HIV dementia and HIV-related brain impairment (HRBI)

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HIV dementia andHIV-related brain impairment
(HRBI)

• Jeanette Meadway FRCP
• Consultant Physician
• Mildmay Hospital UK
• Hackney Road, London E2 7NA

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What is HIV dementia?

• An AIDS-defining illness with WHO definition
  (ICD10)
• Objectively defined decline in recent memory
• Evidence of HIV infection
• Exclusion of opportunistic infections, tumours or
  other brain disorders
• Absence of acute brain syndrome (delirium)

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HIV dementia - cause

• HIV affecting the brain
• No HIV in nerve cells (neurons)
• HIV in macrophages and glial cells
• Damage due to increased cytokines?
• Damage due to toxic effects of HIV envelope
  protein gp120?
• Damage leads to cell apoptosis (cell death) and
  structural changes

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Diagnosis of HIV dementia

• Function cognitive impairment, motor
  dysfunction, behavioural changes
• HIV disease usually advanced with low CD4
  (lt200), high viral load, no ARV treatment or
  inadequate ARVs despite deterioration
• CT and MRI scans show brain shrinkage and white
  matter changes

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MRI changes

• Brain shrinkage rim of CSF inside skull,
  flattened gyri
• White matter changes, most likely to affect
  frontal lobes as in this scan
• (contrast medium in ventricles)

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What is HIV-related brain impairment?

• Not a diagnosis, an assessment of function which
  is useful for rehabilitation
• Cognitive dysfunction (- behaviour change and
  motor dysfunction) due to HIV-related pathology
• Includes HIV-related illnesses causing cognitive
  impairment
• Does not include unrelated brain impairment in an
  HIVve person eg due to alcohol
• The same diagnoses are not included in HRBI if
  there is no cognitive dysfunction

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Why this definition of HRBI?

• The conditions which lead to behavioural
  problems, cognitive impairment and motor problems
  in the context of advanced HIV offer the same
  challenge for rehabilitation
• All are likely to benefit from supervised
  adherence to ARVs, multidisciplinary approach to
  social skills and other rehabilitation

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HRBI diagnoses

• HIV dementia
• PML (progressive multifocal leukoencephalopathy)
  due to JC virus
• Cerebral toxoplasmosis
• Herpes simplex virus encephalopathy
• Cryptococcal meningitis
• Cerebral lymphoma
• other infections eg TB meningitis

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Cerebral toxoplasmosis

• When CD4 low toxoplasma causes a cerebral abscess
• When contrast is injected, there is high uptake
  around the abscess a ring-enhancing lesion
• Toxoplasma may cause cognitive impairment

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Cryptococcal Meningitis

• Cryptococcal meningitis is more insidious than
  bacterial meningitis
• Varied neurological changes occur eg cognitive
  impairment

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PML

• Progressive without treatment deteriorating
  neurology and death
• Multifocal affects separate parts of the brain,
  as seen with 3 in this scan
• Leuko affects white matter

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HRBI rehab at Mildmay

• Patients accidentally rehabbed at first
• Those improving had full effective ARVs and full
  multidisciplinary team involvement
• Emphasis on self-medication programme, relearning
  social skills and skills to allow independent
  activity
• Some patients return to live independently
• Behavioural improvements allow more appropriate
  placements for most patients

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A new type of dementia

• A patient restarted on ARVs later deteriorated
  and died despite fully controlled viral load and
  good CD4
• PM showed no HIV in brain, no other infections or
  tumours, and vacuolated cells
• This may be immune reconstitution syndrome
• Occurs only in a minority of patients

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Summary - HRBI

• Cognitive - behavioural and motor impairment due
  to HIV disease
• Occurs only in advanced HIV
• Most improve with full regular ARVs
• Improvement with rehab team input
• Rehab allows easier placement and improved
  quality of life
• Deterioration on ARVs is uncommon

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