Acquired immunodeficiency syndrome (AIDS)

A condition in humans in which progressive failure of the immune system allows life-threatening opportunistic infections and cancers to thrive.

The most common conditions producing focal CNS lesions in AIDS: ¹⁾

1. CNS Toxoplasmosis in AIDS

2. Primary central nervous system lymphoma in AIDS

3. Progressive multifocal leukoencephalopathy (PML)

4. Cryptococcal abscess

5. TB (Tuberculoma).

Neurologic complications are common in patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Although both the central nervous system (CNS) and the peripheral nervous system can be affected, 80% of patients with HIV/AIDS have CNS involvement during the course of their illness. The brain is the primary site of HIV/AIDS-associated CNS complications. Spinal cord involvement is rare, particularly focal intramedullary spinal cord lesions without any associated cerebral lesions. Among various opportunistic infections and malignancies, toxoplasmosis and CNS lymphoma are the most common causes of focal neurologic disease in patients with HIV/AIDS. Distinguishing between toxoplasmosis and CNS lymphoma is challenging, as the diseases have similar clinical presentations.

40–60% of all patients with acquired immunodeficiency syndrome (AIDS) will develop neurologic symptoms, with one–third of these presenting initially with their neurologic complaint ²⁾ ³⁾ Only ≈ 5% of patients that die with AIDS have a normal brain on autopsy.

⁴⁾

Aside from opportunistic infection and tumors caused by the immunodeficient state, infection with the Human Immunodeficiency Virus (HIV) itself can cause direct neurologic involvement including:

1. AIDS encephalopathy: the most common neurologic involvement, occurs in ≈ 66% of patients with AIDS involving the CNS

2. AIDS dementia AKA HIV dementia complex

3. aseptic meningitis

4. cranial neuropathies: including “Bell’s palsy” (occasionally bilateral)

5. AIDS-related myelopathy: vacuolization of spinal cord; see Myelopathy

6. peripheral neuropathies

Although the number of patients with AIDS who require brain biopsy has decreased, the procedure still has merits. The paradigm we developed was useful for selecting patients for early biopsy. Patients with AIDS who also have intracerebral lesions should have toxoplasmosis titers performed, and those whose titers are negative for toxoplasmosis should undergo early brain biopsy ⁵⁾.

Cryptococcosis is a fungal infection caused by Cryptococcus spp. that enters the body via inhalation, which mainly invades the lungs and central nervous system.

Patients with CNS toxoplasmosis have a median survival of 446 days, which is similar to that with PML but longer than AIDS-related PCNSL ⁶⁾.

Patients with CNS lymphoma in AIDS survive on average a shorter time than similarly treated CNS lymphoma in nonimmunosuppressed patients (3 months vs. 13.5 mos). Median survival is < 1 month with no treatment. CNS lymphoma in AIDS tends to occur late in the disease, and patients often die of unrelated causes (e.g. Pneumocystis carinii pneumonia) ⁷⁾.

The human immunodeficiency virus (HIV) is a lentivirus (a subgroup of retrovirus) that causes the acquired immunodeficiency syndrome (AIDS).

125I-fibrinogen: radiolabeled fibrinogen is incorporated into the developing thrombus. Better for calf Deep-vein thrombosis than proximal Deep-vein thrombosis. Expensive, and many false positives. The risk of HIV transmission has resulted in the withdrawal of use.

Acquired immunodeficiency syndrome treatment.

Human immunodeficiency virus-associated vasculopathy.

Epstein-Barr virus-associated smooth muscle tumour (EBV-SMT) is a rare disease occurring in immunosuppressed patients, such as those with AIDS, post-transplantation immunodeficiency and congenital immunodeficiency.

Valve vegetation is one of the most fearful findings for physicians. The first diagnosis that comes to their mind is infective endocarditis (IE), but it can also be noninfective; nonbacterial thrombotic endocarditis (NBTE). NBTE can be even more challenging than IE for physicians because of the wide range of differential diagnoses such as malignancies, autoimmune disorders and human immunodeficiency virus ⁸⁾.

Specific comorbidities and tobacco use were implicated in frailty, suggesting that it is comorbidities causing frailty. However, some frailty still appears to be HIV-related. The higher prevalence of cognitive and emotional frailty highlights the fact that physical frailty should not be the only focus in HIV ⁹⁾

Neurocognitive decline was uncommon in a sample of aviremic HIV+ individuals. The 3-year risk of decline ranged from 2% in those with no risk factors to 95% in those with all.

The strongest predictor was glomerular filtration rate, also a predictor of cardiovascular disease. This raises the possibility that controlling vascular risk factors could reduce the risk of neurocognitive decline ¹⁰⁾

Without treatment, average survival time after infection with HIV is estimated to be 9 to 11 years, depending on the HIV subtype.

