Neurological Complications Neurological Complications in HIV Infection/AIDSin HIV Infection/AIDS

Dr.K.Bujji Babu, MD., HIV PhysicianDr.K.Bujji Babu, MD., HIV PhysicianConsultant Consultant

Bujji Babu HIV ClinicBujji Babu HIV ClinicKanuruKanuru

VijayawadaVijayawada

IntroductionIntroduction

Deadly DUO in HIV infection Deadly DUO in HIV infection --Opportunistic infections --Opportunistic infections -- Neoplasms -- Neoplasms

Team effortTeam effort -- HIV physician-- HIV physician -- Neurologist -- Neurologist -- Radiologist, Microbiologist & -- Radiologist, Microbiologist & PathologistPathologist

Discuss patient profiles in AIDSDiscuss patient profiles in AIDS

Diagnostic dilemmasDiagnostic dilemmas

Treatment: Options, Complications, Treatment: Options, Complications, LimitationsLimitations

AIMSAIMS

EpidemiologyEpidemiology

Duration: 2 yearsDuration: 2 years

Total no HIV/AIDS cases: 490Total no HIV/AIDS cases: 490

No of patients with neurological No of patients with neurological complications:50 complications:50

Male:Female: 31:19Male:Female: 31:19

Age group : 25-55 yearsAge group : 25-55 years

Patient ProfilePatient Profile

Clinical examinationsClinical examinations

Laboratory InvestigationsLaboratory Investigations• Confirmation of serological status by ELISA/W.BConfirmation of serological status by ELISA/W.B• Hb%, TC, DC, ESR, VDRL, Hep A,B & C, Hb%, TC, DC, ESR, VDRL, Hep A,B & C,

S.Bilirubin, S.Creatinine, S.Amylase, Serum IgG S.Bilirubin, S.Creatinine, S.Amylase, Serum IgG for Toxo, Montoux, CXR, USG abdomen, Urine for Toxo, Montoux, CXR, USG abdomen, Urine examinationexamination

• CD4 for Immunological status CD4 for Immunological status

CNS ExaminationCNS Examination

Clinical ExaminationClinical ExaminationExamination of fundusExamination of fundusLaboratory studyLaboratory study

CSF StudyCSF Study Chemical Analysis, AFB, Gramstain, Culture sensitivity, Chemical Analysis, AFB, Gramstain, Culture sensitivity,

KOH, VDRL, Indian Ink Preparation for Crypto, KOH, VDRL, Indian Ink Preparation for Crypto, Cryptococcal antigen, PCR.Cryptococcal antigen, PCR.

MRI studyMRI study

Tubercular meningitisTubercular meningitisNo. of Patients: 8 (M:F-5:3)No. of Patients: 8 (M:F-5:3)Clinical Features: Fever, Headache & Clinical Features: Fever, Headache & VomitingVomitingCSF AnalysisCSF Analysis

AFB Positive for 3 (1F, 2 M)AFB Positive for 3 (1F, 2 M) AFB Negative for 5 (1F, 4M)AFB Negative for 5 (1F, 4M)

CD4 countCD4 countMortality: One patient died in advanced Mortality: One patient died in advanced stage, even after shunting for TBM with stage, even after shunting for TBM with hydrocephaloushydrocephalous

TB SpineTB Spine

No. of Patients : 2 (M:F-1:1)No. of Patients : 2 (M:F-1:1)

Clinical Features: Fever, Backache, Loss Clinical Features: Fever, Backache, Loss of weightof weight

Diagnosis : MRI spine Diagnosis : MRI spine

Treatment : ATT followed by ARTTreatment : ATT followed by ART

Results:Therapeutic response very good Results:Therapeutic response very good both TBM & TB spine when the CD4 > 150both TBM & TB spine when the CD4 > 150

Cryptococcal MeningitisCryptococcal Meningitis

No. of patients: 8 [M:F- 5:3] No. of patients: 8 [M:F- 5:3] Clinical features: Throbbing Headache, Fever, Clinical features: Throbbing Headache, Fever, Occasional Convulsions.Occasional Convulsions.CD4 < 150CD4 < 150CSF: High Pressure, Clear FluidCSF: High Pressure, Clear FluidIndian ink for Cryptococcus +ve (5 cases)Indian ink for Cryptococcus +ve (5 cases)Cryptococcal antigen +ve (3 cases)Cryptococcal antigen +ve (3 cases)Treatment: Fluconazole 200mg IV BD, Treatment: Fluconazole 200mg IV BD, Amphotericin B 0.7mg/kg & followed by ARTAmphotericin B 0.7mg/kg & followed by ARTMortality: 2 [M:F-1:1]Mortality: 2 [M:F-1:1]

