Neurological complications of infection with human immunodeficiency virus type 1. A review of literature and 241 cases

A comparative study of human T-cell lymphotropic virus-associated myelopathy in HIV-positive and HIV-negative patients in KwaZulu-Natal

Background

KwaZulu-Natal is an endemic area for HIV and human T-cell lymphotropic virus (HTLV) infection. The main neurological manifestation of HTLV is HTLV-associated myelopathy/tropical spastic paraparesis (HAM/TSP). The effect of HIV co-infection in patients with HAM/TSP is not well documented.

Aims

To determine the prevalence of HIV seropositivity in patients with HAM/TSP and compare the clinical, laboratory and radiological features of patients mono-infected with HTLV and those dually infected with HTLV and HIV.

Methods

Adult patients referred to the Neurology Department at Inkosi Albert Luthuli Central Hospital in KwaZulu-Natal, South Africa, for the period 01 January 2004 to 31 December 2015 with a positive HTLV serology were identified from the National Health Laboratory Service database. A retrospective chart review was conducted to identify all patients who had a diagnosis of HAM/TSP and to record their HIV status. Clinical, laboratory and radiological data were compared for HIV-positive and HIV-negative patients.

Results

A total of 52 patients with HAM/TSP were identified. HIV results were available in 44 patients of whom 23 (52%) patients were HIV co-infected. Patients who were HIV-positive had a younger age of presentation compared to HIV-negative patients (median: 31 vs 50 years, p = 0.002). HIV-positive patients had a median duration of symptoms at presentation of 12 months compared to 16 months for HIV-negative patients, but the difference did not reach statistical significance (p = 0.082). The CD4 cell counts of HIV-positive patients were well preserved with a median count of 781 cells/µL.

Conclusions

HIV co-infection is commonly seen in the setting of HAM/TSP in KwaZulu-Natal. An interaction between the viruses may accelerate the development of HAM/TSP, leading to a younger age of presentation. Co-infection may have treatment implications because of CD4 counts being preserved in these patients.

Hemiballistic movements in a newly HIV patient

Infections of central nervous system (CNS) include a broad group of conditions and pose a particular challenge to physicians, especially in immunocompromised individuals.

This case refers to a 26-year-old male patient with a history of smoked hashish and drug abuse admitted to the infectious disease department with hemiballismus of left hemibody and a positive HIV serologic test. A magnetic resonance imaging (MRI) study showed lesions at lower left and right cerebellar hemisphere, one of them thalamus – mesencephalic suggesting an opportunistic infection or an HIV associated encephalopathy. Lumbar puncture, brain biopsy and successive neuroimaging were not conclusive for one disease and despite the use of directed therapy for cerebral toxoplasmosis, meningeal tuberculosis, anti-retrovirals and sedative medication, after over 6 weeks of hospitalization pallidotomy was performed. After 5 months of oral and surgical treatment the patient showed clinical, immunological and radiological recovery.

Ascending paralysis associated with HIV infection

We present two patients with a high viral load of HIV-1 who developed symptoms of ascending paralysis leading to respiratory failure and autonomic instability. One patient had symptom improvement with highly active antiretroviral therapy (HAART) and a subsequent decrease in viral load. The other patient improved with intravenous immunoglobulin therapy and did not show much improvement on HAART alone. There are several proposed mechanisms for peripheral neuropathies seen in HIV-infected patients, including a direct action of HIV on the nerve by neurotropic strains or formation of autoantibodies against nerve elements. The comparison of the response to different therapies in these two cases highlights the importance of understanding different pathophysiologies, as the treatment modality may differ.

Nuclear magnetic resonance based profiling of biofluids reveals metabolic dysregulation in HIV-infected persons and those on anti-retroviral therapy

BACKGROUND

Although HIV causes immune deficiency by infection and depletion of immunocytes, metabolic alterations with clinical manifestations are also reported in HIV/AIDS patients. Here we aimed to profile metabolite changes in the plasma, urine, and saliva of HIV/AIDS patients, including those on anti-retroviral therapy (ART).

METHODS

Metabolic profiling of biofluids collected from treatment naïve HIV/AIDS patients and those receiving ART was done with solution-state nuclear magnetic resonance (NMR) spectroscopy followed by statistical analysis and annotation.

