KOMPLIKASI NEUROLOGIS

AIDS

Dr Aris Catur Bintoro

PERJALANAN PENYAKIT HIV
1. Transmisi virus
2. Infeksi HIV primer
3. Serokonversi
4. Infeksi kronik asimtomatik
5. Infeksi kronik simtomatik
6. AIDS (jumlah CD4 < 200/mm3
7. Infeksi HIV lanjut, jumlah CD4 < 50/mm3
 GEJALA KLINIS INFEKSI PRIMER

KELOMPOK GEJALA KEKERAPAN (%)

Umum Demam 90
Nyeri otot 54
Nyeri sendi -
Rasa lemah -
Mukokutan Ruam kulit 70
Ulkus di mulut 12
Limfadenopati 74
Neurologi Nyeri kepala 32
Nyeri belakang -
Mata -
Fotofobi -
Depresi -
Meningitis 12
Saluran cerna Anoreksia -
Nausea -
Diare 32
Jamur di mulut 12
 GEJALA AIDS DI RS CIPTO M.
Demam lama 100%
Batuk 90,3%
Penurunan berat badan 80,7%
Sariawan dan nyeri menelan 75,8%
Diare 69,2%
Sesak napas 40,0%
Pembesaran kel getah bening 28,8%
Penurunan kesadaran 17,3%
Ganggua penglihatan 15,3%
Neuropati 2,5%
Ensefalopati 4,5%
 INFEKSI OPORTUNISTIK
Kandidiasis mulut + esofagus 80,8%
Tuberkulosis 40,1%
Sitomegalovirus 28,8%
Ensefalitis Toksoplasma 17,3%
Pneumonia P carinii (PCP) 13,4%
Herpes Simpleks 9,6%
M avium kompleks (MAC) 4,0%
Kriptosporodiosis 2,0%
Histoplasmosis paru 2,0%
HIV ENCEPHALITIS. Hyperintense lesions in periventricular. The
lesion cotton like and poor circumscribed. Cortical atrophy.
 CNS COMPLICATION OF HIV
NECROPSY SERIES

Categories France India Brazil

Number of patients 148 67 230
Period 1982-88 88-96 85-90
Focal Disorders :
Cerebral toxoplasmosis 44 % 16 % 34%
Primary Lymphoma 11% 0 4%
PML 3% 0 0
Non focal disorders
CMV encephalitis 17% 9% 79%
 CNS COMPLICATION OF HIV
NECROPSY SERIES

Categories French India Brazil

Number of patients 148 67 230
Period 1982-88 88-96 85-90
MENINGITIS :
Cryptococcal 1% 10 % 13,5%
Tuberculosis 0,6% 15 % 0
Aseptic meningitis NA NA NA
Bacterial meningitis NA NA NA
 CNS COMPLICATION OF HIV
CLINICAL SERIES

Categories Cote dIvore Mexico USA

Number of patients 42 40 130
Period 1995 86-88 86-88
Focal Disorders :
Cerebral toxoplasmosis 36 % 7,5 % 4,6%
Primary Lymphoma 0 2,5% 8,4%
PML 0 2,5% 3,8%
Non focal disorders
CMV encephalitis 0 0 18,5%
 CNS COMPLICATION OF HIV
CLINICAL SERIES

Categories Cote dIvore Mexico USA

Number of patients 42 40 130
Period 1995 86-88 86-88
MENINGITIS :
Cryptococcal 12 % 17,5% 13%
Tuberculosis 7% 10 % 1%
Aseptic meningitis 0 7,5% 6,1%
Bacterial meningitis 12% 0 0
 SOME COMMON (TREATABLE)
NEUROLOGICAL COMPLICATIONS
Cryptococcal meningitis
Tuberculous meningitis
Toxoplasmic encephalitis
Neuromuscular complications
Myelopathy
 CRYPTOCOCCAL MENINGITIS IN
PATIENTS WITH NON HIV AND HIV
INFECTION
A 10 fold increase in annual hospital admission of
CM, which occurred exclusively in HIV
Duration of illness before diagnosis is shorter
Clinical presentation may be nonspecific
Heavier fungal load but less inflammatory response
High intracranial pressure is still a major problem
Immediate mortality was much higher at 60% and
30% of the patients was still alive at the end of 1
year.
 CRYPTOCOCCAL BRAIN INFECTION
Multiple tiny bilateral hyperintense lesion in caudatue
and putamen
 TUBERCULOUS MENINGITIS IN HIV

