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  1. 1. NEURO HIV/AIDS Objectives 1. Review the various etiological agents that cause neurological disorders 2. Give key points when taking a history 3. Describe the clinical presentation of each disorder 4. List the recommended diagnostics and common findings for each disorder 5. Understand the treatment and management of neurological disorders 6. Discuss preventive measures
  2. 2. Overview Reported incidence (16% to 72%) of neurological abnormalities varies greatly. A wide range of neurological manifestations is reported: cognitive defects, focal deficits, painful feet syndrome, encephalopathy. Pathogens are: the HIV itself While 5-year survivalneoplasms toxo several Ois & after the episode was 8% in 1990-1993, it had drugs climbed to 30 % by 1994-1996. This rate has risen to approximately 80 % since 1997 in countries where HAART is readily available.
  3. 3. INTERNATIONAL CENTRE FOR EYE HEALTH TEACHING SET NO.8 HIV/AIDS Source UNAIDS / WHO 1. Epidemiology of HIV/AIDS Adults and Children Estimated to be Living with HIV/AIDS (June 2000)
  4. 4. HIV and AIDS IN CANADA •58,929 from November 1985 up to June 30, 2005. •4,200 New HIV cases every year! • 33% HIV-positive Canadians don't know they are infected! • $36 million funding CIDA gave to HIV/AIDS initiatives in 2001-02 Source: Public Health Agency of Canada
  5. 5. Acute HIV Infection Fever 96% Headache 32% LAD 74% N/V 27% Pharyngitis 70% HSM 14% Rash 70% Wt loss 13% Myalgia/arthralgia 54% Thrush 12% Diarrhea 32% Neuro Sx 12% Neuro: meningoencepalitis or aseptic meningitis; peripheral neuropathy or radiculopathy; facial palsy, Guillain-Barre syndrome; brachial neuritis; cognitive impairment or psychosis CDC 2002
  6. 6. • >12% of Primo Infection & “seroconversion” have neuro Sx! • Problems & Special Cases • The "diagnostic window“ • Needle-stick injury or other occupational exposure
  8. 8. Major Pathogens 15% of patients have concurrent (>2) AIDS-related CNS OIs. Protozoal infection Toxoplasma Gondii (toxoplasmosis) Mycobacterial infection M. tuberculosis (TB meningitis) Bacterial Strep pneumoniae, Neisseria meningitis (bacterial meningitis) Fungal infection Cryptococcus neoformans (cryptococcal meningitis) Viral infection Cytomegalovirus (CMV) Other: Progressive multifocal leukoencephalopathy (PML) Primary CNS lymphoma HIV-associated dementia (HAD) Painful sensory and motor peripheral neuropathies Neurosyphilis
  9. 9. Protozoal infection: Toxoplasma gondii (toxoplasmosis) Presenting Signs and Symptoms reactivation of a latent infection Usually: acute neurological syndrome Clinical symptoms may evolve quickly • Focal neurological deficits • Headache (severe, localized) • Seizures HE • personality changes, cognitive disorders • Fever • Confusion • Myalgia • Arthralgia
  10. 10. Diagnostics > 85% seropositive for T. gondii antibodies. PCR (blood or CSF) has little relevance CSF values tachyzoites within pseudocysts (Grocott's silver) • Normal: 20-30% • Protein: 10-150/ml • WBC: 0-40 (monos) An HIV-infected individual presenting with typical signs and symptoms and normal cerebrospinal fluid findings should be put on treatment for toxoplasmosis. Response to therapy (within 2 weeks) then confirms the diagnosis.
  11. 11. • 1/3 solitary, 1/3 several (2-5) or 1/3 multiple; deep or juxtacortical lesions w/oedema ; big or small. immunostaining • 90% smooth, peripheral ring enhancement •The more lesions there
  12. 12. Unique Features, Caveats One of the most common HIV-related neurological complications without HAART If patient does not receive maintenance therapy, disease will recur. Usually occurs when CD4<100 Check blood picture regularly for toxicity. Leukopenia, thrombocytopenia and rash are common. Folinic (not folic!) acid reduces the risk of myelosuppression. During treatment, patients should maintain a high fluid intake and urine output. Empirical treatment may be diagnostic, but any lesion that failed to improve after 2-4 weeks biopsy needed! Rare: chorioretinitis (vs CMV)
  13. 13. Mycobacterial Infection: M. tuberculosis (TB Meningitis) Presenting Signs and Symptoms Most common feature of extrapulmonary TB is cervical lymphadenopathy, but every organ can be involved. Gradual onset of headache and decreased consciousness • Low grade evening fevers • Night sweats, Weight loss • Neck stiffness, Kernig’s, etc • Cranial nerve palsies (III & IV !)