Infection with HIV occurs by the transfer of blood, semen, vaginal fluid, pre-ejaculate, or breast milk. Within these bodily fluids, HIV is present as both free virus particles and virus within infected immune cells.

Antiretroviral therapy (ART) has converted human immunodeficiency virus (HIV) infection into a chronic condition, and patients now undergo a variety of surgical procedures, but current surgical outcomes are inadequately characterized.

The most common procedures in a retrospective study related with neurosurgery was spine surgery (9.8%).

Current postoperative mortality rates among individuals with HIV infection who are receiving Antiretroviral therapy (ART) are low and are influenced as much by hypoalbuminemia and age as by CD4 cell status. Human immunodeficiency virus infection and CD4 cell count are only 2 of many factors associated with surgical outcomes that should be incorporated into surgical decision making ¹¹⁾.

Early brain biopsy may be indicated in HIV patients with focal brain lesion.

A study aimed to evaluate and compare the safety and diagnostic value of brain biopsy in HIV patients in the pre-highly active antiretroviral therapy (HAART) versus post-HAART era via meta-analysis. Appropriate studies were identified per search criteria. The local database was retrospectively reviewed to select a similar patient cohort. Patient demographics, brain biopsy technique, histopathology and patient outcomes were extracted from each study. Study-specific outcomes were combined per random-effects model. Outcomes were compared between the pre-HAART and post-HAART era. Correlations between outcomes and baseline characteristics were assessed via meta-regression analysis. The proportions of histopathological diagnosis were tabulated and compared between the pre- and post-HAART era. Survival analysis was performed for patients in the post-HAART era. A total of 26 studies (including the local database) with 1209 patients were included in this meta-analysis. The most common indications for brain biopsy were diagnosis unlikely to be toxoplasmosis, focal brain lesion or both.

The weighted proportions for diagnostic success were 92%, change in management 57.7% and clinical improvement 36.6% (. Morbidity and mortality were 5.7% and 0.9%, respectively. Diagnostic success rate was significantly higher in the post-HAART than the pre-HAART era (97.5% vs 91.9%, p=0.047). The odds ratio (OR) for diagnostic success in patients with contrast-enhanced lesions was 2.54 (1.25 to 5.15), p<0.01). The median survival for HIV patients who underwent biopsy in the post-HAART era was 225 days (90-2446). Brain biopsy in HIV patients is safe with high diagnostic yield. Early brain biopsy should be considered in patients without classic presentation of toxoplasmosis encephalitis ¹²⁾.

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384: Anson JA, Glick RP, Reyes M. Diagnostic accuracy of AIDS-related CNS lesions. Surg Neurol. 1992 Jun;37(6):432-40. PubMed PMID: 1595048.

385: Levy RM, Berger JR. Neurosurgical aspects of human immunodeficiency virus infection. Neurosurg Clin N Am. 1992 Apr;3(2):443-70. Review. PubMed PMID: 1633470.

386: Scaravilli F. Neuropathology of HIV-1 and HTLV-1 infection. Baillieres Clin Neurol. 1992 Apr;1(1):211-38. Review. PubMed PMID: 1344650.

387: Levy RM, Russell E, Yungbluth M, Hidvegi DF, Brody BA, Dal Canto MC. The efficacy of image-guided stereotactic brain biopsy in neurologically symptomatic acquired immunodeficiency syndrome patients. Neurosurgery. 1992 Feb;30(2):186-9; discussion 189-90. PubMed PMID: 1545885.

388: Tenhula WN, Xu SZ, Madigan MC, Heller K, Freeman WR, Sadun AA. Morphometric comparisons of optic nerve axon loss in acquired immunodeficiency syndrome. Am J Ophthalmol. 1992 Jan 15;113(1):14-20. PubMed PMID: 1370189.

389: Sharief MK, Ciardi M, Noori MA, Thompson EJ, Salotti A, Sorice F, Rossi F, Cirelli A. Free circulating ICAM-1 in serum and cerebrospinal fluid of HIV-1 infected patients correlate with TNF-alpha and blood-brain barrier damage. Mediators Inflamm. 1992;1(5):323-8. PubMed PMID: 18475479; PubMed Central PMCID: PMC2365354.

390: Sharief MK, Ciardi M, Thompson EJ, Sorice F, Rossi F, Vullo V, Cirelli A. Tumour necrosis factor-alpha mediates blood-brain barrier damage in HIV-1 infection of the central nervous system. Mediators Inflamm. 1992;1(3):191-6. PubMed PMID: 18475460; PubMed Central PMCID: PMC2365337.

391: Ball PA, Marchand EP, Benzel EC, Willis BK. Stereotactic biopsy in AIDS patients. Br J Neurosurg. 1992;6(5):505-6. PubMed PMID: 1449677.

