Neurological complications of acquired immune deficiency syndrome: analysis of 50 patients

Early HIV-related neuropsychological impairment: relationship to stage of viral infection

Sixty male outpatients with no past neuropsychiatric history were examined for evidence of early HIV-related neuropsychological impairment. Significant cognitive deficit, as measured by the RAVLT and WAIS-R Digit Symbol Substitution tests, and moderate correlation with indices of immune function, were observed in a group of patients with AIDS-Related Complex [ARC]. Patients with asymptomatic HIV-infection demonstrated no significant differences in performance compared to a group of HIV-seronegative controls. No significant group differences in age, education, predicted-IQ or self-rated depression and anxiety were observed. These results support the hypothesis that HIV-related cognitive disturbance occurs within the context of immunosuppression.

Spontaneous subarachnoid hemorrhage in an HIV patient

In an HIV-seropositive patient presenting generalized tonic-clonic seizures, magnetic resonance imaging and cerebrospinal fluid examination disclosed the signs of a previous subarachnoid bleed. No vascular malformation was observed with cerebral angiography. Laboratory tests revealed an autoimmune thrombocytopenia. A spontaneous subarachnoid hemorrhage induced by thrombocytopenia should be considered when investigating HIV patients presenting even non-specific neurological symptoms.

Monocyte-mediated entry of pathogens into the central nervous system

The origin of the microglia has long been a subject of debate. However it is now clear that monocytes enter the normal central nervous system and follow a series of morphological transformations as they differentiate into microglia. Thus, microglia are of monocytic origin. Since monocytes migrate into the normal CNS, they represent potential vehicles for the entry of pathogens into the nervous system and indeed may carry particulate matter into the CNS. Both viruses and bacteria use this 'Trojan horse' mechanism of entry in the pathogenesis of CNS disease.

Brain imaging in acquired immunodeficiency syndrome dementia complex

Human immunodeficiency virus (HIV) infections are accompanied by many different types of neurological complications. Opportunistic infections and neoplasms, particularly lymphoma, are often an underlying cause for these complications in patients with acquired immunodeficiency syndrome (AIDS). Frequently, these can be detected by cerebrospinal fluid (CSF) examination, double-dose contrast transmission computed tomography (CT), and/or magnetic resonance imaging (MRI). It has become apparent that the HIV itself is responsible for a significant percentage of neurological disease in the HIV-seropositive individual. The onset may be subtle and may occur before the onset of frank immunosuppression. Diagnosis of HIV encephalitis or AIDS dementia complex (ADC) is complicated by the frequent coexistence of opportunistic infections. Structural neuroimaging (CT or MRI) shows atrophy and in some case white matter abnormalities, but imaging-pathological correlation suggests that these modalities are relatively insensitive to the presence of HIV brain infection. Functional neuroimaging, both 18fluorodeoxyglucose positron emission tomography (PET) for evaluation of glucose metabolism and 123I iodoamphetamine or 99mTc-HMPAO single-photon emission computed tomography (SPECT) for evaluation of cerebral perfusion, can demonstrate abnormalities in the subcortical gray matter structures and the cerebral cortex in patients with ADC. These abnormalities may be observed early in the course of ADC even when MRI is negative and the patient is relatively asymptomatic. Also, PET and SPECT may be useful to follow progression of the dementia or response to therapy.

[Psychiatric morbidity in patients hospitalized for AIDS: experiences in a Quebec hospital]

Neuropsychiatric complications in AIDS patients are common and have been reported in many recent articles. The author reviewed the medical charts of 80 patients admitted for AIDS between April 1984 and April 1988 to determine the frequency and nature of psychiatric complications in these patients and to compare these with recent reports made by other authors. The most frequent complications requiring psychiatric intervention seem to be organic mental disorders and adjustment disorders. Practical conclusions are drawn.

Clinical Utility of cranial CT in HIV positive and AIDS patients with neurological disease

An analysis was made of the clinical, pathological and radiological data relating to 117 requests for cranial CT on 83 patients who were HIV positive or had AIDS in one year at St Mary's Hospital. Central to the design was grouping of the patients according to clinical presentation. The aim was to establish whether there was evidence to support the view that, because of their immunocompromised state, these patients may commonly harbour serious, potentially treatable intracranial disease without the usual overt clinical signs. No patient who was only HIV antibody positive had treatable intracranial disease without focal neurological signs. In patients with AIDS, treatable or potentially treatable lesions were mainly confined to those with objective neurological signs or seizures. There is little evidence in this data to support the original hypothesis. While it would be inappropriate to advise that CT should never be carried out in the absence of focal signs or seizures, the results of this study should be useful in ascribing an appropriate degree of urgency to requests for cranial CT in these patients.

