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riety of opportunistic disorders, both focal and nonfocal, occur in such patients, as outlined in Table 33-2 Interestingly, there appears to be a predilection for certain ones CMV infection, primary Bcell lymphoma, cryptococcosis, toxoplasmosis, and progressive multifocal leukoencephalopathy (page 651), in this order of frequency (Johnson) The focal encephalitis and vasculitis of VZV infection, considered earlier in this chapter, and unusual types of tuberculosis and syphilis are other common opportunistic infections of AIDS Usually P carinii infection and Kaposi sarcoma do not spread to the nervous system Toxoplasmosis Of the focal complications, cerebral toxoplasmosis is the most frequent (and treatable; see page 623) In the autopsy series of AIDS reported by Navia and colleagues, areas of in ammatory necrosis due to Toxoplasma were found in approximately 13 percent (see Fig 32-7) Lumbar puncture, contrastenhanced CT scanning, and MRI are useful in diagnosis The spinal uid usually shows an elevation of protein in the range of 50 to 200 mg/dL, and one-third of patients have a lymphocytic pleocytosis Since the disease represents reactivation of a prior Toxoplasma infection, it is important to identify Toxoplasmaseropositive patients early in the course of AIDS and to treat them vigorously with oral pyrimethamine (100 mg initially and then 25 mg daily) and a sulfonamide (4 to 6 g daily in four divided doses) Curiously, the toxoplasmosis infection, so common in the brains of AIDS patients, is not a frequent cause of the typical infestation, namely, myositis The main clinical problem in reference to toxoplasmosis in AIDS is its differentiation from cerebral lymphoma as discussed below and in Chap 31 CNS Lymphoma In the Johns Hopkins study (see Johnson), about 11 percent of AIDS patients developed a primary CNS lymphoma, which may in some cases be dif cult to distinguish from toxoplasmosis clinically and radiologically If the cytologic study of the CSF is negative and there has been no response to antibiotics, stereotaxic brain biopsy may be necessary for diagnosis The prognosis in such patients is considerably less favorable than in nonAIDS patients; the response to radiation therapy, methotrexate, and corticosteroids is short-lived, and survival is usually measured in months In the face of enhancing focal brain lesions in AIDS, the current approach is to assume initially the presence of toxoplasmosis, which is treatable Antibody tests for toxoplasmosis should be obtained; the absence of IgG antibodies mandates that treatment be changed in order to address the problem of brain lymphoma Also, if antitoxoplasmal therapy with pyrimethamine and sulfadiazine fails to reduce the size of the lesions within several weeks, another cause should be sought, again mainly lymphoma In those patients who cannot tolerate the frequent side effects of pyrimethamine or sulfonamides (rash or thrombocytopenia), clindamycin may be of value Recently it has been suggested that thallium isotope singlephoton emission computed tomography (SPECT) and positron emission tomography (PET) can reliably exclude lymphoma as the cause of a mass lesion in the AIDS patient The less frequent possibilities of tuberculous or bacterial brain abscess should be kept in mind if none of the other avenues allow a con dent diagnosis Cytomegalovirus Among the nonfocal neurologic complications of AIDS, the most common are CMV and cryptococcal infections At autopsy, about one-third of AIDS patients are found to be infected with CMV However, the contribution of this infection to. how to open pdf file in popup window in asp.net c# Display pdf in a div after getting it from sql | The ASP . NET Forums
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13 Mar 2019 ... ASP . NET MVC Pdf Viewer . C#, VB; ASP . NET ; Download C# sample ... This sample demonstrates how to open a local pdf file in PdfViewer . the total clinical picture is often uncertain Despite this ambiguity, certain features have emerged as typical of CMV encephalitis in the AIDS patient According to Holland and colleagues, late in the course of AIDS and usually concurrent with CMV retinitis, the encephalopathy evolves over 3 to 4 weeks Its clinical features include an acute confusional state or delirium combined, in a small proportion of cases, with cranial nerve signs including ophthalmoparesis, nystagmus, ptosis, facial nerve palsy, or deafness In one of our patients, there were progressive oculomotor palsies that began with light- xed pupils Pathologic specimens and MRI show the process to be concentrated in the ventricular borders, especially evident as T2 signal hyperintensity in these regions It may be seen to extend more diffusely through the adjacent white matter and be accompanied by meningeal enhancement by gadolinium in a few cases Extensive destructive lesions have also been reported; this has been true in two of our own cases Such lesions may be associated with hemorrhagic changes in the CSF in addition to showing an in ammatory response CMV may also produce a painful lumbosacral polyradiculitis in AIDS The diagnosis of CMV infection during life is often dif cult Cultures of the CSF are usually negative and IgG antibody titers are nonspeci cally elevated Newer PCR methods may prove useful here Where the diagnosis is strongly suspected, treatment with the antiviral agents ganciclovir and foscarnet has been recommended; but, as pointed out by Kalayjian and colleagues, the CMV disease may develop and progress while patients are taking these medications as a form of maintenance therapy Cryptococcal Infection Meningitis with this organism and less often solitary cryptococcoma are the most frequent fungal complications of HIV infection Flagrant symptoms of meningitis or meningoencephalitis may be lacking, however, and the CSF may show little abnormality with respect to cells, protein, and glucose For these reasons, evidence of cryptococcal infection of the spinal uid should be actively sought with India ink preparations, antigen testing, and fungal cultures Treatment is along the lines outlined (on page 621) Varicella Zoster Cerebral infections with this virus are less common complications of AIDS, but when they do occur, they tend to be severe They take the form of multifocal lesions of the cerebral white matter, somewhat like those of progressive multifocal leukoencephalopathy, a cerebral vasculitis with hemiplegia (usually in association with ophthalmic zoster), or rarely a myelitis Encephalitis due to HSV-1 and HSV-2 has also been identi ed in the brains of AIDS patients, but the clinical correlates are unclear There is no evidence that acyclovir or other antiviral agents are effective in any of these viral infections Shingles involving several contiguous dermatomes is known to occur in AIDS, as in other immunosuppressed conditions Tuberculosis Two particular types of mycobacterial infection tend to complicate AIDS Mycobacterium tuberculosis and Mycobacterium avium-intracellulare Tuberculosis predominates among drug abusers and AIDS patients in underdeveloped countries, and a higher than usual proportion of these immunosuppressed individuals develop tuberculous meningitis Diagnosis and treatment are along the same lines as in non-AIDS patients (page 612) Atypical mycobacterial infections are usually associated with other destructive cerebral lesions and respond poorly to therapy. display pdf in mvc E5095 - How to implement a simple PDF viewer in web ASP . NET ...
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