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Table 33-2 Neurologic complications in patients infected with HIV Brain Predominantly nonfocal AIDS dementia complex (subacute/chronic HIV encephalitis) Acute HIV-related encephalitis Cytomegalovirus encephalitis Varicella zoster virus encephalitis Herpes simplex virus encephalitis Metabolic encephalopathies Predominantly focal Cerebral toxoplasmosis Primary CNS lymphoma Progressive multifocal leukoencephalopathy Cryptococcoma Brain abscess/tuberculoma Neurosyphilis (meningovascular) Cerebrovascular disorders notably nonbacterial endocarditis, cerebral hemorrhages associated with thrombocytopenia, and vasculitis Spinal cord Vacuolar myelopathy Herpes simplex or zoster myelitis Meninges Aseptic meningitis (HIV) Cryptococcal meningitis Tuberculous meningitis Syphilitic meningitis Metastatic lymphomatous meningitis Peripheral nerve and root Infectious Herpes zoster Cytomegalovirus lumbar polyradiculopathy, virus- or immune-related Acute and chronic in ammatory HIV polyneuritis Mononeuritis multiplex Sensorimotor demyelinating polyneuropathy Distal painful sensory polyneuritis Diffuse in ltrative lymphocytic syndrome (DILS) Muscle Polymyositis and other myopathies (including drug-induced)
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binski signs, grasp and suck re exes, weakness of the legs progressing to paraplegia, bladder and bowel incontinence re ecting spinal cord or cerebral involvement, and abulia or mutism are prominent in the later stages of the disease In the untreated case, the dementia evolves relatively rapidly, over a period of weeks or months; survival after the onset of dementia is generally 3 to 6 months but may be considerably longer Tests of psychomotor speed seem to be most sensitive in the early stages of dementia (eg, trail-making, pegboard, and symbol-digit testing) Epstein and colleagues have described a similar disorder in children, who develop a progressive encephalopathy as the primary manifestation of AIDS The disease in children is characterized by an impairment of cognitive functions and spastic weakness and secondarily by impairment of brain growth The CSF in patients with AIDS dementia (but lacking other manifestations of AIDS) may be normal or show only a slight elevation of protein content and, less frequently, a mild lymphocytosis HIV can be isolated from the CSF In the CT scan there is widening of the sulci and enlargement of the ventricles; MRI may show patchy but con uent or diffuse white matter changes with illde ned margins (Fig 33-2) These ndings are particularly useful in diagnosis, although CMV infection of the brain in AIDS patients produces a similar MRI appearance, as described further on The pathologic basis of the dementia appears to be a diffuse and multifocal rarefaction of the cerebral white matter, accompanied by scanty perivascular in ltrates of lymphocytes and clusters of a few foamy macrophages, microglial nodules, and multinucleated giant cells (Navia et al) Evidence of CMV infection may be added, but accumulating virologic evidence indicates that the AIDS dementia complex is due to direct infection with HIV Which of these changes, or the cortical atrophy, correspond most closely to the presence and severity of dementia has not been settled The pathologic changes in AIDS dementia are actually not as uniform as portrayed here In one group of patients, there is a diffuse pallor of the cerebral white matter, most obvious with myelin stains, accompanied by reactive astrocytes and macrophages; the myelin pallor seems to re ect a breakdown of the blood-brain barrier In another form of this process, referred to as diffuse poliodystrophy, there is widespread astrocytosis and microglial activation in the
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Adapted by permission from Brew B, Sidtis J, Petito DK, Price RW: The neurologic complications of AIDS and human immunode ciency virus infection, in Plum F (ed), Advances in Contemporary Neurology Philadelphia, Davis, 1988, chap 1
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present in this manner, but the frequency is far higher, close to twothirds, after the constitutional symptoms and opportunistic infections of AIDS are established In children with AIDS, dementia is more common than all opportunistic infections, over 60 percent of children eventually being affected This disorder takes the form of a slowly or rapidly progressive dementia (loss of retentive memory, inattentiveness, language disorder, and apathy) accompanied by abnormalities of motor function Patients complain of being unable to follow conversations, taking longer to complete daily tasks, and becoming forgetful Inco-ordination of the limbs, ataxia of gait, and impairment of smooth pursuit and saccadic eye movements are usually early accompaniments of the dementia Heightened tendon re exes, Ba-
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Figure 33-2 MRI of AIDS leukoencephalopathy There are large areas of white matter change that underlie one form of AIDS dementia; cortical atrophy and ventricular enlargement are evident
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