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Kolinko Y, Kralickova M, Cendelin J. Reduction of Microvessel Number and Length in the Cerebellum of Purkinje Cell Degeneration Mice. CEREBELLUM (LONDON, ENGLAND) 2024; 23:471-478. [PMID: 37071329 DOI: 10.1007/s12311-023-01556-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/05/2023] [Indexed: 04/19/2023]
Abstract
Degenerative effects of nerve tissues are often accompanied by changes in vascularization. In this regard, knowledge about hereditary cerebellar degeneration is limited. In this study, we compared the vascularity of the individual cerebellar components of 3-month-old wild-type mice (n = 8) and Purkinje cell degeneration (pcd) mutant mice, which represent a model of hereditary cerebellar degeneration (n = 8). Systematic random samples of tissue sections were processed, and laminin was immunostained to visualize microvessels. A computer-assisted stereology system was used to quantify microvessel parameters including total number, total length, and associated densities in cerebellar layers. Our results in pcd mice revealed a 45% (p < 0.01) reduction in the total volume of the cerebellum, a 28% (p < 0.05) reduction in the total number of vessels and a lower total length, approaching 50% (p < 0.001), compared to the control mice. In pcd mutants, cerebellar degeneration is accompanied by significant reduction in the microvascular network that is proportional to the cerebellar volume reduction therefore does not change density of in the cerebellar gray matter of pcd mice.
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Affiliation(s)
- Yaroslav Kolinko
- Biomedical Center in Pilsen, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.
- Department of Histology and Embryology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.
| | - Milena Kralickova
- Biomedical Center in Pilsen, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
- Department of Histology and Embryology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Jan Cendelin
- Biomedical Center in Pilsen, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
- Department of Pathophysiology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
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Nuzhnyi EP, Brsikyan LA, Fedotova EY, Illarioshkin SN. [Cerebellar degeneration associated with HIV infection]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:123-130. [PMID: 37315251 DOI: 10.17116/jnevro2023123051123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
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.
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Affiliation(s)
- E P Nuzhnyi
- Research Center of Neurology, Moscow, Russia
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Boardman E, Babu C, McKee D. A rare case of HIV encephalopathy presenting with an isolated cerebellar syndrome. Int J STD AIDS 2022; 33:806-808. [PMID: 35651322 DOI: 10.1177/09564624221106516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Emily Boardman
- The Hathersage Centre, The Northern Contraception, Sexual Health and HIV Service, 105551Manchester Royal Infirmary, Manchester, UK
| | - Chitra Babu
- The Hathersage Centre, The Northern Contraception, Sexual Health and HIV Service, 105551Manchester Royal Infirmary, Manchester, UK
| | - David McKee
- The Hathersage Centre, The Northern Contraception, Sexual Health and HIV Service, 105551Manchester Royal Infirmary, Manchester, UK.,105621Salford Royal Hospital, Salford, UK
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Ma SY, KWAN KM. Size Anomaly and Alteration of GABAergic Enzymes Expressions in Cerebellum of a Valproic acid Mouse Model of Autism. Behav Brain Res 2022; 428:113896. [DOI: 10.1016/j.bbr.2022.113896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 03/29/2022] [Accepted: 04/13/2022] [Indexed: 11/02/2022]
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Fontes F, Rocha S, Sánchez R, Pessina P, Sebastian M, Benavides F, Breijo M. Detection of high antibodies titers against rat leukemia virus in an outbreak of reproductive disorders and lymphomas in Wistar rats. Lab Anim 2022; 56:437-445. [PMID: 35360996 DOI: 10.1177/00236772221085356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Young female Wistar rats from a specific pathogen free breeding colony presented an outbreak of infertility along with neurological symptoms and malignant lymphomas. We evaluated the presence and the potential role of the rat leukemia virus (RaLV) in the disease because these clinical signs could be compatible with a retrovirus. RaLV is a mammalian type C endogenous retrovirus initially isolated from in vitro Sprague-Dawley rat embryo cultures. There are no reports of clinical disease in rats associated with this virus, and little is known about its interaction with the host. Using reverse transcription polymerase chain reaction and enzyme-linked immunosorbent assay, we studied the synthesis of the viral particles and the development of an immune response against the virus in this rat colony. The results showed that healthy and diseased Wistar rats synthetized viral RNA but only diseased animals developed a detectable immune response against RaLV envelop protein. Furthermore, rats with lymphomas tended to have higher titers of antibodies against RaLV epitopes than those with infertility or neurological symptoms. The results suggest that increases in the RaLV infectious particle loads could be involved in the development of lymphomas in young rats. The potential causes of RaLV reactivation are discussed.
