Transcript HIV dementia and HIV-related brain impairment (HRBI)

HIV dementia and
HIV-related brain
impairment (HRBI)
Jeanette Meadway FRCP
Consultant Physician
Mildmay Hospital UK
Hackney Road, London E2 7NA
What is HIV dementia?
 An
AIDS-defining illness with WHO
definition (ICD10)
 Objectively defined decline in recent
memory
 Evidence of HIV infection
 Exclusion of opportunistic infections,
tumours or other brain disorders
 Absence of acute brain syndrome
(delirium)
HIV dementia - cause
 HIV
affecting the brain
 No HIV in nerve cells (neurons)
 HIV in macrophages and glial cells
 Damage due to increased cytokines?
 Damage due to toxic effects of HIV
envelope protein gp120?
 Damage leads to cell apoptosis (cell
death) and structural changes
Diagnosis of HIV dementia
 Function:
cognitive impairment,
motor dysfunction, behavioural
changes
 HIV disease: usually advanced with
low CD4 (<200), high viral load, no
ARV treatment or inadequate ARVs
despite deterioration
 CT and MRI scans show brain
shrinkage and white matter changes
MRI changes
Brain shrinkage –
rim of CSF inside
skull, flattened gyri
 White matter
changes, most
likely to affect
frontal lobes as in
this scan
 (contrast medium
in ventricles)

What is HIV-related brain
impairment?
Not a diagnosis, an assessment of function
which is useful for rehabilitation
 Cognitive dysfunction (+- behaviour
change and motor dysfunction) due to
HIV-related pathology
 Includes HIV-related illnesses causing
cognitive impairment
 Does not include unrelated brain
impairment in an HIV+ve person eg due
to alcohol
 The same diagnoses are not included in
HRBI if there is no cognitive dysfunction

Why this definition of HRBI?
 The
conditions which lead to
behavioural problems, cognitive
impairment and motor problems in
the context of advanced HIV offer
the same challenge for rehabilitation
 All are likely to benefit from
supervised adherence to ARVs,
multidisciplinary approach to social
skills and other rehabilitation
HRBI diagnoses
 HIV
dementia
 PML (progressive multifocal
leukoencephalopathy) due to JC virus
 Cerebral toxoplasmosis
 Herpes simplex virus encephalopathy
 Cryptococcal meningitis
 Cerebral lymphoma
 other infections eg TB meningitis
Cerebral toxoplasmosis



When CD4 low
toxoplasma causes
a cerebral abscess
When contrast is
injected, there is
high uptake
around the
abscess – a ringenhancing lesion
Toxoplasma may
cause cognitive
impairment
Cryptococcal Meningitis
Cryptococcal
meningitis is
more insidious
than bacterial
meningitis
 Varied
neurological
changes occur eg
cognitive
impairment

PML
Progressive –
without treatment
deteriorating
neurology and
death
 Multifocal – affects
separate parts of
the brain, as seen
with 3 in this scan
 Leuko – affects
white matter

HRBI rehab at Mildmay
Patients accidentally rehabbed at first
 Those improving had full effective ARVs
and full multidisciplinary team
involvement
 Emphasis on self-medication programme,
relearning social skills and skills to allow
independent activity
 Some patients return to live independently
 Behavioural improvements allow more
appropriate placements for most patients

A new type of dementia
A
patient restarted on ARVs later
deteriorated and died despite fully
controlled viral load and good CD4
 PM showed no HIV in brain, no other
infections or tumours, and
vacuolated cells
 This may be immune reconstitution
syndrome
 Occurs only in a minority of patients
Summary - HRBI
 Cognitive
+- behavioural and motor
impairment due to HIV disease
 Occurs only in advanced HIV
 Most improve with full regular ARVs
 Improvement with rehab team input
 Rehab allows easier placement and
improved quality of life
 Deterioration on ARVs is uncommon