  14. 14. Diagnostics Tuberculoma (rare) CSF Values • Normal: 5-10% • Protein: High (40mg/dl-100 mg/dl) • WBC: 5-2000 (average is 60-70% monos) • Glucose: low (<20 mg/dl) • AFB smear : 20% (negative if “no bacteria” after 8 weeks) • PCR sensitivity:95% specificity 40-77%
  15. 15. Unique features, Caveats CD4<350, and if <100 circulating CD4 cells/µl, the risk of mortality is high. MAC is rare until <50 CD4s MTB meningitis in up to 10% of patients who present with TB (from the rupture of a tuberculoma or blood-borne) Always exclude cryptococcal meningitis by CSF microscopy (India ink stain) Multidrug-resistant tuberculosis is rising (12-25% now!)
  16. 16. Bacterial Infection: Strep pneumoniae, Neisseria Meningitis (Bacterial Meningitis) Presenting Signs and Symptoms Symptoms tend to present within one week of infection. May be preceded by a prodromal respiratory illness or sore throat. - Fever - Vomiting - Headache - Malaise - Stiff neck - Irritability - Photophobia - Drowsiness - Coma
  17. 17. Diagnostics CSF Values • leukocytosis • cerebrospinal fluid shows increased pressure • cell count (100 –10,000/mm3) • protein (>100 mg/dl) • decreased glucose (<40 mg/dl or <50% of the simultaneous glucose blood level) • gram-stained smear of the spun sediment of the CSF can reveal the etiologic agent
  18. 18. Management and Treatment Penicillin (24 million units daily in divided doses every 2-3 hours) or Ampicillin (12 gr daily in divided doses every 2-3 hours) or Chloramphenicol (4 to 6 grams IV/day). Treatment should be continued for 10 to 14 days. Crystalline penicillin 2-3 mega units and chloramphenicol 500-750 mg every 6 hours for 10- 14 days
  19. 19. Unique features, Caveats Often encountered during late stages of HIV disease. Prompt diagnosis and aggressive management and treatment ensure a quick recovery
  20. 20. Fungal Infection: Cryptococcus neoformans (cryptococcal meningo-encephalitis) Presenting Signs and Symptoms Presentation usually nonspecific for > 1 month. • Protracted headache and fever may be the only signs • Nausea, vomiting, and stiff neck may be absent and focal neurological signs are uncommon early on. • Signs of raised ICP? • Extraneural symptoms: pneumonitis, pleural effusions, skin lesions (rare) and retinitis • Fever, malaise, nuchal pain signify a worse prognosis • Imaging may be unrevealing: cryptococcomas are rare!
  21. 21. Diagnostics GMS stain Imaging? LP !!! CSF Values • Normal 20% • Culture (+) 95-100% • Protein 30-150/dl • WBC: 0-100 (monos) • Glucose decreased: 50-70mg/dl • Crypt Ag nearly 100% sensitive and specific
  22. 22. Cryptoccocal meningitis: CSF India ink examination positive in > 80%!!!
  23. 23. Triple therapy effective (80% remission) but controversial (flucytosine only IV and is toxic)
  24. 24. Unique features, Caveats If untreated, it is slowly progressive and ultimately fatal CSF is negative in approximately 60 % of cases after two weeks of successful therapy (< 4 weeks!) Most common life-threatening fungal infection in HIV/AIDS patients. Also the most common cause of meningitis in patients with HIV/AIDS in Africa and Asia. Occurs most often in patients with CD4<50 It is better prevented than treated
  25. 25. Unique features, Caveats Headache is secondary to fungal accumulation. Headache increases gradually over time and then follows a recurring pattern. It becomes harder to get rid of, and then becomes continuous. This is what the patient reports. Requires lifelong suppressive treatment unless immune reconstitution occurs If there is raised ICP, CSF drainage may become necessary. Steroids are useless here.