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Affiliation(s)
- Florencia Fontes
- Unidad de Reactivos y Biomodelos de Experimentación, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Sergio Rocha
- Unidad de Reactivos y Biomodelos de Experimentación, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Rosina Sánchez
- Laboratorio de Análisis Clínicos, Facultad de Veterinaria, Universidad de la República, Montevideo, Uruguay
| | - Paula Pessina
- Laboratorio de Análisis Clínicos, Facultad de Veterinaria, Universidad de la República, Montevideo, Uruguay
| | - Manu Sebastian
- Department of Epigenetics and Molecular Carcinogenesis, The University of Texas MD Anderson Cancer Center, Smithville, USA
| | - Fernando Benavides
- Department of Epigenetics and Molecular Carcinogenesis, The University of Texas MD Anderson Cancer Center, Smithville, USA
| | - Martín Breijo
- Unidad de Reactivos y Biomodelos de Experimentación, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
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Shrivastava S, Ray RM, Holguin L, Echavarria L, Grepo N, Scott TA, Burnett J, Morris KV. Exosome-mediated stable epigenetic repression of HIV-1. Nat Commun 2021; 12:5541. [PMID: 34545097 PMCID: PMC8452652 DOI: 10.1038/s41467-021-25839-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 08/31/2021] [Indexed: 11/25/2022] Open
Abstract
Human Immunodeficiency Virus (HIV-1) produces a persistent latent infection. Control of HIV-1 using combination antiretroviral therapy (cART) comes at the cost of life-shortening side effects and development of drug-resistant HIV-1. An ideal and safer therapy should be deliverable in vivo and target the stable epigenetic repression of the virus, inducing a stable "block and lock" of virus expression. Towards this goal, we developed an HIV-1 promoter-targeting Zinc Finger Protein (ZFP-362) fused to active domains of DNA methyltransferase 3 A to induce long-term stable epigenetic repression of HIV-1. Cells were engineered to produce exosomes packaged with RNAs encoding this HIV-1 repressor protein. We find here that the repressor loaded anti-HIV-1 exosomes suppress virus expression and that this suppression is mechanistically driven by DNA methylation of HIV-1 in humanized NSG mouse models. The observations presented here pave the way for an exosome-mediated systemic delivery platform of therapeutic cargo to epigenetically repress HIV-1 infection.
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Affiliation(s)
- Surya Shrivastava
- Center for Gene Therapy, City of Hope-Beckman Research Institute, Duarte, CA, USA
| | - Roslyn M Ray
- Center for Gene Therapy, City of Hope-Beckman Research Institute, Duarte, CA, USA
| | - Leo Holguin
- Center for Gene Therapy, City of Hope-Beckman Research Institute, Duarte, CA, USA
| | - Lilliana Echavarria
- Center for Gene Therapy, City of Hope-Beckman Research Institute, Duarte, CA, USA
| | - Nicole Grepo
- Center for Gene Therapy, City of Hope-Beckman Research Institute, Duarte, CA, USA
| | - Tristan A Scott
- Center for Gene Therapy, City of Hope-Beckman Research Institute, Duarte, CA, USA
| | - John Burnett
- Center for Gene Therapy, City of Hope-Beckman Research Institute, Duarte, CA, USA
- Hematological Malignancy and Stem Cell Transplantation Institute at the City of Hope, Duarte, CA, USA
| | - Kevin V Morris
- Center for Gene Therapy, City of Hope-Beckman Research Institute, Duarte, CA, USA.