Problem with diagnosis

Culture is insensitive
Anti-tuberculosis treatment can effect others

2200 patients with cultured proved Tbc :

450 HIV patients : 10% (+)
1750 non HIV patients : 2% (+)
 TUBERCULOUS MENINGITIS IN HIV

CNS involvement in patient with tuberculosis

was more common in HIV
Clinical manifestations of TBM are not different
from non-HIV (adenopathy is more common in
HIV)
TBM can developed in HIV receiving anti-Tbc
Prolong illness before Rx (14d) and low
CD4(<200) was associated with reduced
survival.
Tuberculosis of the brain
with cerebritis and
tuberculoma formation.

Heterogeneous lesion are

seen in the frontal and
parietal region
 TOXOPLASMIC ENCEPHALITIS

Most common cause of focal brain lesion in

AIDS
Morbidity associated with brain biopsy
Reluctant of neurosurgeon to perform operation
Limitation of immunological and imaging
diagnosis
Predictable clinical and clinical response
 TOXOPLASMIC ENCEPHALITIS

The diagnosis of cerebral toxoplasmosis in

tropical countries should be made on clinical
grounds, including the response to treatment .
. As usually patients respond within
a few days of starting therapy
 CLINICAL MANIFESTATION OF CNS
TOXOPLASMOSIS (CHIANG MAI HOSPITAL)

Headache 96%
Fever 84%
Stiff neck 48%
Hemiparesis 44%
Conciouse change
drowsy 42,9%
stupor 3,8%
Cranial nerve palsy 42,3%
Seizure 39%
TOXOPLASMOSIS WITH AIDS. A-C pretreatment , D post treatment
Edematouse lesion (A,B : hypo, C : hyperintense)
The lesion : central and concentric hypointense core
NEUROMUSCULAR COMPLICATION

Neuropathy and myopathy are often masked by

neurological or systemic condition
Different forms of neuropathy can be
distinguished by signs and symptoms at different
stage of HIV infection
Variety of pathogenesis can be involved (HIV,
toxic, immune, opportunistic infections)
 Distal symmetrical polineuropathy
Toxic neuropathy
Inflammatory Demyelinating Polineuropathy
Progressive polyradiculopathy
Mononeuropathy multiplex
 MYELOPATHY
myelopathy (spinal cord dysfunction) develop
slowly progressive painless gait disturbance,
lower extremity sensory complaints, and
sphincter abnormalities.
Neurologic signs include spastic paraparesis,
hyper-reflexia, extensor plantar responses, and
mild sensory impairment.
The most common cause of myelopathy in AIDS
is vacuolar myelopathy (40% of cases at
autopsy), other causes toxoplasmosis,
lymphoma, varicella zoster granulomatous
myelitis, herpetic necrotizing myelitis
 TERAPI INFEKSI OPORTUNISTIK

INFEKSI TERAPI
Kandidiasis esofagus Flukonazol
Tuberkulosis Rif, INH, Etam, PZA, Strep
MAC Klaritromisin, Etambutol,
Rifabutin Siprofloksasin
Toksoplasmosis Pirimetamin, Sulfadiazin,
Asam folat, Klindamisin
Sitomegalovirus Gansiklovir, foskarnet
Herpes simpleks/zooster Asiklovir
Kriptokokus meningeal Amfoterisin B, flukonasol,
Itrakonazol
PCP Kotrimoksazol
PRIMARY CNS
LYMPHOMA