392: Carpenter S, Karpati G. The pathological diagnosis of specific inflammatory myopathies. Brain Pathol. 1992 Jan;2(1):13-9. Review. PubMed PMID: 1341942.

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394: Cornford ME, Ho HW, Vinters HV. Correlation of neuromuscular pathology in acquired immune deficiency syndrome patients with cytomegalovirus infection and zidovudine treatment. Acta Neuropathol. 1992;84(5):516-29. PubMed PMID: 1334328.

395: Batman PA, Miller AR, Sedgwick PM, Griffin GE. Autonomic denervation in jejunal mucosa of homosexual men infected with HIV. AIDS. 1991 Oct;5(10):1247-52. PubMed PMID: 1786151.

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397: Poppi M, Staffa G, Martinelli P, Fabrizi AP, Giuliani G. Neuropathy caused by spontaneous intraneural hemorrhage: case report. Neurosurgery. 1991 Feb;28(2):292-5. PubMed PMID: 1847740.

398: Levy RM, Breit R, Russell E, Dal Canto MC. MRI-guided stereotaxic brain biopsy in neurologically symptomatic AIDS patients. J Acquir Immune Defic Syndr. 1991;4(3):254-60. PubMed PMID: 1992103.

399: Strigle SM, Gal AA. Review of the central nervous system cytopathology in human immunodeficiency virus infection. Diagn Cytopathol. 1991;7(4):387-401. Review. PubMed PMID: 1935518.

400: Pell MF, Thomas DG, Whittle IR. Stereotactic biopsy of cerebral lesions in patients with AIDS. Br J Neurosurg. 1991;5(6):585-9. PubMed PMID: 1772604.

401: Takasu A, Taneda M, Otuki H, Okamoto Y, Oku K. Gd-DTPA-enhanced MR imaging of cryptococcal meningoencephalitis. Neuroradiology. 1991;33(5):443-6. PubMed PMID: 1749478.

402: Zimmer C, Daeschlein G, Patt S, Weigel K. Strategy for diagnosis of Toxoplasma gondii in stereotactic brain biopsies. Stereotact Funct Neurosurg. 1991;56(1):66-75. PubMed PMID: 1719595.

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406: Schiff SJ. A surgeon's risk of AIDS. J Neurosurg. 1990 Nov;73(5):651-60. Review. PubMed PMID: 2213154.

407: Nitta T, Yagita H, Okumura K, Sato K. [Analysis of receptor expression on astrocytic cells]. No To Shinkei. 1990 Oct;42(10):945-50. Japanese. PubMed PMID: 1705127.

408: Montgomery H, Adam A, Dollery CT, Weber J, Volberding P, Griffin B, Scaravilli F. Cerebral mass lesions in patients with AIDS. BMJ. 1990 Jul 28;301(6745):226-8. PubMed PMID: 2203488; PubMed Central PMCID: PMC1663569.

409: Levin HS, Williams DH, Borucki MJ, Hillman GR, Williams JB, Guinto FC Jr, Amparo EG, Crow WN, Pollard RB. Magnetic resonance imaging and neuropsychological findings in human immunodeficiency virus infection. J Acquir Immune Defic Syndr. 1990;3(8):757-62. PubMed PMID: 2366146.

410: Koppel BS, Daras M, Duffy KR. Intramedullary spinal cord abscess. Neurosurgery. 1990 Jan;26(1):145-6. PubMed PMID: 2294468.

411: Chaudhari AB, Singh A, Jindal S, Poon TP. Haemorrhage in cerebral toxoplasmosis. A report on a patient with the acquired immunodeficiency syndrome. S Afr Med J. 1989 Sep 16;76(6):272-4. PubMed PMID: 2781426.

412: Tracey KJ, Cerami A. Cachectin/tumor necrosis factor and other cytokines in infectious disease. Curr Opin Immunol. 1989 Feb;1(3):454-61. Review. PubMed PMID: 2679705.

413: Younger DS, Chou S, Hays AP, Lange DJ, Emerson R, Brin M, Thompson H Jr, Rowland LP. Primary lateral sclerosis. A clinical diagnosis reemerges. Arch Neurol. 1988 Dec;45(12):1304-7. PubMed PMID: 3196189.

414: Namiki TS, Nichols P, Young T, Martin SE, Chandrasoma P. Stereotaxic biopsy diagnosis of central nervous system lymphoma. Am J Clin Pathol. 1988 Jul;90(1):40-5. PubMed PMID: 2968762.

415: Gasnault J, Roux FX, Vedrenne C. Cerebral astrocytoma in association with HIV infection. J Neurol Neurosurg Psychiatry. 1988 Mar;51(3):422-4. PubMed PMID: 3361334; PubMed Central PMCID: PMC1032871.

