NEUROLOGICAL COMPLICATIONS OF HIV INFECTION : ZIMBABWE 2005

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NEUROLOGICAL COMPLICATIONS OF HIV INFECTION
ZIMBABWE 2005
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Department of Medicine College of Health Sciences
,
Harare
Jens Mielke
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Epidemiology of HIV in Zimbabwe

• 2/3 of the people in the world living with HIV
  live in sub-Saharan Africa,
  
• 2 million people in Zimbabwe HIV
• 24.6 of adults 15-49 are HIV
• life expectancy in Zimbabwe
• 52 years in 1990 / 34 years in 2005.
• In 2003, 170 000 people in Zimbabwe died of AIDS.
  
  
• 66.6 of HIV-1-infected women were infected with
  subtype C, 48.3 with subtype A, and 33.3 with
  subtype B

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Healthcare resources

• the worlds slowest growing economy (-3.1
  growth in 2004)
  
• little public funding available for HIV care.
• For political reasons excluded from many US
  based funding programmes for roll-out
  
• antiretroviral drug rollout programmes are not
  yet treating significant numbers of patients
  

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Healthcare resources

• However urban and rural health care
  infrastructures in place
  
• Active collaborative HIV research prevention,
  treatment and complications
  
• High awareness at government and medical school
  of priorities
  
• 90 of hospital admissions in internal medical
  and paediatric services are HIV infected

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Status of Antiretrovirals

• In 2004 ARVs first offered in the public sector,
  in dedicated opportunistic disease clinics
  
• but the majority of recipients of ARVs are
  purchasing them privately and are receiving
  treatment from private sector
  
• In 2005, 6000 of the 290 000 people who need to
  be on treatment are receiving treatment

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Status of Antiretrovirals

• combination generic antiretroviral medications at
  lower cost have accelerated the use of ARVs
  considerably
  
• There are published national ARV use guidelines,
  
  
• the mainstay of therapy is a combination drug
  (stavudine, lamivudine and nevirapine).
  
• Protease inhibitors are included in second line
  therapy

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Epidemiology of HIV opportunistic diseases

• Little systematic review
• tuberculosis the commonest opportunistic disease
  by far
  
• 90 of tuberculosis cases are pulmonary, but
  extrapulmonary (pleural, lymph node, peritoneal,
  pericardial, ileal and meningeal) do occur more
  commonly than in non-HIV infected individuals

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Epidemiology of HIV opportunistic diseases

• Other opportunistic diseases probably present
  with roughly the same frequency as elsewhere,
  
• important exceptions
• Kaposis sarcoma (which is possibly commoner),
• cryptococcal meningitis (which is the commonest
  CNS opportunistic infection) and
  
• toxoplasmosis encephalitis (which is relatively
  uncommon).

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Epidemiology of Neurological Opportunistic
Infections

• Meningitis
• increased dramatically since the onset of the HIV
  pandemic
  
• outcome of meningitis is seriously altered by the
  presence of HIV infection, with in-hospital
  mortality exceeding 60 for patients with
  bacterial and tuberculous meningitis in Zimbabwe

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Epidemiology of Neurological Opportunistic
Infections

• Cryptococcal meningitis remains the commonest
  cause of adult meningitis
  
• 45 cryptococcus neoformans, 16 pyogenic (mainly
  streptococcus pneumoniae), 12 tuberculous, the
  remainder an unidentified mixed bag of
  mononuclear meningitis presumably viral and
  partially treated bacterial meningitis).

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Epidemiology of Neurological Opportunistic
Infections

• since 2003 fluconazole has been available in the
  public sector,
  
• 960 patients treated at one referral centre but
  very poor follow-up and re-prescription rate
  (on ARVs.
• Immune reconstitution syndromes are a serious
  complication of antiretroviral therapy.

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Epidemiology of Neurological Opportunistic
Infections

• Cryptoccocoma presenting as an intracranial mass
  lesion,
  
• cryptococcal myelitis presenting as an acute
  spinal cord syndrome
  
• cryptococcal meningitis in children all
  routinely seen
  
• Complications of cryptococcal meningitis seen
  include optic neuritis and other cranial
  mononeuropathies, cerebrovascular accident and
  hydrocephalus

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Intracranial mass lesions

• MRI scan since 1995
• stereotactic biopsy (and therefore frequently
  histological diagnosis) remains unavailable
  
• Polymerase chain reaction diagnosis for viral
  agents is not available.
  
• likely that toxoplasma encephalitis and
  tuberculoma are similar to published results from
  South Africa , (toxoplasmosis less common than
  tuberculoma as compared to opposite findings in
  the northern hemisphere).
• Bacterial abscesses and as a distant fourth
  primary CNS lymphoma make up the remainder

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Spinal cord disease

• acute presentation
• vertebral tuberculosis
• transverse myelitis (sometimes zoster)
• Spinal meningitis (TB, cryptococcal)
• Intraspinal (intramedullary or extradural)
  lymphoma
  
• Chronic / subacute
• progressive radiculopathy
• vacuolar myelopathy
• Syphilis not common (widespread penicillin use)

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Peripheral Neuropathy

• Distal symmetrical peripheral neuropathy
• drug induced neuropathy has become an important
  differential diagnosis
  
• Acute demyelinating (postinfectious) and chronic
  inflammatory demyelinating polyneuropathy
  
• Cranial neuropathies, (facial nerve palsy,
  isolated third or sixth nerve palsy, mononeuritis
  multiplex syndrome, peripheral mononeuropathies.)

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AIDS Dementia

• not systematically studied in Zimbabwe
• Anecdotal cases of AIDS dementia definitely exist
  
  
• Do patients survive long enough to become overtly
  demented ?

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Conclusion

• adverse economic and political circumstances in
  Zimbabwe seriously hamper efforts to counter the
  effects of the HIV pandemic
  
• opportunities for learning about the neurological
  manifestations of HIV and associated
  opportunistic diseases continue.
  
• co-existence of AIDS victims naïve to ARVs and
  treated groups,
  
• late presentations of opportunistic diseases,
• high prevalences of fungal and bacterial
  diseases