HIV NEUROLOGY

CENTRAL NERVOUS SYSTEM DISORDERS ASSOCIATED

WITH HIV
General Considerations
Table Common neurologic complication of HIV classified by the stage in which each occurs
EARLY STAGE (CD 4+> 500 )
HIV Meningitis (acute conversion syndrome)
Shingles (varicella- zoster)
Acute inflamatory demyelinating polyneuropathy (AIDP)
MIDDLE STAGE (CD4+ 200-500)
Distal Sensory Polyneuropathy (DSP)
HIV- associated dementia (HIVD)
HIV associated neuromuscular weakness syndrome
Mononeuropathy multiplex
HIV associated myopathy
LATE STAGE
CNS Toxoplasmosis
Cryptococcal meningitis
Primary CNS lymphoma (PCNSL)
Progressive multifocal leukoencephalopathy
HIV associated myelopathy
Varicella Zoster vasculitis
CMV ventriculitis or polyradiculitis ( CD4+ < 100)

CRYPTOCOCCAL MENINGITIS
Essential of Diagnosis
1. A late stage complication of HIV
infection
2. Subacute onset of headache,
general malaise, and fever followd
by encephalopathy ang cranial
neuropathies from increased
intracranial pressure
3. Cryptococcal antigen and culture
from cerebrospinal fluid (CSF) are
diagnostic

CLINICAL FINDINGS
Table Essential clinical information when
forming HIV related differential diagnosis

Duration of HIV infection

History of HIV related illness

CD4+ cell count (current and nadir)

HIV RNA level

Medication use and adherence

Antiretroviral agents, current and past
Chemoprophylactic agents (Sulfamethoxasoletrimethoprim fluconazole, acyclovir)

Serum Toxoplasma IgG antibody status

Serum syphilis serology

TOXOPLASMOSIS OF THE CENTRAL NERVOUS SYSTEM

Essential of Diagnosis
1. A late stage complication of HIV infection
2. Focal neurologic deficits, subacute
encephalopathy, and fever
3. Multiple ring-enhancing lesions on MRI
4. Presence of serum Toxoplasma IgG
antibody
5. Clinical and radiologic improvement with
pyrimethamine and either slfadiazine of
cindamycin

COMPARISON OF CNS TOXOPLASMOSIS AND PRIMARY

LYMPHOMA
Toxoplasmosis

PCNSL

Location

Basal Ganglia
Gray White Junction

Periventricular

Number of lesions

Multiple

Solitary > multiple

Enchancement
pattern

Ring

Heterogenous or
homogenous

Edema

Moderate to marked

Variable

T2 weighted image

Hyperintense

Isotense to hypotense

Diffusion weighted
image

Usually Hypointense

Often hyperintense

MR perfusion

Decreased

Increased

MR Spectroscopy

Markedly elevated
lactate

Markedly elevated
choline

SPECT Thalium

COLD no thalium
uptake

HOT Increased
thalium uptake

Other

Toxo IgG Antibodi

EBV DNA amplified by

TREATMENT

Pyrimethamine
Sulfadiazine
Folic acid
Clindamycin
Corticosteroid

PROGNOSIS

Complete Recovery should be

expected.
Toxoplasmosis cerebri can recur,
particulary in immunosupressed and
despite adherence to antibiotics
Remote seizure are also a common
complication