  26. 26. Viral Infection: Cytomegalovirus (CMV) Resenting Signs and Symptoms Fever ± delirium, lethargy, disorientation, malaise, headache most common. Stiff neck, photophobia, cranial nerve deficits less common. Usually no focal neurological deficits Other manifestations of disseminated CMV infection are rare (15 %), and can affect every organ. Pneumonia, esophageal ulcers, colitis and encephalitis are most frequently involved. Sinusitis and myelitis may also occur.
  27. 27. Diagnostics Retinal exam to check for changes. Consult an “HIV- experienced” ophthalmologist! CMV retinitis, characterized by creamy yellow white, hemorrhagic, full thickness retinal opacification, which can cause visual loss and lead to blindness if untreated; patient may be asymptomatic or complain of floaters, diminished acuity or visual field defects. Retinal detachment if disease is extensive CMV serology (IgG almost always positive, IgM variable) is usually not helpful. CMV PCR or a blood test for pp65 antigen to detect antibodies against a CMV-specific phosphoprotein may be more useful. CMV retinitis or a recurrence is unlikely with a negative PCR or pp65 result.
  28. 28. Management and Treatment HAART has dramatically improved prognosis. The previously required life-long daily infusions of ganciclovir or foscarnet via port, pumps and nursing service are luckily now a thing of the past. If there are relapses under oral valganciclovir, we recommend re- induction and maintenance therapy with foscarnet or possibly with cidofovir.
  29. 29. Unique features, caveats Evolution occurs in less than 2 weeks Mainly in untreated patients when CD4<100 Although any part of the retina may be involved, there is a predilection for the posterior pole; involvement of the optic nerve head and macula region is common Characteristically involves the retinal vessels which are always abnormal in areas involved by retinitis. There is minimal or no accompanying uveitis Rare but devastating illness pre HAART. Treatment is very expensive and usually not available. CMV management needs special care. Therefore, early referral is essential – leads to blindness in 30% patients
  30. 30. Viral Infection: Progressive mulltifocal leukoencephalopathy (PML) Presenting Signs and Symptoms Afebrile, alert, no headache Progressively impaired cognition & behaviour, speech, vision & motor function. Cranial nerve deficit and cortical blindness JCV was named after the initials of the first patient in 1971 Seroprevalence is high (80 %); latent persistent infection must be assumed often. PML doesn’t always indicate the final stage of HIV infection
  31. 31. Diagnostics CT may be normal or MRI may show some diffuse asymmetrical demyelination PCR of CSF (not sera!) for detection of JC virus sensitivity 80%; specificity 90% (in good hands) Definitive diagnosis EM Luxol fast blue
  32. 32. Management and Treatment ART can improve symptoms and prolong life. Foscarnet, interferon, immune stimulants, cytosine arabinoside and steroids failed! Cidofovir and camptothecin being tested now The absolute priority should currently be to optimize ART
  33. 33. Unique Features, Caveats CD4<100 (but possible with ~200 CD4 T cells) PML is very rare in the general community, but 2nd most common nowadays in AIDS patients. Evolution occurs over weeks to months. Always fatal in the pre-HAART era, prognosis is still poor. peripheral enhancement observed after “immune reconstitution inflammatory syndrome - IRIS” (PML’s ‘inflammatory phase’). Although lesions are huge, every PML starts small: very discrete, localized, solitary lesions do not exclude the diagnosis! Must differentiate from HHV-6 or HIV encephalopathies.
