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Old 03-22-2012
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Neuro Motor and Cognitive Deterioration in HIV patient!

A 35-year-old HIV-positive man comes to medical attention with a 6-month history of progressive memory loss and incontinence. He is taking zidovudine and a protease inhibitor. He first noticed difficulties with handwriting. Neurologic examination demonstrates deficits in cognitive and fine motor control functions. Laboratory investigations show a CD4 cell count of 25/mm3. MRI studies reveal moderate brain atrophy but no focal lesions. A lumbar puncture shows no CSF abnormalities. Which of the following is the most likely diagnosis?

a) CMV encephalitis
b) Cryptococcal meningoencephalitis
c) HIV encephalitis
d) HIV myelopathy
e) Primary brain lymphoma
f) Progressive multifocal leukoencephalopathy
g) Toxoplasmosis
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E) Primary brain lymphoma
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Doesnt a Lymphoma show up on MRI?
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c. HIV encephalitis
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The answer is C) HIV encephalitis, clinically known as AIDS dementia complex. It is a subacute inflammatory infiltration of the brain caused by direct spread of HIV to the CNS. Presence of the HIV genome can be demonstrated by in situ hybridization in microglia and histiocytes. The diagnosis of HIV encephalitis (or AIDS dementia complex) must be reached by exclusion of other infective and neoplastic conditions associated with AIDS as its shown in the question stem - MRI & Lumbar puncture. AIDS dementia complex is characterized by cognitive impairment, incontinence, impairment of motor skills, and confusion.
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The correct answer is C. AIDS may lead to various complications affecting the CNS. Among these, HIV encephalitis, clinically known as AIDS dementia complex, is the most common. The pathologic substrate is a subacute inflammatory infiltration of the brain caused by direct spread of HIV to the CNS. Presence of the HIV genome can be demonstrated by in situ hybridization in microglia and histiocytes. The diagnosis of HIV encephalitis (or AIDS dementia complex) must be reached by exclusion of other infective and neoplastic conditions associated with AIDS. AIDS dementia complex is characterized by cognitive impairment, incontinence, impairment of motor skills, and confusion. MRI studies and CSF analysis are useful in excluding other CNS diseases (see below).

CMV encephalitis (choice A) usually affects the periventricular regions of the brain and the retina. CMV encephalitis is usually associated with disseminated infection. CMV can be isolated in the CS
F. MRI may also demonstrate periventricular white matter abnormalities.

Cryptococcal meningoencephalitis (choice B) is an acute life-threatening disease manifesting with signs and symptoms of increased intracranial pressure and fever. The CSF would show numerous cryptococcal organisms.

HIV myelopathy (choice D) manifests mainly with spastic paraparesis. It is a complication similar in pathologic substrate to vitamin B12 deficiency, i.e., vacuolar degeneration of the posterior and lateral columns of the spinal cord. Its pathogenesis is still unclear, but a direct viral effect is suspected.

Primary brain lymphoma (choice E) is a frequent manifestation of AIDS. The MRI would show a ring-enhancing mass, which is not the typical radiologic presentation of brain lymphomas in immunocompetent hosts.

Progressive multifocal leukoencephalopathy (choice F) consists of multifocal areas of myelin destruction. These changes would be visible on MRI. This complication is due to JC virus, a papovavirus that causes asymptomatic infections in immunocompetent individuals.

Toxoplasmosis (choice G) manifests on MRI in a manner similar to lymphoma, i.e., a ring-enhancing mass. This opportunistic infection is extremely frequent in AIDS patients.
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