JC, Hoepelman AM, Jansen GH. Fatal disseminated hemorrhagic toxoplasmic encephalitis as the initial manifestation of AIDS. Annals of Neurology 29:683-686, 1991.

[19] 19. Wolffenbuttel L, Wainstein MV, Ferreira L, Lubianca JF, Petrillo VF, Kronfeld M. Prevalência da encefalite por toxoplasma em pacientes com SIDA no Hospital de Clínicas de Porto Alegre. Revista da Associação Médica do Rio Grande do Sul 35:23-26, 1991.

[20] 20. Wong B, Gold JW, Brown AE, Lange M, Fried R, Grieco M, Mildvan D, Giron J, Tapper ML, Lemer CW, Armstrong D. Central-nervous-system toxoplasmosis in homosexual men and parenteral drugabusers. Annals oflnternal Medicine 100:36- 42, 1984.