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420: Richards P. AIDS and the neurosurgeon. Br J Neurosurg. 1987;1(2):163-71. PubMed PMID: 3267284.

421: Snow RB, Lavyne MH. Intracranial space-occupying lesions in acquired immune deficiency syndrome patients. Neurosurgery. 1985 Feb;16(2):148-53. PubMed PMID: 3974825.

422: Hilfenhaus J, Weidmann E. Fibrin glue safety: inactivation of potential viral contaminants by pasteurization of the human plasma components. Arzneimittelforschung. 1985;35(11):1617-9. PubMed PMID: 3004516.

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Acquired immunodeficiency syndrome case reports

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Ciricillo SF, Rosenblum ML. Use of CT and MR Imaging to Distinguish Intracranial Lesions and to Define the Need for Biopsy in AIDS Patients. J Neurosurg. 1990; 73:720–724

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Levy RM, Bredesen DE, Rosenblum ML. Neurological manifestations of the acquired immunodeficiency syndrome (AIDS): Experience at UCSF and review of the literature. J Neurosurg. 1985; 62: 475–495

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Simpson DM, Tagliati M. Neurologic Manifestations of HIV Infection. Ann Intern Med. 1994; 121: 769–785

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Levy RM, Bredesen DE, Rosenblum ML. Neurological manifestations of the acquired immunodeficiency syndrome (AIDS): Experience at UCSF and review of the literature. J Neurosurg. 1985; 62: 475–495

⁵⁾

Rosenow JM, Hirschfeld A. Utility of brain biopsy in patients with acquired immunodeficiency syndrome before and after introduction of highly active antiretroviral therapy. Neurosurgery. 2007 Jul;61(1):130-40; discussion 140-1. PubMed PMID: 17621028.

⁶⁾

Sadler M, Brink NS, Gazzard BG. Management of Intracerebral Lesions in Patients with HIV: A Retrospective Study with Discussion of Diagnostic Problems. Q J Med. 1998; 91:205–217

⁷⁾

Chappell ET, Guthrie BL, Orenstein J. The Role of Stereotactic Biopsy in the Management of HIVRelated Focal Brain Lesions. Neurosurgery. 1992; 30:825–829

⁸⁾

Hashimoto T, Aoki T, Kawabata Y, Owai Y, Matsuda Y, Tamura S. Nonbacterial Thrombotic Endocarditis Associated with Acute Promyelocytic Leukemia: An Autopsy Case Report. Medicina (Kaunas). 2021 Nov 18;57(11):1264. doi: 10.3390/medicina57111264. PMID: 34833482; PMCID: PMC8625368.

⁹⁾

Inceer M, Brouillette MJ, Fellows LK, Morais JA, Harris M, Smaill F, Smith G, Thomas R, Mayo NE. Factors partitioning physical frailty in people aging with HIV: A classification and regression tree approach. HIV Med. 2022 Feb 1. doi: 10.1111/hiv.13236. Epub ahead of print. PMID: 35106895.

¹⁰⁾

Yuen T, Brouillette MJ, Fellows LK, Ellis RJ, Letendre S, Heaton R, Mayo N; CHARTER group,. Personalized Risk Index for Neurocognitive Decline Among People With Well-Controlled HIV Infection. J Acquir Immune Defic Syndr. 2017 Sep 1;76(1):48-54. doi: 10.1097/QAI.0000000000001466. PubMed PMID: 28797021.

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King JT Jr, Perkal MF, Rosenthal RA, Gordon AJ, Crystal S, Rodriguez-Barradas MC, Butt AA, Gibert CL, Rimland D, Simberkoff MS, Justice AC. Thirty-Day Postoperative Mortality Among Individuals With HIV Infection Receiving Antiretroviral Therapy and Procedure-Matched, Uninfected Comparators. JAMA Surg. 2015 Feb 25. doi: 10.1001/jamasurg.2014.2257. [Epub ahead of print] PubMed PMID: 25714794.

¹²⁾

Lee AM, Bai HX, Zou Y, Qiu D, Zhou J, Martinez-Lage Alvarez M, Zhang P, Tao Y, Tang X, Xiao B, Yang L. Safety and diagnostic value of brain biopsy in HIV patients: a case series and meta-analysis of 1209 patients. J Neurol Neurosurg Psychiatry. 2016 Jan 12. pii: jnnp-2015-312037. doi: 10.1136/jnnp-2015-312037. [Epub ahead of print] Review. PubMed PMID: 26758989.

Acquired immunodeficiency syndrome (AIDS)

Complications

Primary effects of HIV infection

Outcome

Risk Factors

Treatment

Complications

Outcome

Unsorted

Case reports

References

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