- Hematological Malignancy and Stem Cell Transplantation Institute at the City of Hope, Duarte, CA, USA.
- Menzies Health Institute Queensland, School of Medical Science Griffith University, Gold Coast Campus, Brisbane, Australia.
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Wang Q, Su S, Xue J, Yu F, Pu J, Bi W, Xia S, Meng Y, Wang C, Yang W, Xu W, Zhu Y, Zheng Q, Qin C, Jiang S, Lu L. An amphipathic peptide targeting the gp41 cytoplasmic tail kills HIV-1 virions and infected cells. Sci Transl Med 2021; 12:12/546/eaaz2254. [PMID: 32493792 DOI: 10.1126/scitranslmed.aaz2254] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 04/28/2020] [Indexed: 12/26/2022]
Abstract
HIV-associated morbidity and mortality have markedly declined because of combinational antiretroviral therapy, but HIV readily mutates to develop drug resistance. Developing antivirals against previously undefined targets is essential to treat existing drug-resistant HIV strains. Some peptides derived from HIV-1 envelope glycoprotein (Env, gp120-gp41) have been shown to be effective in inhibiting HIV-1 infection. Therefore, we screened a peptide library from HIV-1 Env and identified a peptide from the cytoplasmic region, designated F9170, able to effectively inactivate HIV-1 virions and induce necrosis of HIV-1-infected cells, and reactivated latently infected cells. F9170 specifically targeted the conserved cytoplasmic tail of HIV-1 Env and effectively disrupted the integrity of the viral membrane. Short-term monoadministration of F9170 controlled viral loads to below the limit of detection in chronically SHIV-infected macaques. F9170 can enter the brain and lymph nodes, anatomic reservoirs for HIV latency. Therefore, F9170 shows promise as a drug candidate for HIV treatment.
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Affiliation(s)
- Qian Wang
- Key Laboratory of Medical Molecular Virology (MOE/NHC/CAMS), School of Basic Medical Sciences and Shanghai Public Health Clinical Center, Fudan University, 130 Dong An Rd., Xuhui District, Shanghai 200032, China
| | - Shan Su
- Key Laboratory of Medical Molecular Virology (MOE/NHC/CAMS), School of Basic Medical Sciences and Shanghai Public Health Clinical Center, Fudan University, 130 Dong An Rd., Xuhui District, Shanghai 200032, China
| | - Jing Xue
- Key Laboratory of Human Disease Comparative Medicine, Chinese Ministry of Health, Beijing Key Laboratory for Animal Models of Emerging and Re-emerging Infectious Diseases, Institute of Laboratory Animal Science, Chinese Academy of Medical Sciences and Comparative Medicine Center, Peking Union Medical College, Beijing 100021, China
| | - Fei Yu
- College of Life and Science, Hebei Agricultural University, Baoding 071001, China
| | - Jing Pu
- Key Laboratory of Medical Molecular Virology (MOE/NHC/CAMS), School of Basic Medical Sciences and Shanghai Public Health Clinical Center, Fudan University, 130 Dong An Rd., Xuhui District, Shanghai 200032, China
| | - Wenwen Bi
- Key Laboratory of Medical Molecular Virology (MOE/NHC/CAMS), School of Basic Medical Sciences and Shanghai Public Health Clinical Center, Fudan University, 130 Dong An Rd., Xuhui District, Shanghai 200032, China
| | - Shuai Xia
- Key Laboratory of Medical Molecular Virology (MOE/NHC/CAMS), School of Basic Medical Sciences and Shanghai Public Health Clinical Center, Fudan University, 130 Dong An Rd., Xuhui District, Shanghai 200032, China
| | - Yu Meng
- Key Laboratory of Medical Molecular Virology (MOE/NHC/CAMS), School of Basic Medical Sciences and Shanghai Public Health Clinical Center, Fudan University, 130 Dong An Rd., Xuhui District, Shanghai 200032, China
