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Unit 8
Neurologic System Conditions
Training on Clinical Care of HIV, AIDS and
Opportunistic Infections
Learning Objectives
• Explain the causes of meningitis, encephalitis
and other non-focal brain disease, among HIV
and AIDS patients
• Explain the causes of focal brain disease
among HIV and AIDS patients
• Interpret cerebrospinal fluid (CSF) findings in
HIV patients
• Treat common causes of meningitis
• Use empiric therapy for toxoplasmosis
appropriately
• Distinguish between AIDS dementia and
depression
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 2
Diagnostic Categories of HIVAssociated CNS Disease
• Meningitis and encephalitis syndromes
• Inflammation of the meninges
• Decrease in mental status
• Usually no focal findings
• Disease with focal (lateralizing) neurologic
findings
• Suggests focal brain disease
• Headache without meningitis, focal signs, or
change in mental status
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 3
Meningitis & Encephalitis
Symptoms and Signs
•
•
•
•
Fever
Headache
Photophobia
Meningismus
• Sign of meningeal irritation
• Stiff neck
• Kernig’s and Brudzinsky’s signs
• Change in mental status
• Implies brain parenchymal involvement
• Encephalitis or meningoencephalitis
• Cranial nerve signs
• Increased intracranial pressure
• Exudate around base of brain
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 4
Causes: Meningitis & Encephalitis
• Bacterial meningitis
• S. pneumonia, N. meningitidis, H. influenza, Listeria
monocytogenes, Leptospirosis
•
•
•
•
Cryptococcus (rarely other fungi)
Tuberculosis (rarely MOTT)
Malaria
Viral meningitis
• Enterovirus, mumps, other
• Mosquito-borne
• HIV itself
• Viral encephalitis
• HIV, Varicella, CMV, HSV, other
• Neurosyphilis
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 5
Uncommon Causes: Meningitis &
Encephalitis
• Para-meningeal infection
• Malignancy
• Lymphoma metatstatic to brain & meninges
• Carcinomatous meningitis
• Parasitic
• Trypanosomiaisis
• Ameobic meningitis
• Auto-immune
• Systemic Lupus Erythematosis (SLE)
• Drug induced
• NSAIDs
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 6
Meningitis & Encephalitis Effect of
CD4 on Differential
• Any CD4 (but more common with lower
counts)
• Pyogenic Bacteria, Syphilis, TB, HIV Meningitis
• CD4 < 50
• Cryptococcus
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 7
Confirmation of Meningitis
• A lumbar puncture must be performed to
obtain CSF to confirm suspected meningitis
and determine the aetiology
• Contraindications to LP
• Brain mass causing increased intracranial pressure
• Bilateral optic disc papilledema suggesting
increased intracranial pressure
• Infection overlying the lumbar region
• High risk of bleeding
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 8
CSF Findings in Meningitis
Test
Bact.
