Reports — Clinical Practice and Surgical Cases

Background and Clinical Significance: Longstanding human immunodeficiency virus (HIV) may remain clinically unrecognized until adolescence. Growth failure, delayed puberty, and recurrent or atypical infections may represent manifestations of underlying immunodeficiency but can initially be attributed to other conditions. Case Presentation: A 16-year-old male, adopted at 4 years of age, was admitted with prolonged low-grade fever, chronic productive cough, and recurrent sinonasal symptoms. Marked growth retardation and absent pubertal development were also present. No perinatal or early-childhood medical records were available, and maternal HIV status could not be established. Laboratory investigations demonstrated severe CD4+ T-cell depletion, hypergammaglobulinemia, and elevated liver enzymes. Repeated SARS-CoV-2 antigen/PCR tests were positive, while anti-SARS-CoV-2 antibodies were undetectable. CT demonstrated chronic pansinusitis and hepatosplenomegaly. HIV infection was confirmed by positive ELISA and Western blot, with a plasma HIV RNA level of 127,721 copies/mL. The findings were consistent with advanced HIV infection with severe immunosuppression. Although the clinical history suggested longstanding infection, the timing and route of HIV acquisition could not be established. Similarly, the available SARS-CoV-2 results did not allow definitive differentiation between persistent infection and separate infection or reinfection episodes. Previous CMV IgG positivity had contributed to an earlier attribution of the hepatic abnormalities to CMV, although active CMV disease was not documented. Conclusions: Severe growth failure, absent pubertal development, recurrent or atypical infections, and profound CD4+ T-cell depletion should prompt consideration of underlying immunodeficiency, including HIV. In patients with incomplete medical records, previous diagnoses should be reassessed, especially when the clinical course remains unexplained.

Background and Clinical Significance: Cryptococcal meningitis remains a life-threatening complication of advanced HIV infection. Its recognition can be challenging when neurological manifestations are nonspecific or cerebrospinal fluid inflammation is limited. This case series illustrates the diagnostic variability and therapeutic challenges encountered in five patients managed at a regional HIV/AIDS center in northeastern Romania. Case Presentation: Five men aged 26–69 years were hospitalized between November 2022 and March 2025 with HIV-associated cryptococcal disease involving the central nervous system. All had profound immunosuppression, with CD4+ T-cell counts of 6–31 cells/mm³. Clinical manifestations included headache, confusion, altered consciousness, and focal neurological deficits. Cerebrospinal fluid opening pressures were elevated, while inflammatory findings ranged from lymphocytic pleocytosis to an almost acellular profile. Microbiological investigations included direct microscopy, fungal culture, and molecular testing, according to availability. In one patient, culture confirmed Cryptococcus neoformans despite negative India ink microscopy and absent documented pleocytosis. Antifungal treatment included liposomal amphotericin B and fluconazole-based regimens, with treatment selection constrained by drug availability and organ dysfunction. Three cases had fatal outcomes during hospitalization. Conclusions: Cryptococcal meningitis should remain a diagnostic consideration in profoundly immunosuppressed patients with neurological symptoms, even when initial microscopy is negative or cerebrospinal fluid inflammation is minimal. These cases emphasize the importance of complementary microbiological investigations, assessment and management of intracranial pressure, reliable access to recommended antifungal regimens, and appropriate timing of antiretroviral therapy.

Background/Objectives: World Health Organization (WHO) Grade 2–3 meningiomas have high recurrence rates despite postoperative radiotherapy. This study aimed to characterize patterns of failure and clinical outcomes after postoperative external beam radiotherapy. Methods: We retrospectively analyzed 10 patients with WHO Grade 2 (n = 6) or Grade 3 (n = 4) meningiomas treated at a single institution between January 2017 and May 2024. Nine patients underwent gross total resection. Radiotherapy was delivered using three-dimensional conformal radiotherapy (n = 6) or intensity-modulated radiotherapy (n = 4), with a median dose of 60 Gy in 30 fractions. Recurrence patterns were assessed relative to the high-dose region. Results: The 1- and 3-year overall survival rates were 90% (95% CI, 47–99%) and 79% (95% CI, 38–94%), respectively; corresponding local control rates were 70% (95% CI, 33–89%) and 39% (95% CI, 7–71%), respectively. Recurrence occurred in six patients, predominantly within the high-dose region. Acute toxicities were limited to Grade 1 radiation dermatitis. During follow-up, Grade 3 seizures occurred in three patients, and worsening of pre-existing Grade 2 paresis occurred in four patients. Two seizure events and two cases of worsening paresis were considered more likely related to recurrent or progressive disease, whereas attribution of the remaining neurological events to radiotherapy was uncertain. Conclusions: Despite postoperative radiotherapy, local control remained limited in this small, single-institution series, with a predominance of in-field recurrence. This pattern raises the possibility that tumor biological factors, in addition to technical and treatment-related factors, may contribute to treatment failure in WHO Grade 2–3 meningiomas. These findings are exploratory and warrant validation in larger studies incorporating molecular stratification and standardized treatment approaches.