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Hiv in neurology
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- 3. HIV associated neurocognitivedisorder (HAND) 1. Asymptomatic neurocognitive impairment 2. Minor neurocognitive disorder 3. HIV associated dementia (HAD)/AIDS dementia complex/HIV encephalopathy AIDS defining illness E4 allele for apoE
- 4. HAND • Decline incognitive ability, impaired concentration, increased forgetfulness, difficulty reading, performing complex tasks. • Sub Cortical Dementia – Defective Short term memory and executive function. • Gait disturbance, tremor, disdiadokinesia • Apathy, irritability, loss of initiative, vegetative state • Motor, language, judgment • AIDS defining illness • Clinical staging – Frascati criteria • Baseline MMSE
- 5. Aseptic meningitis • Invery late stages of HIV infection • Headache, photophobia, meningismus, CN 7,5,8. • CSF – Lymphocytic pleocytosis, Raised protein, Normal glucose • Resolves within 2-4 weeks
- 6. Cryptococcal meningitis • Leadingcause • C.neoformans, C.gattii • AIDS defining illness • CD4+ <100 • Fever , nausea, vomiting, altered mental status, headache, meningeal signs. • Coma, CN involvement • 1/3rd patients have pulmonary disease
- 7. Cryptococcal meningitis • Lymphadenopathy,palatal/glossal ulcers, artritis, prostatitis • Prostate is the reservoir of smouldering cryptococcal infection • CSF – High opening pressure, India Ink preparation • Blood culture • Biopsy – cryptococcoma • IV amphotericin B 0.7 mg/kg OR liposomal amphotericin 4-6mg/kg with flucytosine 25 mg/kg qid for 2 weeks followed by Fluconazole 400 mg/d for 8 wks then 200 mg/d till CD4>200 for 6 months • C.immitis, H.capsulatum, Acanthmoeba and Nagleria.
- 8. Seizures • Phenytoin treatmentof choice • Phenobarbital, valproic acid
- 9. Toxoplasmosis • CD4 <200 • Reactivation of latent tissue cysts • IgG to T.gondii • Fever, headache focal neurological deficit • Seizure, hemiparesis, aphasia • Confusion, dementia, lethargy • MRI – multiple lesion, multiple sites • Double-dose contrast CT
- 10. D/Ds of Multipleenhancing lesions in a HIV patient • Toxoplasmosis • CNS lymphoma • TB • Abscess –Fungal/ Bacterial Brain biopsy – definitive diagnosis
- 11. Treatment of toxoplasmosis •Sulfadizine + Pyrimethamine and leucovorine for wks • Alternative • Clindamycin + Pyrimethamine • Atovaquone + Pyrimethamine • Aztihromycin + Pyrimethamine + Ridabutin • Relapse are common • Maintenance therapy - Sulfadizine + Pyrimethamine and leucovorine of CD4 < 200 • Primary prophylaxis – CD4 < 100 and IgG antibody to toxoplasma
- 12. Progressive multifocal leukoencephalopathy •JC virus • Multifocal neurologic deficits • 20% Seizures • T2 hyperintensities Multiple non-enhancing white matter lesions with predilection to occipital and parietal lobes • JC DNA in CSF • Paradoxical worsening of PML after initiation of cART • Baseline CD4 > 100, HIV viral load < 500 = better prognosis
- 13. Spinal cord disease •Vacuolar myelopathy • Similar to SACD • Sub acute onset • Ataxia, spasticity • Bowel, bladder • ↑DTR, extensor plantar • Dorsal column • Pure sensory ataxia • Paraesthesias lower limbs • Do not respond well to cART • Supportive treatment
- 14. • CMV relatedpolyradiculopathy and myelopathy • Fulminant, rapidly progressive • Lower extremity, sacral and lower limb paraesthesia, difficulty walking, urinary retention, ascending sensory loss, areflexia. • CSF- Neutrophilic leucocytosis, CMV DNA CSF PCR • Ganciclovir, FoscarnetHTLV-1 associated myelopathy, neurosyphilis, HSV and varicella zoster. Spinal cord disease
- 15. Peripheral Neuropathy • EarlyAIDP • Progressive/relapsing Remitting CIDP • Progressive weakness, areflexia, minimal sensory loss • CSF Mononuclear pleocytosis • Mononeuritis multiplex d/t necrotizing arteritis
- 16. • Distal sensorypolyneuropathy – MC (Painful sensory neuropathy) (HIV SN) • Dideoxy nucleoside therapy – walking on ice • Common in tall and lower CD4 count • Painful burning sensation foot and lower limbs, stocking type sensory loss to pin prick, temp, touch, loss of ankle reflex, weakness intrinsic foot muscle. • d/ds DM, B12 deficiency, metronidazole, dapsone. • Gabapentin, Carbamazepine, TCA, analgesic. Peripheral Neuropathy
- 17. Myopathy • HIV/ Zidovudineinduced • Myalgia, proximal muscle weakness • Asymptomatic post exercise increase in CPK • Prolonged zidovudine – Profound muscle wasting, muscle pain • Red ragged fibres are histologic hallmark of Zidovudine induced myopathy.
Editor's Notes
- #4 50% HIV patients have neurocognitive impairment