| | - Cong Wang
- Key Laboratory of Medical Molecular Virology (MOE/NHC/CAMS), School of Basic Medical Sciences and Shanghai Public Health Clinical Center, Fudan University, 130 Dong An Rd., Xuhui District, Shanghai 200032, China
| | - Wenqian Yang
- Key Laboratory of Medical Molecular Virology (MOE/NHC/CAMS), School of Basic Medical Sciences and Shanghai Public Health Clinical Center, Fudan University, 130 Dong An Rd., Xuhui District, Shanghai 200032, China
| | - Wei Xu
- Key Laboratory of Medical Molecular Virology (MOE/NHC/CAMS), School of Basic Medical Sciences and Shanghai Public Health Clinical Center, Fudan University, 130 Dong An Rd., Xuhui District, Shanghai 200032, China
| | - Yun Zhu
- National Laboratory of Biomacromolecules, Institute of Biophysics, Chinese Academy of Sciences, Beijing 100101, China
| | - Qinwen Zheng
- Key Laboratory of Medical Molecular Virology (MOE/NHC/CAMS), School of Basic Medical Sciences and Shanghai Public Health Clinical Center, Fudan University, 130 Dong An Rd., Xuhui District, Shanghai 200032, China
| | - Chuan Qin
- Key Laboratory of Human Disease Comparative Medicine, Chinese Ministry of Health, Beijing Key Laboratory for Animal Models of Emerging and Re-emerging Infectious Diseases, Institute of Laboratory Animal Science, Chinese Academy of Medical Sciences and Comparative Medicine Center, Peking Union Medical College, Beijing 100021, China.
| | - Shibo Jiang
- Key Laboratory of Medical Molecular Virology (MOE/NHC/CAMS), School of Basic Medical Sciences and Shanghai Public Health Clinical Center, Fudan University, 130 Dong An Rd., Xuhui District, Shanghai 200032, China. .,Lindsley F. Kimball Research Institute, New York Blood Center, New York, NY 10065, USA
| | - Lu Lu
- Key Laboratory of Medical Molecular Virology (MOE/NHC/CAMS), School of Basic Medical Sciences and Shanghai Public Health Clinical Center, Fudan University, 130 Dong An Rd., Xuhui District, Shanghai 200032, China.
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Angiostrongylus cantonensis infection induces MMP-9 and causes tight junction protein disruption associated with Purkinje cell degeneration. Parasitol Res 2020; 119:3433-3441. [PMID: 32789733 DOI: 10.1007/s00436-020-06840-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 08/02/2020] [Indexed: 10/23/2022]
Abstract
Angiostrongylus cantonensis causes a human central nervous system (CNS) infection characterized by eosinophilic meningitis or meningoencephalitis. Individuals infected with A. cantonensis exhibit unbalanced walking. The mechanism of extensive neurological impairments of hosts caused by A. cantonensis larvae remains unclear. Tight junction proteins (e.g., claudin-5 and zonula occludens-1) are the most important regulators of paracellular permeability and cellular adhesion. In a previous study, we found that increased matrix metalloproteinase-9 (MMP-9) activity may be associated with blood-CNS barrier disruption and/or the degeneration of Purkinje cells in eosinophilic meningitis caused by A. cantonensis. In the present study, the co-localization of MMP-9 and tight junction proteins on the degeneration of Purkinje cells was measured via confocal laser scanning immunofluorescence microscopy. The statistical evidence indicated that MMP-9 correlated between tight junction protein disruption and Purkinje cell degeneration at 20 days post-infection with A. cantonensis. In conclusion, Purkinje cell degeneration is highly correlated with tight junction protein disruption via the MMP-9 activation pathway.
