Nature, incidence and prognosis of neurological involvement in the acquired immunodeficiency syndrome in central London

Neurological Presentations of AIDS-when to Test for HIV

Nine of 122 patients dead from AIDS in central London presented with neurological disease, confirmed pathologically in seven. Seven had no other major systemic manifestations. AIDS needs to be considered in the differential diagnosis of meningitis, dementia, diffuse and focal encephalopathies, brainstem syndromes, myelopathy, visual failure and peripheral nerve syndromes. As AIDS becomes more widespread there will be an increasing need for diagnostic HIV testing in many neurological syndromes.

AIDS: Neurological Opportunist Infections in Central London

Twenty six (41%) of 64 central London cases of AIDS with nervous system involvement during the course of the illness had neurological opportunist infection. Cytomegalovirus and Toxoplasma gondii were the commonest agents in 22 cases with central nervous system (CNS) infection. Eight cases had herpes zoster radiculopathy. Other infections included those caused by Cryptococcus neoformans, Mycobacterium tuberculosis and papova JC virus. Prognosis was generally poor, irrespective of whether the opportunist infection was treatable.

[Treatment of neuro-AIDS on a neurological intensive care unit: epidemiology and predictors of outcome]

BACKGROUND

Investigations concerning the outcome for patients suffering from neuro-AIDS treated on a neurological intensive care unit and specific predictors indicating "dead" were analyzed.

MATERIAL AND METHODS

A total of 56 patients with a mean age of 39 ± 0.7 years, a mean CD4+ cell count of 130 ± 166 CD4+ cells/µl and viral load of 146,520 ± 198,059 copies/ml were treated on a neurological intensive care unit due to different forms of neuro-AIDS.

RESULTS

Of the patients, 34% were immigrants of whom 74% came from sub-Saharan regions. In 57% of the patients the diagnosis of HIV infection was made during therapy on the neurological intensive care unit. The median for the time between diagnosis of HIV infection and the treatment on the neurological intensive care unit was 8 days for immigrants and 10 years for residents. The most common manifestations of neuro-AIDS were cerebral toxoplasmosis, cryptococcosis and progressive multifocal leukoencephalopathy (PML). Fifty per cent of the patients (n=28) died during treatment on the neurological intensive care unit. Negative predictors for the outcome "dead" were (a) artificial ventilation, (b) antiretroviral naïve immigrant, (c) primary cerebral lymphoma and (d) missing antiretroviral therapy as a result of admission to the intensive care unit.

DISCUSSION

The rate of death during treatment of neuro-AIDS on a neurological intensive care unit is much higher than during treatment of internal medicine problems of HIV infection. Antiretroviral naïve immigrants show a much higher rate of death compared to residents in Germany. A lot of research and effort is necessary to improve the availability of the Highly Active Anti-Retroviral Therapy (HAART) worldwide in order to improve the outcome especially for immigrants with neuro-AIDS treated on a neurological intensive care unit.

Effect of progression of disease on cognitive performance in HIV/AIDS

BACKGROUND

HIV infection causes a range of cognitive and behavioral symptoms that become more frequent and severe as the immune system deteriorates and symptomatic illness ensues.

OBJECTIVE

To determine the impact of disease progression on cognitive abilities of Nigerian Africans who present in the HIV/AIDS clinic of the University Teaching Hospital, Benin City, Nigeria, using the CD4 levels as the measure of disease progression.

METHODS

A total of 288 subjects comprising 96 randomly selected symptomatic AIDS patients, 96 randomly selected asymptomatic HIV-positive patients and 96 HIV-negative controls participated in the study. Enzyme-linked immunosorbent assay (ELISA) method was used to detect HIV infection, and CD4 levels were obtained for all subjects. The Community Screening Interview for Dementia (CSI 'D') was used to assess cognitive performance of subjects. Subjects were matched for age, sex and level of education.

RESULTS

Each category of subjects comprised 48 males and 48 females. The mean ages were 32.94 +/- 8.0 years, 31.47 +/- 6.7 years and 33.56 +/- 7.1 years for the controls, asymptomoatic HIV-positive and symptomatic AIDS subjects respectively (p = 0.127). The mean CD4 levels were 684 +/- 44/microL (controls), 284 +/- 62/microL (asymptomatic HIV positive) and 142 +/- 36/microL (symptomatic AIDS). The mean CS1 'D' scores were 66.46 +/- 1.90 (controls), 66.31 +/- 2.14 (asymptomatic HIV positive) and 56.62 +/- 4.23 (symptomatic AIDS).

CONCLUSION

Cognitive abilities of HIV/AIDS patients decline as the disease progresses. This is reflected in the cognitive performances of the symptomatic AIDS patients. The lower the CD4 levels, the worse the cognitive deficits. There was, however, no significant difference in the performance of asymptomatic HIV-positive patients and the controls.

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.