Opening Pressure
Viral
Fungal
TB
Usually
Normal
Variable
Variable
WBC
>1000
<100
Variable
Variable
Differential
PMN’s
Lymphs
Lymphs
Lymphs
Protein
Glucose Ratio
to
Nml to
Nml to
Usually
Normal
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Slide 9
Bacterial Meningitis
• Not especially common in HIV patients
• Common causes respond to ceftriaxone IV (2
grams IV 12 hourly)
• S. pneumonia, N. meningitidis, H. influenza
• Leptospirosis (1 gram IV daily)
• Rare causes:
• Listeria monocytogenes, a gram positive rod, is
resistant to ceftriaxone and responds to IV
ampicillin
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 10
AIDS-Associated Cryptococcal
Meningitis
• Clinical presentation:
• Occurs in advanced immune damage CD4 < 50
• Characterized by subtle clinical manifestations;
headache, fever, malaise, signs of meningitis occur
in only 1/3 of patients
• Altered sensorium in 25% cases; and focal signs in
5%
• Cranial nerve abnormalities common with increased
intracranial pressure from communicating
hydrocephalus
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 11
AIDS-Associated Cryptococcal
Meningitis (2)
• Diagnosis
•
•
•
•
•
•
CSF cell count may be normal or slightly elevated
Protein may be up, glucose may be low
CSF India ink preparation yield is 75%
CSF culture is diagnostic
Blood culture may be positive
Cryptococcal antigen assays, CSF/serum (when
sending CSF, ask lab to do CSF CrAg if India ink
negative)
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 12
CSF of Patient with cryptococcal
meningitis
CSF
India Ink
High Magnification
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Slide 13
Treatment of Cryptococcal
Meningitis
• See Handout 8.1
• Induction
• IV amphotericin B 0.7 mg/kg/day for 14 days
• If amphotericin B not available, fluconazole 400 mg
po daily for 14 days
• Consolidation: fluconazole 400 mg daily po for
8 wks
• Maintenance: fluconazole 200 mg po daily life
long or until CD4 count > 200 for 6 months on
HAART
• Fluconazole / nevirapine drug interaction may
affect HIV treatment
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 14
Treatment of Cryptococcal
Meningitis (2)
• Management of raised intracranial pressure
• Daily CSF drainage until CSF pressure is <20
cm (<200 mm) H2O or until patient stable
• Manometers generally not available in Namibia;
consultants recommend removing 20-30 ml per day
• A randomized trial in Thailand showed that
acetazolamide caused more problems than
repeat lumbar punctures
• Mannitol is not recommended
• Data do not support use of steroids
Newton PN et al. Clinical Infectious Disease. 2002;35:769.
Saag M et al. Clinical Infectious Disease. 2000;30:710.
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 15
AIDS-Associated Cryptococcosis:
Non-meningeal Disease
• Pneumonia
• May precede, accompany, or follow meningitis
• Lung is portal of entry for organism
• Skin lesions
• May accompany meningitis or disseminated
disease
• Bone and joint
• Adrenal glands
• Prostate
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 16
• Cryptococcal skin
lesions mimic
mollucscum
contagiosum
• Painless
umbilicated papules
on face
Source: ©Wellcome Trust, 2000
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 17
Tuberculous Meningitis
• Common form of extra-pulmonary TB in
persons with HIV-associated
immunsuppression
• Characteristics
• Subacute
• May be evidence of active TB elsewhere
• Cranial nerve palsies because basilar meningitis
may occur
• Typically lymphocytic meningitis with high protein,
low glucose,
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 18
CSF in TB Meningitis
Source: International Union Against Tuberculosis and Lung Disease (IUATLD) www.tbrieder.org
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 19
Tuberculous Meningitis
• CSF may be atypical in HIV/AIDS patients
• Glucose normal in 15%
• Protein normal in 40%
• White cell counts normal in 10%
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 20
Tuberculous Meningitis (2)
• CSF AFB smear rarely positive
• CSF AFB culture
• 33% positive
• Sputum smears for AFB
• Chest x-ray
• 50% positive
• Aspirate or biopsy of another site for AFB
• Lymph nodes, liver, bone marrow
• Look for clinical evidence of TB elsewhere in
body
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 21
Treatment of TB Meningitis
• Modified category I regimen anti-TB therapy
• Isoniazid, Rifampicin, Pyrazinamide, Streptomycin
• Vitamin B6 (pyridoxine)
• Total course 6-9 months
• Corticosteroids
• Prednisone 45 mg bd x 4 weeks then 15 mg bd x 4
weeks, then taper per clinical condition
• Note steroid dose has been adjusted in the first 4
weeks for concurrent rifampicin
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 22
Neurosyphilis
• Can occur at any stage of syphilis.
