HIV-CNS
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
Delirium - EEG shows diffuse slowing. Normal EEG does not rule out delirium
- Can cause psychotic symptoms
- Fluctuating mental status is the key
- Substance abuse
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
Metabolic - B12 deficiency
- Thiamine Deficiency
Treatment - 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
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