  34. 34. Diagnosis of PML vs. MS Typical of PML Differentiation vs. MS Clinical Clinical Tempo: Sub-acute Tempo: Acute Location: Sub-cortical, Location: ON, cord, cerebellum and other localizations MRI MRI Non-enhancing Gd enhancement No mass effect Edema, mass effect Sub-cortical Not only sub-cortical CSF CSF JCV DNA detectable JCV DNA negative
  35. 35. Clinical Features of MS and PML Features Suggestive of MS PML Onset • Acute • Sub-Acute Evolution • Over hours to days • Over weeks • Normally stabilize • Progressive • May resolve even spontaneously Typical • Diplopia • Behavioral and Clinical • Paraesthesiae neuropsychological alteration Presentation • Paraparesis • Cortical signs and symptoms • Optic neuritis • Retrochiasmal visual deficits • Myelopathy • Hemiparesis • Marked cerebellar findings • Gait/limb abnormalities
  36. 36. Unique Features, Caveats
  37. 37. Unique Features, Caveats
  38. 38. Primary CNS lymphoma Presenting Signs and Symptoms Afebrile w/Headache, mental status, personality or behavioral changes over several weeks. Focal and multifocal neuro deficits, seizures. Severely immunocompromised, constitutional symptoms may mask the actual problem.
  39. 39. Cerebral lymphoma
  40. 40. Diagnostics CT Scan MRI Peri-ventricular in one or more sites Prominent edema, irregular and solid on enhancement. CSF: • Normal;—30-50% • Protein—10-150/ml • WBC—0-100 (monos) • Cytology positive in <5% • Suspect with negative toxo IgG or failure to respond to empiric toxo treatment
  41. 41. Management and Treatment There is no cytotoxic chemotherapy for this disease but a treatment attempt with IV MTX can be justified (3 g/m2 every 14 days with leucovorin rescue). Irradiation (fractionated, 40 Gy total dose) can help some patients, but is considered palliative. Dexamethasone 8 mg tid can help if raised ICP. The decisive factor is the best possible immune reconstitution!
  42. 42. Unique features, Caveats PCNSL is rare in the general community, but affects up to 10% of AIDS patients CD4 <50 Typical end-stage complication of HIV disease EBV-associated in almost 100 % of cases.
  43. 43. HIV-associated dementia (HAD) HIV encephalopathy (HIVE) AIDS dementia complex; AIDS dementia HIV-associated cognitive motor complex. Presenting Signs and Symptoms 10-20% – decreased with HAART but now increasing due to increased life expectancy CD4 <200 Afebrile; general lethargy Triad of cognitive, motor and behavioral dysfunction
  44. 44. Diagnostics CSF normal/decreased WBC w/ raised protein (OCB(+)!) subcortical dementia MMS not sensitive Memorial Sloan Kettering scale (Price 1988).
  45. 45. HIV-E Differential diagnoses
  46. 46. Management and Treatment Widely controversial and vastly unproven yet! Possible benefit from ARV agents that penetrate the CNS (zidovudine, lamivudine (high concentrations in ventricular CSF), nevirapine and indinavir) Benefit of early AZT at higher dose for mild cases. ? selegeline, nimodipine, lexipafant and the antioxidant agent CPI-1189
  47. 47. HIV-associated myelopathy (HIV-M) Clinically progressing with less prominent or no cognitive decline. Cervical/ thoracic w/ lipid-laden macrophages “vacuolar myelopathy” May be sub-clinical. Mainly with advanced immunosuppression Diagnosis: only non-specific findings Treatment: Early observations of significant improvement with zidovudine monotherapy were later confirmed with HAART.
