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Involvement of the nervous system in HIV infection is common, manifesting in about half of
Neurologic complications
Aseptic meningitis. At the time of HIV seroconversion or primary infection, patients may present with symptoms of aseptic meningitis, such as fever, headache, stiff neck, and a
AIDS dementia complex
AIDS dementia complex is reported in about 6% to 7% of patients with AIDS. Clinical features include cognitive dysfunction, impaired motor performance, and behavioral changes. Subclinical cognitive and motor impairment may occur at all stages of
Progressive symptoms may include mental slowing, forgetfulness, poor concentration, apathy, social withdrawal, loss of spontaneity, and reduced libido. Patients display personality changes, including reduced emotional expression, increased irritability, mania, and disinhibition. Loss of fine motor control (deterioration in handwriting), slowing of gait, unsteadiness, urinary incontinence, and tremor may be seen. Seizures occur in 10% of
AIDS dementia complex is a diagnosis of exclusion because depression, metabolic disorders, and other infectious causes of encephalitis may present in a similar manner. Clinical diagnosis may be aided by neuropsychologic testing.
Myelopathy
HIV-related spinal cord involvement is uncommon. It presents as spastic paraparesis with bowel and bladder dysfunction, gait ataxia, and variable sensory loss, usually in the context of advanced immunodeficiency.
Diagnosis must exclude cord-compression lesions (eg, lymphoma, epidural abscess), vitamin B12 deficiency, and other viral infections (eg, human T-cell lymphotropic virus type I, varicella-zoster virus, cytomegalovirus), progressive multifocal polyneuropathy, polynuropaty, polyneuropaty
Myelopathy may respond to highly active antiretroviral therapy. Additional treatment should be directed at ameliorating symptoms.
Distal symmetric polyneuropathy
Distal sensory polyneuropathy may develop as a consequence of HIV infection, but it is more commonly associated with use of antiretroviral agents, specifically zalcitabine (HIVID), didanosine (Videx), and stavudine (Zerit). It tends to
Physical examination reveals diminished ankle reflexes and decreased sensation to pinprick, light touch, and vibration. Nerve-conduction tests demonstrating axonal neuropathy can confirm the diagnosis. The possibility of vitamin B12
Management consists of dose reduction or discontinuation of any potentially offending agents. Symptomatic treatment with tricyclic antidepressants, anticonvulsants (eg, carbamazepine, gabapentin [Neurontin]), lidocaine 30% cream
Infectious processes
Cerebral toxoplasmosis
Cerebral toxoplasmosis occurs as a consequence of reactivation, developing in about 2% to 10% of patients with HIV
Clinical manifestations include headache, confusion, fever, focal neurologic deficits, and seizures. CT and MRI reveal lesions with ring enhancement. Lesions are often multiple with associated mass effect involving the frontal and parietal lobes and basal ganglia. Characteristic CT or MRI findings and positive serologic results are indications for empirical therapy. Definitive diagnosis is by brain biopsy.
Treatment regimens consisting of sulfadiazine or of clindamycin (Cleocin) plus pyrimethamine (Daraprim) for 6 weeks
Cryptococcal meningitis
Cryptococcus neoformans can cause fungal meningitis in the presence of HIV infection, usually in patients with a CD4+ count less than 100 cells/FL. The organism disseminates widely, with predilection for the CNS.
Progressive multifocal leukoencephalopathy
Reactivation of latent JC virus results in progressive multifocal leukoencephalopathy. This condition usually occurs when CD4+ counts are less than 100 cells/FL. Clinical features are subacute in onset and include limb
CT typically shows hypodense white-matter lesions, usually parietooccipital, with no enhancement or mass effect. MRI
CMV encephalitis
In patients with a CD4+ T-lymphocyte count less than 100 cells/FL, CMV disease develops within 2 years in 21.4%. The usual presentation consists of retinitis and esophagitis, with or without colitis; pneumonitis, hepatitis, encephalitis, and polyradiculopathy also may occur.
Clinical features of encephalitis include rapidly progressive confusion, delirium, apathy, and focal neurologic deficits.
Ganciclovir sodium (Cytovene) and foscarnet (Foscavir) have had variable effectiveness in treatment of CMV infection of the CNS.
Neurosyphilis
In patients with HIV infection, neurosyphilis develops within a shorter interval. The prevalence of syphilitic meningitis,
Neoplasm
Lymphoma in the CNS occurs in 5% of patients with AIDS, usually late in the disease course. Manifestations may include headaches, mental status changes, seizures, and focal neurologic signs and symptoms.
Lesions most commonly affect the periventricular gray and white matter; most are supratentorial, but some are