ToxoplasmosisToxoplasmosis

No. of Patients: 6 ( M:F- 5:1) No. of Patients: 6 ( M:F- 5:1) Clinical Features: Fever & SeizuresClinical Features: Fever & SeizuresDiagnosis: Serum IgG Toxo, MRIDiagnosis: Serum IgG Toxo, MRICD4 < 200CD4 < 200Treatment: Anti TOXO Treatment: Anti TOXO Alternative: Clindamycin & DapsoneAlternative: Clindamycin & Dapsone

Followed by ARTFollowed by ARTMortality: 1 Mortality: 1

PMLPML

No. of Patients: 6 (M:F- 4:2) No. of Patients: 6 (M:F- 4:2)

Clinical features: Loss of memory, Clinical features: Loss of memory, irrelevant speech, insomniairrelevant speech, insomnia

Diagnosis : MRIDiagnosis : MRI

CD4 <150CD4 <150

Treatment: Symptomatic & ART Treatment: Symptomatic & ART

Mortality: 1Mortality: 1

Cerebral AtrophyCerebral Atrophy

No. of Patients: 3 (M:F-2:1)No. of Patients: 3 (M:F-2:1)

Clinical Features: Clinical Features:

Loss of memory,irrelevant speech,insomnia Loss of memory,irrelevant speech,insomnia

insomniainsomnia

Diagnosis – MRIDiagnosis – MRI

CD4 < 150CD4 < 150

Treatment: Symptomatic & ARTTreatment: Symptomatic & ART

Pneumococcal MeningitisPneumococcal Meningitis

No. of patients – 2 (M)No. of patients – 2 (M)

Clinical Features: Fever, Headache and Clinical Features: Fever, Headache and vomitingvomiting

Diagnosis: CSF analysis, Gram stain / Diagnosis: CSF analysis, Gram stain / CultureRx CultureRx

Treatment : standard+ ARTTreatment : standard+ ART

Results: 1 patient died, CD4 = 27, one Results: 1 patient died, CD4 = 27, one patient survive CD4 = 150patient survive CD4 = 150

HIV Myelopathy with MyopathyHIV Myelopathy with Myopathy

1 (F) patient1 (F) patient

Clinical Features: Tingling sensation & Clinical Features: Tingling sensation & weakness in lower limbsweakness in lower limbs

CD4:110CD4:110

Treatment : ART Treatment : ART

Facial Palsy due to Herpes-Facial Palsy due to Herpes-ZosterZoster

No. of cases: 6 (M:F-4:2)No. of cases: 6 (M:F-4:2)

Diagnosis – ClinicalDiagnosis – Clinical

CD4 < 200CD4 < 200

Treatment: Acyclovir , Famcyclovir , Treatment: Acyclovir , Famcyclovir , Valcyclovir Valcyclovir

PhysiotherapyPhysiotherapy

Peripheral NeuropathyPeripheral Neuropathy

No. of Patients: 5 (M:F- 3: 2)No. of Patients: 5 (M:F- 3: 2)

Cause : Mainly drug inducedCause : Mainly drug induced

Clinical Features: Numbness, tingling Clinical Features: Numbness, tingling sensations & weakness in lower limbs sensations & weakness in lower limbs

CD4 : 50 – 150CD4 : 50 – 150

Diagnosis : Clinical and NCSDiagnosis : Clinical and NCS

Treatment : Vitamin supplements Treatment : Vitamin supplements

Spinal Masses Other than Spinal Masses Other than KOCH’sKOCH’s

No. of Patients: 3 (M:F- 2:1)No. of Patients: 3 (M:F- 2:1)Clinical Features: Fever, Paraplegia,Urinary Clinical Features: Fever, Paraplegia,Urinary retention, Bowel incontinenceretention, Bowel incontinenceCD4; < 100CD4; < 100Diagnosis: MRI & BiopsyDiagnosis: MRI & BiopsyResults : 1(M) Secondary from renal cell Ca. - Results : 1(M) Secondary from renal cell Ca. - dieddied

1(M) NHL operated - doing well1(M) NHL operated - doing well 1(F) Spinal inflammatory/Neoplastic lesions 1(F) Spinal inflammatory/Neoplastic lesions

nature not known (died because neutropenia) nature not known (died because neutropenia)

ConclusionConclusion

TBM , Crypto, Toxo TBM , Crypto, Toxo CD4 < 200 CD4 < 200

Cerebral atrophy & Cerebral atrophy & PML PML

Neoplasms common Neoplasms common CD4 <100 CD4 <100

Neuro AIDSNeuro AIDS

-- More common-- More common

-- high morbidity-- high morbidity

-- Very high mortality-- Very high mortality

-- ART -- ART