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HIV and Neuro

Clinical Question
26 yo AAM with 1 mth history of worsening of mental status. HIV of ??? duration. MRI is normal. LP is normal. CD 4 count is 7. Viral load is very high. 

DDx. in this patient includes the following 

  • EEG shows diffuse slowing. Normal EEG does not rule out delirium
  • Can cause psychotic symptoms
  • Fluctuating mental status is the key
  • Substance abuse
    • Alcohol:
    • Drug use:
HIV-associated Dementia
  • HIV Dementia Scale (with scores of 10 or less indicat- ing HIV-associated dementia) 
  • The typical presentation is a progressive dementia with subcortical features (apathy, inattention, and loss of retentive memory) and abnormalities of motor function, such as psychomotor slowing 
  • AIDS Mania: When psychosis (prominent agitation, irritability, and delusions) occurs in patient with HIV-associated dementia
  • The extent of the cognitive impairment will require reexamination with a full battery of neuropsychological tests after his acute illness has resolved 
Primary Psychiatry Disorder
  • A first episode of schizophrenia is unlikely, since the onset of schizophrenia is typically not sudden but instead involves a prodromal period of several years, with gradual loss of function and social competence
  • Reactive Psychosis: the very sudden onset of psychosis during the course of a day or so has been called “reactive psychosis,” in response to stressors 
Infection and Malignancy in HIV host
  • Toxo: Not seen in MRI
  • Cryptococcal: LP CSF cell count can be normal, but CSF antigen was negative
  • CMV: CMV in blood and CSF PCR was negative. Yet, cannot rule out when CD4 is that low. Retinal exam will be useful as well. 
  • M Tb: Less likely based on MRI and CSF but cannot be ruled out. 
  • PMLE: MRI rules out
  • Lymphoma : MRI rules out
  • B12 deficiency
  • Thiamine Deficiency
  • Olanzapine, an antipsychotic agent.  proven efficacy and relatively low risk of causing extrapyramidal symptoms and tar dive dyskinesia, which are highly prevalent among patients with HIV. 
  • HIV-associated damage to the dopaminergic basal ganglia system and increased plasma levels of antipsychotic agents because of interactions with antiret- roviral drugs puts hiv patient at risk of extrapyramidal symptoms 
  • Dysfunction of the basal ganglia also heightens the risk for neuroleptic malignant syndrome in hiv, which has been well documented to occur in patients with HIV 
  • Refernces:

Cryptococcal Meningitis (see also in ID with CNS infection)
  • Ag test in CSF is 95 % sensitive