• Most often is tertiary syphilis, after several
years of latent infection
• May occur sooner among HIV-infected persons
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 23
Neurosyphilis (2)
• May present as:
• Sub acute meningitis
• A chronic bacterial infection
• Acute stroke
• An infectious vasculitis
• Chronic brain disease
• Dementia
• Personality changes
• Psychosis
• Spinal cord / cranial nerve dysfunction
• Tabes dorsalis
• Motor and sensory abnormalities
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 24
Diagnosis of Neurosyphilis
• Classical neurologic syndromes
• CSF abnormalities
• Increased mononuclear cells
• Increased protein
• +/- decreased glucose
• Positive blood test
• RPR
• Positive CSF VDRL (not RPR) is diagnostic but
insensitive
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 25
Treatment of Neurosyphilis
• Intravenous penicillin G
• 2-4 million Units IV every 4-6 hours
• Equal to 12-20 million units daily
• 10-14 days of therapy
• Penicillin allergy
• No other therapy considered reliable
• Desensitize to penicillin
• IV Ceftriaxone 2 g IM/IV daily for 14 days
• Oral doxycyline 200 mg bd for 30 days
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 26
Focal Brain Disease
• Disorders presenting with focal neurologic
deficits attributable to brain lesions
• Not spinal cord disease
• Not spinal root disease
• Not peripheral nerve disease
• Most HIV-related focal brain disorders
progress over days to weeks unlike a stroke
• Meningovascular syphilis can present suddenly
as a stroke
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 27
Focal Brain Disease (2)
• Infections
•
•
•
•
•
•
Toxoplasma*
Tuberculoma*
Bacterial abscess
Cysticercosis
Nocardia
Progressive multifocal leukoencephalopathy (PML,
due to JC polyomavirus)
• Herpes simplex encephalitis
* Most common conditions
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 28
Focal Brain Disease (3)
• Malignancy
• Primary brain lymphoma*
• Other primary brain cancers
• Metastatic cancers
* Most
common conditions
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 29
Options in AIDS-Associated Focal
Brain Disease
• Assess degree of immunosuppression
• Clinical assessment of possible aetiologies
• Look for evidence of tuberculosis elsewhere
• Look for conditions associated with brain abscess
• Look for calcified cysts in thigh x-rays
(cysticercosis)
• Look for source of metastatic cancer
• Empiric therapy vs. referral for head CT scan
+/- neurosurgery
• Treat seizures with anticonvulsant
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 30
Options in AIDS-Associated Focal
Brain Disease (2)
• If no other cause apparent…
• Empiric therapy vs. referral for head CT scan
+/- neurosurgery
• Only one CT
scanner for all of
Namibia
• Only intermittent
access to
neurosurgery
VS
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
• Strive for specific
diagnosis and most
effective available
therapy
Unit 8: Neurologic System Conditions, Slide 31
Enhancing Mass Lesion of the
Brain
• Single ring
enhancing
lesion with
oedema on
brain CT scan
• Primary brain
lymphoma
versus
Toxoplasmosis
versus
Tuberculoma
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 32
Headache with Focal Neurologic
Findings: Management
• Treat for Toxoplasmosis
• Cotrimoxazole 10/50 mg/kg/d divided into 2 daily
doses
• For 70 kg: CTX 320/1600 mg bd
– 4 SS tablets bd
– 2 DS tablets bd
• Some give sulfadoxine/pyrimethamine (Fansidar®)
3 tablets/day for the first 3 days instead of CTX,
then continue with the standard dose of CTX
Source: Torre D et al. Antimicrob Ag Chemo 1998;42:1346
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 33
CNS Toxoplasmosis
Response to empiric therapy
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 34
Headache with Focal Neurologic
Findings: Management (2)
• IF patient improves
• Treat for 6 weeks
• Then reduce CTX dose in half for long term
suppression
• Some use Fansidar® 1 tablet twice weekly but this
has substantial toxicity
• If CD4 increases on HAART to above 200 for 6
months, can then discontinue the toxoplasmasuppressive treatment
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 35
Focal Brain Disease Unresponsive
to Toxoplasma Treatment
• Infections
•
•
•
•
Tuberculoma
Bacterial abscess
Cysticercosis
Progressive multifocal leukoencephalopathy
(PML, due to JC polyomavirus)
• Herpes simplex encephalitis
• Malignancy
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 36
Progressive Multifocal
Leukoencephalopathy (PML)
• Opportunistic infection associated with HIV
infection, prevalence up to 5%
• Demyelinating disease of the CNS caused by
reactivation of the polyoma JC virus
• Progressive course:
• 1 year survival with HAART 50%
• 1 year survival without HAART 10%
• Overall survival usually<6/12
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 37
Progressive Multifocal
Leukoencephalopathy (PML) (2)
• Signs and symptoms
•
•
•
•
•
•
•
subacute neurologic deficits
altered mental status
visual symptoms (e.g. hemianopia and diplopia)
hemiparesis or monoparesis
gait ataxia
seizures (up to 18 percent)
May see new onset or clinical worsening of PML
due to IRIS
• May need steroids for IRIS
• Treatment
• No specific treatment
• HAART
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 38
Source: Keller, I. A. et al. N Engl J Med 1999;341:163.