  48. 48. Other Neurological Syndromes Reported with HCV • Demyelinating myelitis • Cord biopsy – Macrophages – Perivascular lymphocytes – Loss of myelin – Reactive gliosis – No HCV antigen • ?Immune mediated myelitis Neurologic AIDS Research Consortium Grewal, J N Sci, 2004
  49. 49. Painful Sensory and Motor Peripheral Neuropathies Presenting signs and symptoms Burning pain and numbness in toes and feet, ankles, calves, fingers in more advanced cases Paraplegia Autonomic dysfunction Poor bowel/bladder control Dizziness secondary to postural hypotension Contact hypersensitivity in some cases Mild/moderate muscle tenderness Muscle weakness Later: Reduced pinprick/vibratory sensation; reduced or absent ankle/knee jerks Sweating
  50. 50. Diagnostics EMG / NCT show predominantly axonal neuropathy CPK usually elevated CSF - look for cytomegalovirus or herpes simplex virus infections—lymphomatous infiltration Spinal fluid to determine etiology Serum B12 and TSH Quantitative sensory testing or thermal thresholds may be helpful
  51. 51. Management and Treatment Exclude neurotoxic drugs, alcoholism, diabetes, B12 deficiency, thyroid problems and treat underlying causes if known. Discontinue presumed neurotoxic medication (d4T, ddC, ddI, possibly also 3TC) often resolves only very slowly, therefore change treatment quickly! Severe, progressive muscular weakness (d4T, ddI) Provide proper nutrition and vitamin supplements
  52. 52. Treatments for neuropathies
  53. 53. HIV myopathies • Myalgia, fatigue and raised CK are frequently found in HIV infection. • The diagnosis of probable myopathy requires weakness, muscle atrophy or myopathic features demonstrated by electromyography. • Treat w/ Prednisone or IvIg • Stop AZT
  54. 54. Neurosyphilis Presenting Signs and Symptoms Can be asymptomatic Headache, fever, photophobia, meningismus ± seizures, focal findings, cranial nerve palsies Tabes dorsalis—sharp pains, parasthesias, decreased DTRs, loss of pupil response General paresis— memory loss, dementia, personality changes, loss of pupil response Meningovascular strokes, myelitis Ocular syphilis—iritis, uveitis, optic neuritis
  55. 55. Diagnostics CT Scan/MRI: Aseptic meningitis—may show meningeal enhancement General paresis—cortical atrophy, sometimes with infarcts Meningovascular syphilis—deep strokes. Dementia? CSF: Protein—45-200/ml WBCs—5-100 (monos) VDRL positive—sensitivity 65%; specificity 100% positive Serum VDRL and FTA-ABS are clue in >90%; false neg serum VDRL in 5-10% with tabes dorsalis or general paresis Definitive diagnosis: positive CSF, VDRL (found in 60-70%)
  56. 56. Management and Treatment Give Aq penicillin G, 18-24 mil units/day x 10-14 days Follow-up VDRL every 6 months until negative Indications to re-treat: • CSF WBC fails to decrease at 6 months or CSF still abnormal at 2 years • Persisting signs and symptoms of inflammatory response at 3 months • Four-fold increase in CSF VDRL at 6 months Failure of CSF VDRL of 1:16 to decrease by two-fold by 2 months or four-fold by 12 months
  57. 57. Unique features, Caveats 0.5% of all HIV/AIDS patients Most common forms in HIV-infected persons are ocular, meningeal, and meningovascular Some evidence that syphilis progresses more rapidly in the context of HIV infection, so that complications may occur at an unusually early phase. Recommended that syphilis testing be offered to all in high prevalence areas because it is treatable in early stages, and has an accelerated course in HIV. CD4<350 Lancet Infect Dis 2004; 4: 456–66 Syphilis and HIV: a dangerous combination. W A Lynn and S Lightman
  58. 58. Last slides after this brief announcement ☺
  59. 59. HIV Risk Factors “Unprotected” sexual contact, since 1978 Any “STD”, HPV/Pap, OCPs… “Recreational” blood exposure IVDU, tattoos, cocaine straws, etc. Receipt of tissue or blood products Risk 1:60,000 / 1985 → 1:675,000 / 1996 (USA) “PARTNER” with above risks Person from high prevalence group Note “6-month” negative window 42
  60. 60. HIV Risk Factors “Unprotected” sexual contact, since 1978 Any “STD”, HPV/Pap, OCPs… “Recreational” blood exposure IVDU, tattoos, cocaine straws, etc. Receipt of tissue or blood products Risk 1:60,000 / 1985 → 1:675,000 / 1996 (USA) “PARTNER” with above risks Person from high prevalence group Note “6-month” negative window 42
  61. 61. Sexual Risk Assessment “Have you…?” ? Ever had sex since 1978 ? ? Used condoms 100% ? ? Used oral contraceptives ? ? Ever been pregnant ? ? Ever had: ? A sexually transmitted infection ? ? An abnormal Pap smear ? ? Had sex with men, women or both ? ? Had sex vaginally, orally or rectally ? Do you know the above for all of your partners ??? 43