Correspondence

Correction

Cerebral Microsporidiosis Due to Encephalitozoon cuniculi

N Engl J Med 1997; 337:640-641August 28, 1997

Article

To the Editor:

The magnetic resonance imaging (MRI) scan shown in Figure 1 of the report by Weber et al. (Feb. 13 issue)1 shows congestion of the ethmoid sinus, not the right maxillary sinus, as the figure legend says. The scan does not show the maxillary sinuses. It is not permissible to diagnose sinusitis only on the basis of an MRI scan, because MRI often demonstrates mucosal thickening without clinical disease.2 Was there a rhinoscopic examination? The authors relate the observed sinus congestion to the Encephalitozoon cuniculi infection. Chronic sinusitis is very common in patients with human immunodeficiency virus (HIV) infection, and the traditional sinus pathogens are usually responsible for the infection.3 Did the authors perform a sinusal lavage to isolate the pathogen? As they observe, detecting E. cuniculi may be difficult in the cerebrospinal fluid or the urinary sediment.

Orlando Guntinas-Lichius, M.D.
University of Cologne, D-50924 Cologne, Germany

3 References

1. 1

   Weber R, Deplazes P, Flepp M, et al. Cerebral microsporidiosis due to Encephalitozoon cuniculi in a patient with human immunodeficiency virus infection. N Engl J Med 1997;336:474-478
   Full Text | Web of Science | Medline

2. 2

   Digre KB, Maxner CE, Crawford S, Yuh WT. Significance of CT and MR findings in sphenoid sinus disease. AJNR Am J Neuroradiol 1989;10:603-606
   Web of Science | Medline

3. 3

   Meiteles LZ, Lucente FE. Sinus and nasal manifestations of the acquired immunodeficiency syndrome. Ear Nose Throat J 1990;69:454-459
   Medline

Author/Editor Response

Dr. Weber and colleagues reply:

To the Editor: Dr. Guntinas-Lichius is correct that the MRI scan in our article showed congestion of the left ethmoid sinus, not the right maxillary sinus. (The MRI is read looking from below.) Nevertheless, the HIV-infected patient we described who had cerebral microsporidiosis due to E. cuniculi also had left maxillary sinusitis, as Figure 1A and 1BFigure 1Axial T₂-Weighted MRI Scans before and after Treatment with Albendazole in an HIV-Infected Patient with Disseminated E. cuniculi Infection and Left Maxillary Sinusitis. shows. We did not perform a rhinoscopic examination, sinonasal lavage, or a mucosal biopsy of the maxillary sinus since sinusitis was not clinically relevant in our patient, who eventually died, most probably from cerebral microsporidiosis. There is, however, indirect evidence of a causal association between the E. cuniculi infection and the sinusitis. Multiple courses of antimicrobial therapy had not improved the patient's condition, but the administration of albendazole alleviated his symptoms and reduced the mucosal thickening of the left maxillary and ethmoid sinuses, in addition to decreasing the urinary excretion of microsporidial spores.

Chronic sinusitis due to bacterial pathogens is common in HIV-infected patients, but sinusitis due to various species of microsporidia, including E. cuniculi, E. hellem, E. intestinalis, and Enterocytozoon bieneusi, has also been described.1-4 In most patients with microsporidial infection of the respiratory tract, the parasites could be detected in specimens of stool or urine. In some HIV-infected patients, sinonasal infection is a predominant manifestation of systemic microsporidiosis.2,4 In these patients, microsporidial parasites have been demonstrated by electron- or light-microscopical examination of mucosal-biopsy specimens or sinonasal washings2-4 and also by molecular diagnostic methods,1 but the sensitivity of these techniques is not known. In our experience with patients who have disseminated infection with an encephalitozoon species, microsporidial spores are best demonstrated by microscopical examination of urine sediments (obtained by the centrifugation of urine at 1500 × g).2,5

Rainer Weber, M.D.
Markus Flepp, M.D.
Werner Wichmann, M.D.
University Hospital, CH-8091 Zurich, Switzerland

5 References

1. 1

   Hartskeerl RA, Schuitema AR, van Gool T, Terpstra J. Genetic evidence for the occurrence of extra-intestinal Enterocytozoon bieneusi infections. Nucleic Acids Res 1993;21:4150-4150
   CrossRef | Web of Science | Medline

2. 2

   Weber R, Bryan RT, Schwartz DA, Owen RL. Human microsporidial infections. Clin Microbiol Rev 1994;7:426-461
   Web of Science | Medline

3. 3

   Molina JM, Oksenhendler E, Beauvais B, et al. Disseminated microsporidiosis due to Septata intestinalis in patients with AIDS: clinical features and response to albendazole therapy. J Infect Dis 1995;171:245-249
   CrossRef | Web of Science | Medline

4. 4

   Rossi RM, Wanke C, Federman M. Microsporidian sinusitis in patients with the acquired immunodeficiency syndrome. Laryngoscope 1996;106:966-971
   CrossRef | Web of Science | Medline

5. 5

   Weber R, Deplazes P, Flepp M, et al. Cerebral microsporidiosis due to Encephalitozoon cuniculi in a patient with human immunodeficiency virus infection. N Engl J Med 1997;336:474-478
   Full Text | Web of Science | Medline

Citing Articles (1)

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1. 1

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