• Primary Brain Lymphoma in an AIDS patient
who does not respond to empiric antiToxoplasma treatment
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 39
Headache in Advanced AIDS
• Focal brain disease
• Infection
• Malignancy
• Cerebrovascular disease
• Non-focal brain disease
• Meningitis
• Encephalitis and encephalopathy
• Regional disease not including brain
• Response to fever or other illness
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 40
Headache: History and Physical
• Fever
• Neurologic signs and symptoms
•
•
•
•
•
Weakness
Sensory change
Cognitive change
Seizures
Neck stiffness
• History of similar headache
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 41
Regional Disease Not Including
Brain
• Sinus infection
• Otitis and mastoiditis
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 42
Response to Fever or Other Illness
•
•
•
•
Malaria
Any febrile illness
Stress or tension headaches
Migraine
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 43
Headache: Effect of CD4 on
Differential
• Any CD4
• Syphilis, Pyogenic Bacteria, TB, HIV Meningitis
• CD4 < 200
• AIDS Dementia
• CD4 < 100
• Cryptococcus, Toxoplasmosis, PML
• CD4 < 50
• CMV, Lymphoma
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 44
Immune Reconstitution
Inflammatory Syndrome
• Recurrence of signs and symptoms of a
disease occurring with immunologic
improvement on HAART
• Among AIDS-related brain disease, IRIS most
common with
• Cryptococcal meningitis
• Toxoplasmosis
• Tuberculosis
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 45
Immune Reconstitution
Inflammatory Syndrome (2)
• Management
• Continue HAART and specific treatment
• Symptomatic treatments
• If severe: consider short course of prednisone
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 46
HIV Associated Dementia (HAD)
• Gradually decreasing cognitive function and
mental status
•
•
•
•
•
•
Impaired short term memory
Decreased concentration
Clumsiness/slowness
Apathy/irritability
Personality changes
Loss of ability to care for self
• May develop focal disease from spinal cord
involvement late in course
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 47
Pathophysiology of HAD
• HIV disseminates to CNS soon after primary
infection probably via infected monocytes.
• Brain macrophages and microglial cells
probably the key cells that are infected with
HIV and likely to be involved in the
pathogenesis of HAD
• Leading theories of the pathologic mechanisms
of neuronal damage involve activation of
macrophages or microglial cells and/or
activation of cytokines and chemokines,
leading to abnormal neuronal pruning.