RESULTS

In Principal Component Analysis (PCA) of the NMR spectra, Principal Component 1 (PC1) alone accounted for 99.3%, 87.2% and 78.8% variations in plasma, urine, and saliva, respectively. Partial least squares discriminant analysis (PLS-DA) was applied to generate three-component models, which showed plasma and urine to be better than saliva in discriminating between patients and healthy controls, and between ART-naïve patients and those receiving therapy. Twenty-six metabolites were differentially altered in any or two types of samples. Our results suggest that urinary Neopterin, and plasma Choline and Sarcosine could be used as metabolic biomarkers of HIV/AIDS infection. Pathway analysis revealed significant alternations in 12 metabolic pathways.

CONCLUSIONS

This study catalogs differentially regulated metabolites in biofluids, which helped classify subjects as healthy controls, HIV/AIDS patients, and those on ART. It also underscores the importance of further studying the consequences of HIV infection on host metabolism and its implications for pathogenesis.

HIV-Associated Central Nervous System Disease in Patients Admitted at the Douala General Hospital between 2004 and 2009: A Retrospective Study

Background. Studies on HIV-associated central nervous system (CNS) diseases in Cameroon are rare. The aim of this study was to describe the clinical presentation, identify aetiological factors, and determine predictors of mortality in HIV patients with CNS disease. Methods. From January 1, 2004 and December 31, 2009, we did at the Douala General Hospital a clinical case note review of 672 admitted adult (age ≥ 18 years) HIV-1 patients, and 44.6% (300/672) of whom were diagnosed and treated for HIV-associated CNS disease. Results. The mean age of the study population was 38.1 ± 13.5 years, and median CD4 count was 49 cells/mm³ (interquartile range (QR): 17–90). The most common clinical presentations were headache (83%), focal signs (40.6%), and fever (37.7%). Toxoplasma encephalitis and cryptococcal meningitis were the leading aetiologies of HIV-associated CNS disease in 32.3% and 25% of patients, respectively. Overall mortality was 49%. Primary central nervous system lymphoma (PCNSL) and bacterial meningitis had the highest case fatality rates of 100% followed by tuberculous meningitis (79.8%). Low CD4 count was an independent predictor of fatality (AOR: 3.2, 95%CI: 2.0–5.2). Conclusions. HIV-associated CNS disease is common in Douala. CNS symptoms in HIV patients need urgent investigation because of their association with diseases of high case fatality.

Histopathological and cognitive defects induced by Nef in the brain

Complex mechanisms of human immunodeficiency virus type-1 (HIV-1) brain pathogenesis suggest the contribution of individual HIV-1 gene products. Among them, the Nef protein has been reported to harbor a major determinant of pathogenicity in AIDS-like disease. The goal of the present study was to determine whether Nef protein expressed in vivo by primary macrophages could induce a brain toxicity also affecting the behavior of the rat. To achieve this goal we grafted Nef-transduced macrophages into the rat hippocampus. Two months post-transplantation, we observed that Nef induces monocyte/macrophage recruitment, expression of TNF-alpha, and astrogliosis. No apoptotic event was detected. We further demonstrated that Nef neurotoxicity is associated with cognitive deficits.

The frequency of peripheral neuropathy in a group of HIV positive patients in Brazil

Peripheral neuropathy is a common neurological complication occurring in asymptomatic and symptomatic stages of HIV infection. The most common syndromes are distal symmetric polyneuropathy, inflammatory demielinating polyneuropathy, poliradiculopathy, mononeuropathy, mononeuropathy multiplex and autonomic neuropathy. PURPOSE: To evaluate the frequency of peripheral neuropathy in a group of HIV seropositive outpatients in São Paulo, Brazil. METHOD: Over a period of 17 months, 49 HIV+ patients where evaluated clinically. Laboratory analysis and electroneuromyography were requested to all patients. RESULTS: >Thirty four (69.4%) of the 49 patients had the diagnosis of peripheral neuropathy established on clinical grounds. The most common sign was impairment (97.1%) of sensibility. Thirteen (33.3%) of the 39 that were subjected to electroneuromyography had features of peripheral neuropathy, being a sensitive-motor axonal neuropathy the most common. No abnormalities were found in the laboratory analysis performed in 42 patients, except in four who had VDRL positive. CONCLUSION: A peripheral neuropathy was frequently found upon clinical examination in our group of HIV positive individuals.

