Neurological manifestations of HIV/AIDS 2012

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Neurological manifestations of HIV/AIDS 2012

  1. 1. NEUROLOGICALMANIFESTATIONS OF HIV INFECTION AN UPDATE Dr. Dibbendhu Khanra
  2. 2. 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%
  3. 3. 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
  4. 4. 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
  5. 5. 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)
  6. 6. 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
  7. 7. 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
  8. 8. MANAGING HAND CART CPE score MME score Thalidomite Memantine Nimodipine Selegiline Minocycline Lexipafant PDGF-BB
  9. 9. HIV AND CEREBRAL SOLTOXO PCNSL TB CRYPTO
  10. 10. PML V/S HIVEPML HIVE MS
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. HIV myopathy ART induced  Peripheral neuropathy Polymyositis  CVA Nemaline (rod body)  Psychiatric myopathy manifestations Vacuolar myopathy  Myopathy IBM  IRIS

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