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part of the brain, and the only clue to the etiology of the cerebral mass is a lung lesion and an abnormality of the CSF Meningovascular lesions, presenting as small deep strokes in an identical manner to meningovascular syphilis, may be superimposed on the clinical picture A pure motor hemiplegia, like that due to a hypertensive lacune, has been the most common type of stroke in our experience The course of the disease is quite variable It may be fatal within a few weeks if untreated More often, the course is steadily progressive over a period of several weeks or months; in a few patients, it may be remarkably indolent, lasting for years, during which there may be periods of clinical improvement and normalization of the CSF Lymphoma, Hodgkin disease, leukemia, carcinoma, tuberculosis, and other debilitating diseases that alter the immune responses are predisposing factors in as many as half the patients Patients with AIDS are particularly vulnerable to cryptococcal infection; estimates are that 6 to 12 percent of AIDS patients are subject to life-threatening meningoencephalitis with the organism The spinal uid shows a variable lymphocytic pleocytosis, usually less than 50 cells per cubic millimeter, but it should be emphasized that there may be few or no cells in a patient with AIDS (two-thirds have 5 or fewer cells per cubic millimeter) The initial CSF formula may display polymorphonuclear cells, but it rapidly changes to a lymphocytic predominance The glucose is reduced in three-quarters of cases (again, it may be normal in AIDS patients) and the protein may reach high levels Speci c diagnosis depends upon nding Cryptococcus neoformans or its antigens in the CSF These are spherical cells, 5 to 15 m in diameter, which retain Gram s stain and are surrounded by a thick, refractile capsule Large volumes of CSF (20 to 40 mL) may be needed to nd the organism in some cases, but in others they are proli c Indiaink preparations are distinctive and diagnostic in experienced hands (debris and talc particles from the gloves used in lumbar puncture may be mistaken for the organism), but the rate of positive tests under the best circumstance is 75 percent The carbon particles fail to penetrate the capsule, leaving a wide halo around the doubly refractile wall of the organism The search for these organisms is particularly important in AIDS patients, in whom the CSF values for cells, glucose, and proteins may be entirely normal A latex agglutination test for the cryptococcal polysaccharide antigen in the CSF is now widely available and gives rapid results The latter test, if negative, excludes cryptococcal meningitis with about a 90 percent reliability in AIDS patients and slightly less in others (see Chuck and Sande) In most cases the organisms grow readily in Sabouraud glucose agar at room temperature and at 37 C, but these results may not appear for days Newer enzyme-linked immunoadsorption tests are being evaluated The principal diseases to be considered in differential diagnosis are tuberculous meningitis (distinguished by fever, distinctive pulmonary lesions, low serum sodium due to inappropriate secretion of ADH, and organisms in CSF); granulomatous cerebral vasculitis (normal glucose values in CSF); multifocal leukoencephalopathy (negative CSF); unidenti able forms of viral meningoencephalitis (normal CSF glucose values); sarcoidosis; and lymphomatosis or carcinomatosis of meninges (neoplastic cells in CSF) Treatment In patients without AIDS, this consists of intravenous administration of amphotericin B, given in a dose of 05 to 07 mg/ kg/day Intrathecal administration of the drug in addition to the intravenous route appears not to be essential Administration of the.

Gain versus frequency 407 reduced, as shown in Fig 22-7 Points X and Y in the graph represent the instantaneous current extremes during the signal cycle

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