Nature and incidence of peripheral nerve syndromes in HIV infection

Fifty four patients with peripheral nerve syndromes were seen during a 15 month period in a population of about 1500 HIV infected patients at all stages of the disease. Distal symmetrical peripheral neuropathies were seen in 38 of the 54 patients, (11.5% of AIDS patients) and could be distinguished into two forms. The most common (n = 25) was a painful peripheral neuropathy during AIDS, which is distinct clinically and pathologically, having axonal atrophy, and is associated with cytomegalovirus infection at other sites. The 13 non-painful neuropathies seen were more heterogeneous. Lumbosacral polyradiculopathy associated with cytomegalovirus and lymphomatous mononeuritis multiplex occurred in fewer than 1% of AIDS patients. Mononeuropathies were seen in 3% of AIDS patients. No patients with acute or chronic inflammatory demyelinating polyradiculoneuropathies were seen. The annual incidence of neuropathies during the AIDS related complex stage was less than 1%; none were seen in asymptomatic HIV seropositive patients.

CT and MRI: prognostic tools in patients with AIDS and neurological deficits

To determine the prognostic value of CT and MRI in AIDS we studied the survival of patients with neurological involvement, in relation to the initial imaging results. Twenty-six initial CT and 15 MRI examinations of 41 patients were reviewed for the presence of cerebral atrophy and/or focal lesions. The mean survival time of patients with initially normal imaging was longer (700 +/- 89 days) than that of patients with isolated cerebral atrophy (326 +/- 65) or isolated focal lesions (202 +/- 97). The shortest survival (78 +/- 44 days) was found in patients with both cerebral atrophy and focal lesions. The risk of death in patients with atrophy alone was 3.6 times higher, that in patients with focal lesions alone 6.4 times higher, and in patients with both changes 19.3 times higher than in patients with initially normal imaging. Cerebral imaging with CT and/or MRI thus allows identification of AIDS-related cerebral changes and may contribute to assessment of prognosis.

Psychiatric illnesses in patients with HIV infection and AIDS referred to the liaison psychiatrist

All referrals made to the liaison psychiatric service for HIV and AIDS patients over one year were reviewed. ICD-9 and CDC diagnoses were applied to each case at presentation. Sixty HIV-positive patients were assessed, of whom 35 had affective disorder, which was significantly associated with CDC group IV disease (AIDS). Adjustment reaction was seen in nine patients, paranoid states in six, dementia in four, personality changes in four and paranoid schizophrenia in two. CT scans of the brain were performed on 23 of the patients: 17 of these showed abnormalities. The proportion of registered AIDS patients who were referred was five times the proportion of HIV patients.

Surgical management of anorectal disease in HIV-positive homosexuals

One thousand and ninety human immunodeficiency virus (HIV)-positive homosexual or bisexual males were seen in one hospital for management of HIV disease over a 9-year period. One hundred and fifty-five patients were referred by acquired immunodeficiency syndrome (AIDS) physicians for general surgical management. The most frequent reason for surgical referral (64 patients) was anorectal disease which occurred in 5.9 per cent of all HIV-positive patients. One or more diagnoses were reached in 61 of the 64 patients referred with anorectal disease: warts (38 per cent of diagnoses), anorectal ulceration (26 per cent), perianal sepsis (15 per cent), neoplasia (14 per cent) and haemorrhoidal disease (8 per cent). Anorectal symptoms were relieved in 68 per cent of patients and the median survival of those treated was 17.5 months from the time of surgical referral. Both warts and perianal sepsis were associated with in situ neoplasia, but no case of progression from in situ to invasive anal squamous carcinoma was detected. The aetiology of anorectal ulcers was not clear, but surgical excision of anal ulcers and skin tags can produce healing. Palliation of anorectal symptoms in HIV-positive homosexual patients is possible but some conditions are unusual and surgeons should be familiar with their presentation and management.

Psychiatric manifestations of HIV disease

This chapter contains a detailed description of the range of psychiatric problems likely to present in HIV patients and their relatives, and a discussion of the principles of psychiatric management. Psychosocial problems at the various disease stages are reviewed, including those at the time of HIV testing, and in asymptomatic and symptomatic individuals. Mania and schizophrenia-like syndromes are discussed, as well as neuropsychiatric disorders occurring in early and advanced HIV disease. The impact of HIV disease on relatives and professional carers is reviewed. The role of physicians and nurses in the psychological care of HIV patients is outlined, together with the role of mental health specialists. Basic information about the recognition and treatment of major psychiatric syndromes is provided. Finally, issues involved in supporting staff working with HIV patients are discussed.

Combined HIV-CMV encephalitis presenting with brainstem signs

Two cases of combined HIV-CMV encephalitis are described. One presented with a sixth nerve palsy and a tetraparesis, the other with an internuclear ophthalmoplegia. Pathologically brain stem involvement was predominantly due to CMV.