NEUROLOGICALMANIFESTATIONS OF HIV INFECTION AN UPDATE Dr. Dibbendhu Khanra
HIV ENTRY – TROJAN HORSE THEORY Presenting feature of HIV/ AIDS in 10-20% Neurologic complications are present in more than 40% of PLHA Autopsy - prevalence of neuro-pathologic abnormalities in 80%
NEUROLOGICAL COMPLICATIONS OF HIV/AIDS HIV itself• HAND• HIV neuropathy• Aseptic meningitis• HIV myelopathy• HIV myopathy OI• TB• Toxoplasma• Cryptococcus• PML• CMV Lymphoma ART related
CHANGING PARADIGM 1981-1994 – OI, ADC 1995-2006 - HAART, Decline of CNS complications 2007-2012 - DSPN, HAND, CHAIN ‘’The most severe HAND diagnosis (HAD) was rare, but milder forms of impairment remained common, even among those receiving CART’’ - CHARTER’ 2010 ‘’The association of sustained impairment with worse current immune status (low CD4 cell count) suggests that restoring immuno- competence increases the likelihood of neuro-cognitive recovery.’’ - ALLRT ‘2007
ASSESSMENT OF HAND Cognition• Modified HIV Dementia Scale Memory registration Motor speed Memory recall construction Motor• Timed Gait• Paper based tapping test Neuropsychology• Trails Making Test A & B• Figural Visual Scanning Task• Digit-Symbol Task (WAIS-R)
Spectrum of Cognitive ImpairmentHAND impairment >=2 of everyday domains function Stages of ADC 1.Language 1.Mental 2.Attention acuity 3.Execution 2.Efficiency 4.Memory in work 5.Motor skill 3.Social 6.Information functioning processingANI >=1 SD below no/mild expectedMND >=1 SD below moderate expectedADC >=2 SD below severe expected
PATHOGENESIS AND CO-FACTORS Low NAA in frontal cortex Fronto-striatal pathway High level of Glx in basal CSF viral load injury ganglia CD4 WM abnormality with Activated Kynurenine increased volume of gray pathway matter Metabolic causes QUIN correlated with Atorphy of posterior greater cell loss in Elevated BMI cerebellar vermis. Neuronal striatum and limbic Poor nutrition loss of granular/ perkinje cortex cell layer of cerebellum. Increased QUIN in CSF Depression Decreased thickness of and correlation with corpus callosum. HAND svereity Cocaine abuse Expansion of ventricular QUIN elevates CCR5 Co-infection size expression and viral (HCV, VZV) replication
STROKE IN HIV EPIDEMIOLOGY ETIOLOGY Prevalence: 6 - 34% – 9.1 for infarction Meningitis- 28% – 12.7 for ICH Vasculitis – 20% Young patients: 33.4 Vasculopathy – 20% yrs v/s 64.0 yrs in HIV Coagulopathy - 19% negative Cardioembolic -14% 42% of HIV+ stroke were first HIV dx
HIV MYELOPATHY In 55% patients dying of AIDS In advanced immuno- suppression Cervical> thoracic Sensory-motor deficits Brisk DTRs Associated Vit B12 deficiency Lipid-laden macrophages Others: HTLV,VZV,CMV, spinal Lymphoma
HIV PERIPHERAL NEUROPATHY Distal sensory polyneuropathy(DSPN) MC neuropathy in HIV/AIDS 33% patients of HIV/AIDS Present in 88% in autopsy With low CD4 count Stocking-glove sensory loss Mononeuritis multiplex Inflammatory demyeliting polyradiculopathy
HIV myopathy ART induced Peripheral neuropathy Polymyositis CVA Nemaline (rod body) Psychiatric myopathy manifestations Vacuolar myopathy Myopathy IBM IRIS
A particular slide catching your eye?
Clipping is a handy way to collect important slides you want to go back to later.