Cerebellar degeneration and progressive ataxia associated with HIV-virus infection

A review of movement disorders in persons living with HIV

BACKGROUND

The human immunodeficiency virus (HIV) causes movement disorders in persons living with HIV (PLH).

OBJECTIVES AND METHODS

We conducted a systematic review on the spectrum of movement disorders in PLH using standard terms for each of the phenomenologies and HIV.

RESULTS

Movement disorders in PLH were commonly attributed to opportunistic infections (OI), dopamine receptor blockade reactions, HIV-associated dementia (HAD), presented during seroconversion, developed due to drug reactions or antiretroviral therapy (ART) itself and lastly, movement disorders occurred as a consequence of the HIV-virus. Parkinsonism in ART naïve PLH was associated with shorter survival, however when Parkinsonism presented in PLH on ART, the syndrome was indistinguishable from Idiopathic Parkinson's disease and responded to therapy. Tremor was often postural due to HAD, drugs or OI. Generalized chorea was most frequent in HIV encephalopathy and toxoplasmosis gondii caused most cases of hemichorea. Ataxia was strongly associated with JCV infection, ART efavirenz toxicity or due to HIV itself. Dystonia was reported in HAD, secondary to drugs and atypical facial dystonias. Both cortical/subcortical and segmental/spinal origin myoclonus were noted mainly associated with HAD. In patients with HIV related opsoclonus-myoclonus-ataxia-syndrome, seroconversion illness was the commonest cause of followed by IRIS and CSF HIV viral escape phenomenon.

CONCLUSIONS

Aetiology of movement disorders in PLH depend on the treatment state. Untreated, PLH are prone to develop OI and HAD and movement disorders. However, as the number of PLH on ART increase and survive longer, the frequency of ART and non-AIDS related complications are likely to increase.

[Cerebellar degeneration associated with HIV infection]

OBJECTIVE

To describe the features of the clinical presentation and evaluate the incidence of HIV-associated cerebellar degeneration in patients with progressive cerebellar ataxia.

MATERIAL AND METHODS

Three hundred and seventy-seven patients with progressive cerebellar ataxia were studied. Brain MRI study, assessment by the Scale for the Assessment and Rating of Ataxia (SARA), screening for cognitive impairment by the Montreal Cognitive Assessment Scale (MoCA) were performed. In patients with HIV infection, autoimmune, deficient and other causes of ataxia, as well as opportunistic infections, multiple system atrophy and frequent forms of hereditary spinocerebellar ataxias were excluded.

RESULTS

Five patients (1.3%) were identified with a combination of cerebellar ataxia and HIV infection (2 men, 3 women, aged 31 to 52 years). The median duration of HIV infection was 5 years, the duration of ataxia was 1 year. In the clinical findings, in addition to progressive ataxia, pyramidal signs, dysphagia, less often ophthalmoparesis, dystonia, postural hand tremor, affective and mild cognitive impairment were observed. In three patients, brain MRI revealed signs of olivopontocerebellar atrophy, two patients had isolated cerebellar degeneration (mainly of the vermis). All patients received combination of antiretroviral therapy in various regimens, but despite this, ataxia was progressive.

CONCLUSION

HIV infection is a rare cause of cerebellar degeneration. This diagnosis remains a diagnosis of exclusion to this day. Cerebellar degeneration can occur and progress even after achieving a stable remission of HIV infection while taking highly active antiretroviral therapy.

A rare case of HIV encephalopathy presenting with an isolated cerebellar syndrome

Cerebellar dysfunction is a well-recognised but an infrequent complication of human immunodeficiency virus (HIV) infection. We present the case of a 44-year-old man living with HIV who presented with subacute cerebellar dysfunction and in whom a thorough diagnostic work-up did not identify any opportunistic infections. Cerebrospinal fluid (CSF) analysis showed a high HIV viral load of 1160 copies/ml and magnetic resonance imaging (MRI) showed multiple high signal abnormalities, disproportionately affecting the posterior fossa especially the cerebellum. This is a rare case of HIV encephalopathy presenting with an isolated cerebellar syndrome and highlights the importance of considering HIV as the aetiology in this clinical scenario.

A Guide for the Differential Diagnosis of Multiple System Atrophy in Clinical Practice

Multiple system atrophy (MSA) is a sporadic and progressive neurodegenerative disorder with a complex differential diagnosis. A range of disorders- also of nondegenerative etiology- can mimic MSA, expanding its differential diagnosis. Both misdiagnosis and diagnostic delays are relatively common in clinical practice. A correct diagnosis is vital for daily clinical practice, in order to facilitate proper counselling and to timely install therapies in treatable disorders that mimic MSA. A correct diagnosis is also essential for including properly classified individuals into research studies that aim to better understand the pathophysiology of MSA, to develop specific biomarkers or to evaluate novel symptomatic or disease-modifying therapies. Here, we offer some practical guidance to support the diagnostic process, by highlighting conditions that may be considered as MSA lookalikes, by emphasizing some key clinical aspects of these mimics, and by discussing several useful ancillary diagnostic tests.

Cerebellar cortical degeneration associated with feline leukemia virus infection and cerebellar lymphoma in a young cat

Background:

Cerebellar cortical degeneration (CCD) is the premature death of cerebellar neurons of heterogeneous etiology that is uncommonly observed as a neurological complication of certain neoplasia.

Case Description:

Here, we report an 8-month-old male domestic cat with altered consciousness, symmetric ataxia, hypermetric gait, vertical positional nystagmus, mydriasis, strabismus, intention tremor of the head, and increased patellar reflexes. Neuroanatomical diagnosis suggested a multifocal brain dysfunction (cerebellar and cerebral). The cat tested seropositive for feline leukemia virus. Cerebrospinal fluid analysis indicated mononuclear and neutrophilic pleocytosis. Contrast computed tomography imaging revealed multiple hypodense heterogeneous areas in both cerebral hemispheres, mild ventriculomegaly at the level of the caudal fossa, and a circular sharply marginated, homogeneously hyperdense mass occupying the right cerebellar hemisphere. Postmortem study indicated a 1.1 × 1.3 × 1.2 cm mass in the right cerebellar hemisphere close to the vermis. Histopathological analysis showed diffuse and severe Purkinje cell loss with a decrease in granular cell density and moderate gliosis compatible with CCD. Further, numerous neoplastic lymphoid cells were observed in the infiltrated mass, consistent with a diagnosis of central nervous system (CNS) lymphoma. Immunohistochemistry showed CD20 expression, indicative of a B-cell immunophenotype. In humans, CCD is reported as a rare paraneoplastic syndrome in patients with Hodgkin lymphoma. CNS lymphoma and/or Feline Leukemia Virus (FeLV) infection were both considered as a possible cause of CCD in this case.

Conclusion:

This is the first described case of possible paraneoplastic cerebellar cortical degeneration associated with CNS lymphoma and/or FeLV infection in a domestic cat.