CNS manifestations of cytomegalovirus infections: diagnosis and treatment

Cytomegalovirus (CMV) infection of the CNS occurs most commonly in patients with severe immunosuppression such as those with advanced HIV infection (i.e. AIDS) or those who have undergone bone marrow or solid organ transplantation. Immunocompetent patients are affected very rarely. The infection of the CNS may affect the brain (diffuse encephalitis, ventriculoencephalitis, cerebral mass lesions) or the spinal cord (transverse myelitis, polyradiculomyelitis). Diagnosis is very difficult and should be based on clinical presentation, results of imaging and virological markers. The most specific diagnostic tool is the detection of CMV DNA by polymerase chain reaction in the CSF. Treatment should be initiated promptly if CMV infection is suspected. Antiviral therapy consists of intravenous ganciclovir, intravenous foscarnet or a combination of both. Cidofovir is the treatment of second choice. Patients who experience clinical improvement or stabilisation during induction therapy should be given maintenance therapy. After immune reconstitution (in HIV-positive patients) or discontinuation of immunosuppressive therapy (in transplant recipients), maintenance therapy may be stopped. Despite therapy, the prognosis for long-term survival is very poor, especially in patients with AIDS.

Cardiac disease in transgenic mice expressing human immunodeficiency virus-1 nef in cells of the immune system

We previously reported that a severe acquired immune deficiency syndrome-like disease develops in transgenic (Tg) mice expressing the human immunodeficiency virus-1 in its natural target cells: immature and mature CD4(+) T cells and cells of the macrophage/dendritic lineage. Here, we show that these mice also develop cardiac disease, characterized most prominently by a focal myocytolysis, occasionally by myocarditis and by deposition of endogenous immunoglobulin on cardiomyocytes. Microfil perfusion demonstrated widespread coronary arteriospasm and echocardiographic analysis revealed depressed cardiac function in Tg mice. A higher (but still modest) level of cardiomyocyte apoptosis was detected in Tg as compared to non-Tg hearts. Tg expression was detected in some of the infiltrating mononuclear cells, but not in cardiomyocytes or in cells of the heart vessels, suggesting a human immunodeficiency virus-1-induced disease process mediated by cells of the immune system. The similarity of the heart disease observed in these Tg mice to that observed in acquired immune deficiency syndrome patients suggests a common pathogenesis.

Central Nervous System Opportunistic Infections in HIV-1 Infection

Neurologic disease is commonly encountered in the population infected with human immunodeficiency virus type 1 (HIV-1). Although HIV-1 is responsible for many of these neurologic complications, other organisms will affect the nervous system as the immune deficiency state progresses. With the wide use of potent antiretroviral therapy, the mortality from and incidence of opportunistic infections (OIs) among persons with advanced HIV-1 infection has decreased. Nevertheless, these diseases are still seen frequently, especially among those with limited access to new antiretroviral therapies. Therefore, it remains important to recognize the most common OIs of the central nervous system (CNS) as well as primary CNS lymphoma, which will be the focus of this review.

Cotrimoxazole is effective as primary prophylaxis for toxoplasmic encephalitis in HIV-infected patients: a case control study

In a case-control study, prophylaxis with cotrimoxazole for toxoplasmic encephalitis (TE) in HIV-infected patients was evaluated. Cotrimoxazole had been given as PCP prophylaxis. 20 patients with TE were identified and 72 matching control cases were found. All patients had IgG-antibodies to Toxoplasma gondii and CD4+ T-cell counts < or = 100/microliter. The use and duration of cotrimoxazole prophylaxis were recorded. It was found that among the patients with TE, none had used cotrimoxazole for > 70% of the observation time, and that the 1-y incidence was 0% in the control group vs. 41% in those patients without sufficient cotrimoxazole use. The conclusion is that cotrimoxazole is effective as primary prophylaxis for TE, even in a dose of 480 mg daily.

