HIV AIDS IN NERVOUS SYSTEMS

DIAH MUSTIKA HW, SpS,KIC

Intensive Care Unit of Emergency Department

Navy Hospital Dr Ramelan Surabaya

Multiple areas of the nervous system may be

involved simultaneously or sequentially.

Without anti-retroviral treatment, up to 80% of

patients are symptomatic and for 30%,

neurologic symptoms are the initial clinical

problem.

Neurologic syndromes may be the sole clinical

problem or cause of death.

All levels of the neuraxis are potential sites of

involvement:

Meninges

Brain

Spinal cord

Cranial and peripheral nerves

Autonomic nervous system

Muscle

CLINICAL SYNDROMES

BRAIN SYNDROMES

Meningitis

Dementia

Stroke

Seizures

Degenerative Disorders

SPINAL CORD SYNDROMES

Transverse myelitis

Progressive myelopathy

NERVE AND MUSCLE

Bells palsy

Hearing loss

Peripheral neuropathies

Autonomic neuropathy

Myopathy

HOW DOES HIV AFFECT THE NERVOUS SYSTEM?

HIV easily crosses the blood-brain barrier

Dave R, Pomerantz RJ. (2005). HIV neuropathogenesis: persistent

infection, persistent questions. Science & Medicine.

HOW DOES HIV AFFECT THE NERVOUS SYSTEM?

General immunosuppression can lead to:

Opportunistic Infections

Fungal (Cryptococcal Meningitis)

Parasitic (Toxoplasmosis)

Viral (Progressive Multifocal

Leukoencephalopathy)

HIV-Related Tumors

HOW DOES HIV AFFECT THE NERVOUS SYSTEM?

Primary HIV Disease can lead to:

AIDS Dementia Complex (brain)

Vacuolar Myelopathy (spinal cord)

Peripheral Neuropathy (nerve)

Meningitis (acute and chronic)

HOW DOES HIV AFFECT THE NERVOUS SYSTEM?

HIV indirectly destroys cells in the nervous system

Kaul, Garden & Lipton (2001). Pathways to neuronal injury and apoptosis in HIV-

associated dementia. Nature 410, 988-994.

HOW DOES HIV AFFECT THE NERVOUS SYSTEM?

10-15% of AIDS patients present with neurologic

symptoms only

35-50% of AIDS patients have neurologic

symptoms during life1,2

75-90% have neuropathologic abnormalities at

death3

1) Brouwman et al, Neurology. 1998 ; 50:1814-20.

2) McArthur J Neuroimmunol 2004; 157 : 3-10

3) Vago et al., AIDS. 2002;16:1925-8.

Primary or HIV-Related Syndromes of Acute

Infection

Meningitis or encephalitis

Seizures, generalized or focal

Transverse myelitis

Cranial or peripheral neuropathy ( Bells palsy or

Guillain-Barre-type neuropathy )

Polymyositis +/- myoglobinuria

Primary or HIV-related Syndromes of Chronic Infection: common disorders

Meningeal pleocytosis +/- symptoms

Dementia and / or psychiatric disturbances (AIDS dementia complex, ADC )

Strokes

Seizures

Progressive myelopathy

Neuropathy or myopathy

HIV AND

CNS INVOLVEMENT

CEREBRAL TOXOPLASMOSIS

Most common CNS impairment seen in HIV

Is a reactivation of a latent protozoal infection

Can also affect myocardium, lung skeletal muscle

Generally presents as multiple enhancing lesions with perifocal oedema in the basal ganglia and grey-white matter interface of the cerebral hemispheres, although can be in any part of brain

TOXOPLASMOSIS

TOXOPLASMOSIS

Common signs and symptoms

Headache, fever

Confusion

Lethargy

Seizure (may be initial clinical manifestation)

Focal neurologic signs (50%-60% of HIV-infected cases)

Usually hemiparesis or visual field defects

Treatment

Antio-toxo drugs: Sulfadiazine, pyrimethamine, clindamycin, pyrimethamine, folinic acid

TOXOPLASMOSIS

Usually responds well to treatment

Usually the worse the initial presentation, the

longer the recovery; may have some long term

residual deficits

Can sometimes have multiple small lesions

which present with quite specific / unusual

sensory / motor / cognitive symptoms

CRYPTOCOCCYL MENINGITIS, TB

MENINGITIS

Both quite common presentations

Crypto caused by fungal infection

TB may also cause focal lesions as well as the

menigitis

Both may or may not have other systemic

illness associated e.g. Cryptococcosis, TB lung,

spine, miliary TB

CMV ENCEPHALITIS (AND OTHERS)

CMV= cytomegalovirus

Quite common; CMV encephalitis is a reactivation of latent CMV infection - features cell death in meninges and peri-ventricular area

Often associated with a CMV retinitis

Rapidly progressing; responds well to treatment if caught in time otherwise responds poorly

CMV ENCEPHALITIS (AND OTHERS)

Treatment is usually IV ganciclovir,

valganciclovir, foscarnet, cidofovir these

drugs can be quite toxic

Presentations vary, however usually involve

confusion, headache, delirium

Can have focal neurology, cranial nerve deficits

CMV ENCEPHALITIS (AND OTHERS)

Therapy approach again is treat what presents;

often complicated by permanent visual field

loss

Other encephalitis presentations include HSV

(Herpes Simplex Virus) and VZV (Varicellar

Zoster Virus)

HIV AND PNS INVOLVEMENT

INFLAMMATORY DEMYELINATING

POLYNEUROPATHY (IDP)

IDP, and its more severe cousin Gullain- Barre

Syndrome sometimes occur acutely in

otherwise well HIV+ patients, or in HIV+

patients with advanced disease.

Seems to be some sort of auto-immune

response that attacks the myelins sheath

mechanism is poorly understood

Treated with IVIg