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HIV-Associated Meningidities and Neuropathies

Classic Meningitis Syndromes

• Early

• Late

-HIV

- Bacterial (pneumococcal, Listeria)

-Coccioidomycosis

- Cryptococcosis

- (CMV)

Tuberculous and lymphomatous meningitis may occur in relatively early.

For the moment, the decline in late manifestations re-emphasizes the importance of common and

Early Meningitis Syndromes

Bacterial

Syphilis

Drug-induced

Approach to Bacterial Meningitis

Antimicrobials should be based upon local incidence of penicillin-resistant Pneumococcus (in reality, MDR Pneumococcus)

If vancomycin is used in the regimen, DO NOT administer corticosteroids since CSF penetration may be

High-Risk Areas

Vancomycin (30 mg/kg/d)

plus

Ceftriaxone or cefotaxime (maximum dose)

with or without

Rifampin 600 mg po qd

*Note that vancomycin is third-line Listeria therapy

Spirochetal Meningitis

Syphilis

- Early - pure "aseptic" meningitis presentation

- Late

Meningovascular +/- uveitis and other signs of 2 syphilis

Accompanying asymptomatic or parenchymatous neurosyphilis

Lyme (eg, lymphocytic meningitis + VII nerve palsy in an endemic area)

HIV and Drug-Induced Meningitis

TMP-SMX probably most common; can occur with prophylactic or high doses

- Acute onset

- Variable CSF findings, but pleocytosis generally

Others

- Intravenous immunoglobulin

- NSAIDs

Late Meningitis - Issues in the Protease Era

Can we/should we offer prophylaxis for endemic fungal meningitis?

Is there rebound meningitis if HAART is interrupted or discontinued?

HIV-Associated Neuropathies

• Early

• Late

- CIDP

- Mononeuritis multiplex (autoimmune)

- DSPN (secondary to HIV or nucleosides)

- CMV PRAM

- Mononeuritis multiplex (CMV)

Distal Sensory Polyneuropathy (DSPN)

• Unlike dementia, no apparent change in incidence during HAART era
• Possible role of acetylcamitine deficiency

• Is the idiopathic form being replaced by nucleoside neuropathy?

• Do PIs or other non-neurotoxic forms of HAART protect from neuropathy?

DSPN-- Therapy

• Peptide T-- NO
• TCAs and mexiletine equal efficacy (and not much more effective than the 30-40% placebo effect)

• Other possibilities

- Capsaicin

- Topical lidocaine

- Gabapentin

- Nerve Growth Factor

Other Neuropathies

• Autonomic - probably underdiagnosed, but may have important quality of life implications
• Lymphomatous - clues are asymmetry and elevated LDH

• Diffuse infiltrative CD8 lymphocytosis syndrome - may be accompanied by LIP, salivary gland enlargement, HSM