[Effect of antiretroviral treatment on early electroencephalographic and otoneurologic manifestations in HIV infection and prognostic importance of verified perturbations]

Electrophysiologic tests may be abnormal in asymptomatic HIV-1-infected individuals. Our study was aimed at determining whether these findings have a prognostic value and could be corrected by antiviral treatment. In 18 patients, followed for 34 or 43 months, these findings were not progressive. Only one patient developed Aids dementia complex (ADC). Three have died (one with normal, two with abnormal tests at baseline). To study the effect of antiviral treatment, another group of seven asymptomatic patients was included into a cross-over double-blind study with either eight weeks zidovudine or eight weeks placebo, separated by eight more weeks without treatment. Electrophysiological evaluation was also performed in a group of 15 patients before antiviral therapy with zidovudine or didanosine was started and again after a mean of three and 13 months treatment. Results did not suggest that treatment reverses early electroencephalographic and otoneurological changes seen in HIV-1 infection.

Neuroepidemiology of HIV infection

There are a variety of HIV-related neurologic complications that have numerous causes. HIV-related neurologic illnesses are specific to the stage of HIV infection, although the greatest burden of neurologic disease and the most disabling syndromes occur in the more advanced stages. As the number of HIV-infected persons continues to increase worldwide and as antiretroviral and other anti-infective therapies improve patient survival in the advanced stages of HIV infection, the burden of neurologic disease will continue to increase.

Spinal tract pathology in AIDS: postmortem MRI correlation with neuropathology

Vacuolar myelopathy (VM) and tract pallor are poorly understood spinal tract abnormalities in patients with the acquired immunodeficiency syndrome (AIDS). We studied the ability of magnetic resonance imaging (MRI) to detect these changes in spinal cord specimens postmortem and whether criteria could be formulated which would allow these conditions to be differentiated from other lesions of the spinal cord in AIDS, such as lymphoma, cytomegalovirus (CMV) and human immunodeficiency virus (HIV) myelitis. We imaged 38 postmortem specimens of spinal cord. The MRI studies were interpreted blind. The specimens included cases of VM myelin pallor, CMV myeloradiculitis, HIV myelitis, lymphoma as well as normal cords, both HIV+ve and HIV-ve. MRI showed abnormal signal, suggestive of tract pathology, in 10 of the 14 cases with histopathological evidence of tract changes. The findings in VM and tract pallor on proton-density and T2-weighted MRI were increased signal from the affected white-matter tracts, present on multiple contiguous slices and symmetrical in most cases. The pattern was sufficiently distinct to differentiate spinal tract pathology from other spinal cord lesions in AIDS.

Review of antiretroviral therapy in the prevention of HIV-related AIDS dementia complex (ADC)

Following the introduction of zidovudine, a major decline was noted in the incidence of AIDS dementia complex (ADC). Several factors point to a causal relationship. It is important now to review the evidence derived from clinical, cerebrospinal fluid (CSF) and neuropathological studies to determine whether the protective effect of zidovudine on the brain of patients with HIV infection has implications for clinical practice. It has been demonstrated in clinical studies that patients with ADC may improve with zidovudine treatment and that the development of ADC is rare in patients receiving the nucleoside analogue long term. In support of these clinical findings, CSF studies have revealed that the presence of HIV-1 p24 antigen has diagnostic value in patients with suspected ADC and that p24 antigen levels decline with zidovudine treatment. Supporting evidence has also come from neuropathological studies, which have demonstrated that zidovudine decreases HIV-specific neuropathological abnormalities. Recently, the Multicenter AIDS Cohort Study reported conflicting data which suggested that antiretroviral therapy is not protective against ADC; however, several methodological weaknesses of this study limit the general applicability of the findings and the conclusions. In view of the increasing body of evidence in support of the efficacy of zidovudine in the prevention and management of ADC in patients with HIV-1 infection, it seems reasonable to include this antiretroviral agent in any combination treatment regimen. Many questions remain to be answered, however, before management of such patients is optimised. Meanwhile, in order to increase both insight and evidence, it is imperative that ongoing and future clinical trials with antiretroviral drugs closely monitor all cases of progression to ADC.(ABSTRACT TRUNCATED AT 250 WORDS)

Expression of human immunodeficiency virus type 1 in the nervous system of transgenic mice leads to neurological disease