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9
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Machado Andrade V, Stevenson M. Host and Viral Factors Influencing Interplay between the Macrophage and HIV-1. J Neuroimmune Pharmacol 2018; 14:33-43. [PMID: 29995208 DOI: 10.1007/s11481-018-9795-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 06/26/2018] [Indexed: 12/29/2022]
Abstract
HIV-1 persists in cellular reservoirs that cannot be eliminated by antiretroviral therapy (ART). The major reservoir in infected individuals on effective ART is composed of resting memory CD4+ T cells that harbor proviral cDNA, and undergo a state of latency in which viral gene expression is minimal to absent. The CD4+ T cell reservoir has been extensively characterized. However, other HIV-1-permissive cells may contribute to HIV-1 persistence. Lentiviruses have a long recognized association with macrophages. However, the role, if any, played by macrophages in HIV-1 persistence is not well understood. Macrophages are resistant to cell death upon HIV-1 infection, and can survive for long periods of time, making them ideal host cells in which the virus might persist. Studying macrophages is challenging, as these cells reside in nearly all tissues. Moreover, detecting viral DNA or RNA in macrophages does not necessarily indicate that these cells will produce replication-competent viral particles. Currently, the gold standard assay to detect cellular reservoirs is the ex vivo quantitative viral outgrowth assay (QVOA), which requires a patient blood draw. However, macrophages reside deep within tissues that are inaccessible in living subjects, such as the central nervous system (CNS). Therefore, tools other than QVOA must be developed to identify cellular reservoirs that reside in the tissues. In this review, we will focus on the main aspects involved in HIV-1 persistence, including the molecular mechanisms of viral evasion, the main cell types responsible for harboring persistent HIV-1 and the tissue compartments that are likely to be reservoirs for HIV-1.
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Affiliation(s)
- Viviane Machado Andrade
- Molecular Cell and Developmental Biology, Miller School of Medicine, University of Miami, Miami, FL, 33136, USA.
| | - Mario Stevenson
- Division of Infectious Diseases, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, 33136, USA
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Kronemer SI, Mandel JA, Sacktor NC, Marvel CL. Impairments of Motor Function While Multitasking in HIV. Front Hum Neurosci 2017; 11:212. [PMID: 28503143 PMCID: PMC5408028 DOI: 10.3389/fnhum.2017.00212] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 04/11/2017] [Indexed: 02/05/2023] Open
Abstract
Human immunodeficiency virus (HIV) became a treatable illness with the introduction of combination antiretroviral therapy (CART). As a result, patients with regular access to CART are expected to live decades with HIV. Long-term HIV infection presents unique challenges, including neurocognitive impairments defined by three major stages of HIV-associated neurocognitive disorders (HAND). The current investigation aimed to study cognitive and motor impairments in HIV using a novel multitasking paradigm. Unlike current standard measures of cognitive and motor performance in HIV, multitasking increases real-world validity by mimicking the dual motor and cognitive demands that are part of daily professional and personal settings (e.g., driving, typing and writing). Moreover, multitask assessments can unmask compensatory mechanisms, normally used under single task conditions, to maintain performance. This investigation revealed that HIV+ participants were impaired on the motor component of the multitask, while cognitive performance was spared. A patient-specific positive interaction between motor performance and working memory recall was driven by poor HIV+ multitaskers. Surprisingly, HAND stage did not correspond with multitask performance and a variety of commonly used assessments indicated normal motor function among HIV+ participants with poor motor performance during the experimental task. These results support the use of multitasks to reveal otherwise hidden impairment in chronic HIV by expanding the sensitivity of clinical assessments used to determine HAND stage. Future studies should examine the capability of multitasks to predict performance in personal, professional and health-related behaviors and prognosis of patients living with chronic HIV.
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Affiliation(s)
- Sharif I Kronemer
- Department of Neurology, Johns Hopkins School of MedicineBaltimore, MD, USA.,Department of Neuroscience, Yale UniversityNew Haven, CT, USA
| | - Jordan A Mandel
- Department of Neurology, Johns Hopkins School of MedicineBaltimore, MD, USA
| | - Ned C Sacktor
- Department of Neurology, Johns Hopkins School of MedicineBaltimore, MD, USA
| | - Cherie L Marvel
- Department of Neurology, Johns Hopkins School of MedicineBaltimore, MD, USA.,Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of MedicineBaltimore, MD, USA
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