HIV and Neurology

Question 1

What is the central nervous system?

Answer 1

consists of the brain and spinal cord
Note: Both brain and spinal cord are enclosed in the meninges

Question 2

What is the peripheral nervous system?

Answer 2

consists of the nerves and ganglia outside of the brain and spinal cord

Question 3

What is a lumbar puncture?

Answer 3

is a procedure in which a needle is inserted into the spinal canal to collect cerebrospinal fluid (CSF) to help diagnosing e.g. meningitis

Question 4

HIV neurological focal lesions causes?

Answer 4

1. toxoplasmosis
2. tuberculoma
3. cryptococcoma
4. pyogenic abscess
5. lymphoma
6. progressive multifocal leukoencephalopathy

Question 5

HIV neurological diffuse disease causes?

Answer 5

1. cryptococcal meningitis
2. tuberculous meningitis
3. CNS syphilis
4. HIV dementia

Question 6

Diagnosing focal lesions?

Answer 6

CT scan

Question 6

What is the problem with diagnosing ‘neurological’ HIV?

Answer 6

1. CSF results are sometimes not helpful
2. imaging studies are rarely diagnostic
3. brain biopsy is invasive
   Therefore: empiric management is often necessary – anywhere in the world

Question 6

Diagnosing diffuse disease?

Answer 6

LP

Question 7

What are seizures?

Answer 7

Seizures are characterized by loss of consciousness and involuntary movements

Question 8

Ddx for seizures in HIV neurology?

Answer 8

1. Toxoplasmosis
2. intracerebral involvement of disseminated TB (brain tuberculoma or TB meningitis)
3. brain abscesses
4. cryptococcal and bacterial meningitis and intracerebral tumors (e.g. CNS lymphoma)

Question 9

Two key things to ALWAYS remember in the management of HIV infected patients with neurology?

Answer 9

1. HIV infection does not prevent the development of a non-HIV related problem, so consider “normal causes”
2. Opportunistic problems are related to the CD4 (+) cell count
   Note: If the count is > 200-300, the problem is probably not related to the HIV infection

Question 10

At what CD4 count do we consider a person immunocompromised?

Answer 10

CD4 count <200

Question 11

What is toxoplasmosis?

Answer 11

One of the most common space occupying lesions especially in a person with a CD4 count <200 (usually < 100)

Question 12

Etiology of Toxoplasmosis?

Answer 12

infection with the Toxoplasma gondii parasite found in cat feces and contaminated food like meat
- can also be caused by reactivation of a previous disease

Question 13

Pesentation of toxoplasmosis?

Answer 13

sub-acute and focal

Question 14

Most common cause of seizures in HIV patients?

Answer 14

toxoplasmosis

Question 15

Describe the CSF of toxoplasmosis infected patient?

Answer 15

non specific

Question 16

Diagnosis of toxoplasmosis?

Answer 16

1. On CT scan multiple ring enhancing lesions are seen (1/3 single lesion)
2. The best diagnostic test is response to treatment as usually the response happens within 10-14 days

Question 17

Treatment of toxoplasmosis?

Answer 17

Treatment: high-dose bactrim (4 tabs bd) for 28 days, followed by three months of 2 tabs bd
NB: bactrim is a combination of the antibiotics sulfamethaxazole and trimethoprim

Question 18

Bactrim can be used as a prophylaxis for?

Answer 18

1. toxoplasmosis
2. malaria
3. PCP
4. diarrhea

Question 19

Etiology of cryptococcosis and TB?
Treatment?

Answer 19

Cryptococcosis and tuberculosis more frequently cause meningitis infections, but in individual cases they can also cause focal lesions in the brain
- Treatment is similar to CM and TBM

Question 20

What is a bacterial brain abscess?
Treatment?

Answer 20

a focal, intra-cerebral infection which develops into a collection of pus
- Treatment : Broad-spectrum antibiotic or even a combination of antibiotics should be given e.g. ceftriaxone plus metronidazole

Question 21

What is a primary CNS lymphoma?
Treatment?

Answer 21

Primary CNS lymphoma is a cerebral mass lesion seen in patients with advanced HIV disease (usually CD4 <50 cells)
Treatment: is not very effective and prognosis is poor

Question 22

What is meningitis?

Answer 22

If there is an inflammation of the meninges (meningitis)

Question 23

Features of menigitis?

Answer 23

1. headache 2. neck stiffness 3. altered mental status 4. photophobia 5. character changes

Question 24

Causes of meningitis?

Answer 24

1. bacterial 2. fungal 3. viral 4. mycobacterial

Question 25

CSF results for bacterial meningitis?

Answer 25

1. increased polymorphs 2. mildly increased lymphocytes 3. increased proteines 4. decreased glucose 5. negative serum CrAg

Question 26

CSF results for mycobacterial meningitis?

Answer 26

1. mildly increased polymorphs 2. increased lymphocytes 3. increased protein 4. decreased protein 5. negative serum CrAg

Question 27

CSF results in viral meningitis?

Question 28

CSF results in fungal meningitis?

Answer 28

1. mildly increased polymorphs 2. increased lymphocytes 3. increased protein 4. decreased glucose 5. positive serum CrAg

Question 29

Common symptoms of stroke in HIV patients?

Answer 29

Symptoms of stroke (e.g. hemiparesis, aphasia) in younger patients are seen relatively commonly in HIV positive patients

Question 30

Risk factors for stroke in HIV?

Answer 30

Traditional risk factors such as hypertension or diabetes are often absent

Question 31

What causes stroke like symptoms?

Answer 31

opportunistic infection as a cause of the symptoms 1. intracranial TB 2. syphilis 3. VZV 4. cryptococcal meningitis

Question 32

HIV associated disease that causes stroke?

Answer 32

HIV-associated cerebral vasculitis has been reported as the etiology of stroke in up to 20% of young HIV-positive stroke patients large South African series

Question 33

Spinal cord disease and HIV?

Answer 33

- Spinal TB should be considered especially in upper motor neuron disease (=> X-ray spine). If there are suggestive signs of TB, TB treatment has to be started - If TB is improbable because hyperreflexia and radiological signs are absent, a clinically carefully monitored treatment trial with steroids seems warranted

Question 34

Peripheral neuropathy and HIV?

Answer 34

- Usually occurs in HIV+ patients at late stages with varying severity - Poorly understood aetiology (could be related to malnutrition and resultant wasting of peripheral nerves, or neurotoxic effect of cytokines), also secondary to NRTI use e.g. AZT

Question 35

Clinical features of peripheral neuropathy?

Answer 35

1. Burning pain, paresthesia 2. Decrease ankle jerk 3. Normal strength but can progress to muscle weakness

Question 36

Treatment of peripheral neuropahty?

Answer 36

Symptomatic Tx: Ibu, Carbamazepine, Amitryptillin

Question 37

CNS syphilis and HIV?

Answer 37

Syphilis can involve the CNS in two stages: Secondary (aseptic meningitis) Tertiary (meningovascular, dementia, tabes dorsales)

Question 38

Diagnosing CNS syphilis?

Answer 38

Our syphilis test is for plasma only No CSF test is available => if positive in plasma and clinic fits=> treat!