Patients infected with the human immunodeficiency virus type 1 (HIV-1) frequently develop central and peripheral nervous system complications, some of which may reflect the effect of the virus itself. In order to elucidate the pathogenic mechanisms of HIV in neurological disease in a small animal model, we generated transgenic mice expressing the entire HIV genome under control of the promoter for the human neurofilament NF-L gene. The transgene was predominantly expressed in anterior thalamic and spinal motor neurons. Animals developed a neurological syndrome characterized by hypoactivity and weakness and by axonal degeneration in peripheral nerves. These results provide evidence for a role of HIV in affecting both the central and peripheral nervous systems. This animal model may also facilitate the development of therapeutic agents against the human disease.

Neuropathology of the spinal cord in the acquired immunodeficiency syndrome

The neuropathologic findings in the spinal cord were reviewed in 138 consecutive autopsies of patients with the acquired immunodeficiency syndrome. In all cases both the brain and spinal cord were examined by conventional histologic techniques, and in 63 cases immunohistochemistry was used to detect human immunodeficiency virus (HIV), Toxoplasma gondii, cytomegalovirus, and JC papovavirus antigens. The most common observation was a normal spinal cord (60%). Vacuolar myelopathy (VM) was observed in 23 (17%) cases. Human immunodeficiency virus myelitis was evident in 8% of cases. Human immunodeficiency virus myelitis was associated with HIV encephalitis in 65% of the cases. Opportunistic infections of the spinal cord were uncommon, consisting of cryptococcosis (five cases), cytomegalovirus (four cases), toxoplasmosis (one case), and progressive multifocal leukoencephalopathy (one case), and almost always were seen with cerebral and/or systemic infection by these agents. Malignant lymphoma rarely involved the spinal cord (four cases); all were B-cell lymphomas and were associated with cerebral and/or systemic lymphoma. Other abnormalities rarely observed were Wallerian degeneration of the corticospinal tracts or posterior columns (6%) and focal microinfarcts. Most cases of VM (78%) were not associated with HIV myelitis, and in the five patients with both VM and HIV myelitis, HIV-infected cells were not found in the regions affected by VM. In contrast, 65% of cases with VM were associated with HIV encephalitis. The pathogenesis of VM remains unknown; it is probably not due to direct infection by HIV.

Medical management of AIDS patients. Bacterial and fungal infections

The rapid and thus far generally inexorable rise in HIV infections has led to a series of opportunistic infection that includes those caused by bacteria, yeasts, and members of the Eumycetes. The infections range in prevalence from occasional to highly prevalent, in severity from trivial to fatal, and in anatomic areas involved from local to disseminated. They occur as isolated, concurrent, or sequential infections with regard to other opportunistic diseases. Some vary in their geographic distribution. They may be newly acquired or reactivated and occur early or late in the course of HIV infection. Bacterial infections are usually easily treated, although they frequently disseminate and often recur after seemingly appropriate treatment. In contrast, all but the mildest fungal infections are difficult to treat and even more difficult or impossible to eradicate. The diagnosis of bacterial and fungal infections begins with clinical suspicion and involves relatively standard methodology. Treatment of the systemic mycoses and some bacterial infections in HIV infected patients is punctuated by exaggerated side effects of therapy, frequent relapses, and the need for maintenance suppressive therapy.

Mental changes in patients with AIDS

Mental changes are common in patients with acquired immunodeficiency syndrome (AIDS). Neuropsychological data of 32 patients with AIDS and cognitive symptoms were reviewed. All patients were neurologically examined and ancillary investigations were performed. According to the neuropsychological data three groups could be distinguished: I) 4 patients with dementia and cortical deficits; II) 16 patients with subcortical dementia; III) 12 patients with subcortical cognitive deficits without global intellectual deterioration. AIDS Dementia Complex (ADC) was diagnosed in 12 patients and occurred in all three groups. The most frequent form of dementia in patients with AIDS is of a subcortical type. Impaired memory or reduced psychomotor speed, or both, are common in patients without global intellectual deterioration. ADC seems an unlikely diagnosis in patients with cortical dementia. Neuropsychological examination is important for diagnosing ADC but the diagnosis cannot be made without regarding the neurological findings and ancillary investigations.