Page 217 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 5 of 7 Original Research

the commencement of antiretroviral therapy. We presume huge challenges both for diagnosis and management.
the latter two to have been para-infectious in nature. Cavernous sinus disease biopsies by neurosurgery even in a
tertiary facility are at most times unobtainable. Trauma
CSF was obtained in 13 patients. It was contraindicated or not consumes most of their time leaving little to disorders where
required in the others. In 31% (4/13) of the cases, the CSF was empirical treatment is the fall-back option. Histological
abnormal and pointed to the diagnosis. In only 25% (1/4) of diagnosis while indicated becomes unobtainable and if systemic
the cases, TB was confirmed on CSF findings. Abnormal CSF evidence is unavailable then confirmation of the diagnosis is
findings confirmed the diagnosis of cryptococcal meningitis in extremely difficult to obtain. In the setting of cavernous sinus
one patient and neurosyphilis in two patients. All three disease, even empirical treatment is unsupported as
patients were treated appropriately but none returned for
follow-up CSF examination. Neurosyphilis was confirmed in epidemiological data regarding cavernous sinus disease are
two patients by serum rapid plasma regain titres of > 1:32. CSF unavailable in South Africa. The different spectrum of disease
pleocytosis and the positive venereal disease research in developed countries cannot be extrapolated to developing
laboratory tests were confirmatory in both cases. countries. So, management strategies usually fall back on expert
opinion. Furthermore, despite the excellent HIV education and
The case of cryptococcal meningitis with pachymeningitis antiretroviral treatment programme in South Africa, non-
8
and unilateral cavernous sinus syndrome occurred in a adherence to treatment by patients is common. The follow-up
patient with CD4+ count of 338 cells/µL. The CSF was mildly of patients is inconsistent despite the high cost of investigations
pleocytotic (polymorphs = 3 cells/µL and lymphocytes = 113 and treatment initially given to patients at the tertiary facilities.
cells/ µL), protein was 0.81 g/L and glucose was 3.1 mmol/L.
Diagnosis was made on a positive cryptococcal antigen test. In this study, we have attempted to obtain reliable and perhaps
Response to amphotericin B and fluconazole was initially reproducible epidemiological data on cavernous sinus disease
promising, but follow-up was absent. in HIV-infected patients but, as expected, were faced with many
challenges. Of the 23 patients with cavernous sinus disease, the
The outcomes varied, and the follow-up of patients was diagnosis was confidently made in 18 patients (78%). The
lacking. Two patients with confirmed TB returned for follow- majority had mild-to-moderate immunosuppression. Only two
up and were recovering on treatment. The three patients with patients had severe immunosuppression of CD4+ < 100 cells/
high-grade B-cell lymphoma were referred to oncology and µL. Histological diagnoses from the biopsy of the cavernous
lost to follow-up. The three patients with meningioma were sinus disease was obtained in 13% (3/23) of the patients.
referred to neurosurgery for further follow-up. Two patients
have since received radiotherapy but remain clinically Systemic evidence and/or expert opinion on radiological
unchanged. The patient with breast carcinoma demised from findings were used for the other cases. In five patients, the cause
pulmonary embolism. The patients with nasopharyngeal was unknown. Fortunately, two patients recovered without
carcinoma and corneal carcinoma were receiving chemotherapy specific intervention, and one responded to intravenous
from oncology, but follow-up showed no change to the antibiotics. Two patients were treated empirically for TB based
cavernous sinus syndrome. The patient with the pituitary solely on radiological findings as their CSF findings were
macroadenoma had debulking surgery and was commenced unhelpful. Both patients did not return for follow-up, and the
on replacement therapy by endocrinology. Her visual acuity outcome of their treatment remains unknown.
loss and left-sided ophthalmoplegia have not improved; she is
awaiting radiotherapy. The patient with the cavernous sinus The most commonly identified diagnosis was TB with
aneurysm was still awaiting neurosurgical intervention three evidence available from pulmonary TB in all four patients.
months after diagnosis. CSF results were only contributory in one patient. High-grade
B-cell lymphoma, metastatic carcinoma and meningioma
Discussion were the next most common. With immunosuppression, the
presence of high-grade B-cell lymphoma was plausible, but
According to 2016 statistics, South Africa has the most high-
profile HIV epidemic in the world, having 7.1 million non-HIV-related metastatic disease and meningioma were
people living with the infection. Despite having probably incidental.
6
the largest antiretroviral treatment programme globally,
the complications from HIV infection continue to burden the Two cases of neurosyphilis were identified in this series, which
limited health resources in South Africa. Determining the is high as there are only two other cases in the literature of
actual duration of HIV infection is difficult for various neurosyphilis affecting the cavernous sinus where HIV was
9,10
reasons, which include late presentation and reluctance to negative or the HIV status was unknown. Neurosyphilis is
know one’s HIV status for the fear of stigmatisation and more common in HIV-infected patients, which could account
apathy. Despite regular and widely published educational, for the higher number found in this series affecting an atypical
screening and treatment programmes for HIV infection in site. Response to treatment was much too early to assess during
South Africa, stigmatisation of the illness is still prevalent. 7 admission and unfortunately both patients failed to return for
follow-up. There were isolated cases of a saccular internal
Neurological sequelae of HIV infection are common, and carotid artery aneurysm and a pituitary macroadenoma, which
cavernous sinus disease in the setting of HIV infection poses were also probably incidental. The increased incidence of

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