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 48
Screening tool for HIV Dementia
• International HIV Dementia Scale (see handout
8.2)
• Developed in the USA, tested in Uganda and
in the USA
• Sensitivity 80% and specificity 55-57% for HIV
dementia for all participants
• In rapid care settings may be useful as a
screening tool
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 49
Diagnosis of HIV Associated
Dementia (HAD)
• Differential Diagnosis
•
•
•
•
•
•
•
PML
Depression (4-14% of HIV Infected Persons)
Nutritional deficiency
Neurosyphillis
Meningitis
Encephalitis, including toxoplasma
Lymphoma
• Non-HIV related causes of dementia also exist
• hypothyroidism
• Investigation should be guided by history and
clinical findings
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 50
HIV Associated Dementia (HAD) (3)
• Lack of focal findings early in course
• May have abnormal reflexes
• Frontal release signs (grasp, root)
• Hyper reflexia
• Impaired saccadic eye movements
• Difficulty with smooth limb movements
especially in lower extremities
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 51
HIV Associated Dementia (HAD) (4)
• Diagnosis of exclusion
• Investigations
• Rule out other potential causes
•
•
•
•
•
•
CSF Exam
Serum Cryptococcal Antigen (CrAg)
Serum VDRL
B12/Folate Levels
FBC
TSH
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 52
Staging of HIV Associated
Dementia
Stage 0
• Normal
Stage 1
• Mild, can do all activities of daily living (ADL)
• Can work
Stage 2
• Moderate, only able to do simple ADL
• Cannot work
Stage 3
• Severe
• Cannot walk
• Major intellectual disability
Stage 4
• Vegetative
• Para/quadraplegia
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Slide 53
Management of HIV Associated
Dementia
• HAART can be very effective if the patient can
adhere
• Often requires a family member or caregiver to
administer medications
• Investigate social support and rehabilitation
options
• Mild sedatives if needed
• Antipsychotics for hallucinations or delusions
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 54
Frequency of HIV Dementia and
Depression Symptoms
HIV Dementia
Depression
Short Term Memory Loss
Very Common
Occasional
Decreased Concentration
Very Common
Very Common
Gait Disturbance
Common
Uncommon
Personality Changes
Very Common
Less Common
Depressed Mood
Occasional
Very Common
CD4 Count
Usually < 200
Any
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Slide 55
Criteria for Diagnosis of Clinical
Depression
• At least 5 of the following, must include at least
one of the first 2:
•
•
•
•
•
•
•
•
•
Depressed mood
Markedly decreased pleasure in all activities
Unintentional weight loss or gain
Insomnia or oversleeping
Fidgetiness or slowed movement
Fatigue or loss of energy
Feelings of worthlessness or excessive guilt
Decreased concentration
Suicidal thoughts
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 56
Management of Clinical Depression
• Always assess for suicidal intent
• Gradual and supervised increasing doses of
antidepressants
• Sedating antidepressants given at bedtime
• Avoid providing large amounts of tricyclic antidepressants
at one time as overdoses can be fatal
• Supportive counseling
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 57
Leg Weakness
• Paraparesis and paraplegia are common
problems in HIV-infected persons
• 3 categories of disease
• Peripheral nerve and roots
• Spinal cord
• Muscle disease
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 58
Aetiology of Leg Weakness
• Peripheral nerve and roots
• Motor neuropathy
• HIV
• VZV
• Poliomyelitis
• Guillan Barré syndrome
• toxins
• Radiculopathy (nerve roots)
• CMV
• VZV
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 59
Aetiology of Leg Weakness (2)
• Spinal cord
•
•
•
•
•
HIV myelopathy
Transverse myelitis
TB spine
Malignancy compressing spinal cord
Tabes dorsalis (tertiary syphilis)
• Diabetes can cause or exacerbate all of these
syndromes
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 60
Aetiology of Leg Weakness (3)
• Muscle disease
• HIV myopathy
• Myopathy from thymidine analogues
• AZT and d4T
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 61
Sensory Neuropathy
• Very common in HIV & AIDS
• Symmetrical numbness, burning and pain in a
stocking and glove distribution
• Aetiologies
• HIV itself causing direct nerve damage
• HAART may help
• Drug toxicity
• d4T and ddI
– Discontinuation may help
• INH
– Pyridoxine 100-200 mg daily
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 62
Key Points
1. First, determine if there are focal findings
2. If NO focal findings, work-up depends on
CSF exam and blood work
3. If focal findings present, treat empirically for
toxoplasmosis
4. HIV dementia is a diagnosis of exclusion
Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 8: Neurologic System Conditions, Slide 63