Neurological manifestations in HIV

1. HIV in Neurology

3. HIV associated neurocognitive disorder
(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 in cognitive 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
• In very 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
• Leading cause
• 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 treatment of 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 Multiple enhancing 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 related polyradiculopathy 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
• Early AIDP
• Progressive/relapsing Remitting CIDP
• Progressive weakness, areflexia, minimal sensory loss
• CSF Mononuclear pleocytosis
• Mononeuritis multiplex d/t necrotizing arteritis

16. • Distal sensory polyneuropathy – 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/ Zidovudine induced
• 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.