HIV in Neurology

HIV associated neurocognitive disorder (HAND)

1. Asymptomatic neurocognitive impairment2. Minor neurocognitive disorder3. HIV associated dementia (HAD)/AIDS dementia complex/HIV

encephalopathy AIDS defining illness

E4 allele for apoE

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

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

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

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.

Seizures

• Phenytoin treatment of choice• Phenobarbital, valproic acid

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

D/Ds of Multiple enhancing lesions in a HIV patient

• Toxoplasmosis• CNS lymphoma• TB• Abscess –Fungal/ Bacterial

Brain biopsy – definitive diagnosis

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

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

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

• 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

Peripheral Neuropathy

• Early AIDP

• Progressive/relapsing Remitting CIDP

• Progressive weakness, areflexia, minimal sensory loss

• CSF Mononuclear pleocytosis

• Mononeuritis multiplex d/t necrotizing arteritis

• 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

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.