Abnormalities in cholesterol metabolism cause peripheral neuropathy and dementia in AIDS--a hypothesis

The AIDS dementia complex and peripheral neuropathy in AIDS are considered to be direct or indirect manifestations of HIV infection, yet the pathogenesis in unclear. There are parallels between AIDS and Tangier disease clinically and histopathologically and in lipid metabolism. The neurological disorders in AIDS may be caused by dysfunction of cellular cholesterol transport. Substitution of high density lipoprotein is recommended in the treatment of severe polyneuropathy and dementia in AIDS.

Stroke in pediatric acquired immunodeficiency syndrome

In a 4 1/2-year period, 4 of 68 children in a longitudinal study of neurological complications of human immunodeficiency virus (HIV) infection had clinical and/or neuroradiological evidence of stroke, yielding a clinical incidence of stroke in this population of 1.3% per year. During this period, 32 subjects died, and permission for autopsy was granted in 18 of the patients, including 3 of 4 who had clinical evidence of stroke. The prevalence of cerebrovascular pathological features in our consecutive autopsy series was higher than the clinical incidence. At autopsy cerebrovascular disease was documented in 6 (24%) of 25 children with HIV infection, including all 3 children who had clinical evidence of stroke. Four patients had intracerebral hemorrhages, 6 patients had nonhemorrhagic infarcts, and 3 had both. Hemorrhage was catastrophic in 1 child and clinically silent in 3 children, all of whom had immune thrombocytopenia. One child had an arteriopathy that affected meningocerebral arteries. In another child, the arteries of the circle of Willis were aneurysmally dilated. Two children had coexisting cardiomyopathy and subacute necrotizing encephalomyelopathy with vascular proliferation. These results suggest that stroke should be considered when children with HIV infection develop focal neurological signs.

Psychiatric aspects of HIV-1 infection and AIDS

The literature on the psychiatric aspects of HIV-1 infection is reviewed. The whole range of psychiatric disorders described in HIV-1 infected subjects, from HIV-1 dementia to adjustment disorders, is covered, along with the AIDS-related psychopathology which may develop in subjects without HIV-1 infection.

Vesicular changes in the myopathies of AIDS. Ultrastructural observations and their relationship to zidovudine treatment

Six patients with AIDS and AIDS related complex (ARC) who developed neuromuscular symptoms associated with vesicular changes in muscle fibres are reported. Two patients in the advanced stages of AIDS, who did not receive zidovudine, developed proximal limb weakness and wasting: both had a necrotising myopathy with an unusual segmental vesicular change of myofibres. There were numerous vesicles 0.1 to 2 microns in diameter produced by dilatations of the sarcoplasmic reticulum in fibres depleted of myofibrils. Four patients developed a myopathy while receiving zidovudine for AIDS. One of these had an inflammatory myopathy which showed the development of vesicular change due to enlargement and electron lucency of mitochondria. The three other patients with ARC developed muscle pains or weakness and elevated serum CK while on zidovudine. These patients also showed vesicular changes due to enlargement and electron lucency of mitochondria associated with disruption of sarcomeres and the presence of cytoplasmic bodies. The muscular symptoms resolved when ziduvodine was stopped and repeat biopsy in one case revealed no abnormalities.

Specific infection of central nervous system white matter by a variant of gross murine leukemia virus

Exposure of neonatal Balb.B mice to a variant of Gross murine leukemia virus, termed WB91-GV, resulted in selective white matter infection within the central nervous system. Viral antigens were detected in brain sections of animals inoculated by either intracerebral or intraperitoneal routes, but were only seen in mice exposed within the first day after birth. This distinct tropism was confirmed by virus replication and gp70 expression in isolated glial cultures in vitro. Analysis of gp70 expression in highly enriched glial subpopulations indicated that oligodendrocytes and perhaps a subset of astrocytes were the targets of this infection.

Soluble interleukin-2 receptor and soluble CD8 in serum and cerebrospinal fluid during human immunodeficiency virus-associated neurologic disease

We have measured levels of soluble interleukin-2 receptor (sIL-2R) and soluble CD8 (sCD8) in serum and cerebrospinal fluid (CSF) of 127 human immunodeficiency virus (HIV)-seropositive and 51 HIV-seronegative individuals. Serum levels of sIL-2R and sCD8 were higher in HIV+ than in HIV- individuals. HIV+ individuals were grouped by neurological status: asymptomatic, abnormal on neuropsychological screening, HIV-related meningitis, inflammatory demyelinating polyneuropathy, opportunistic central nervous system (CNS) infections and HIV-related dementia, myelopathy or sensory neuropathy. Serum levels of sIL-2R and sCD8 were higher in all HIV+ categories compared to HIV- individuals. Patients with HIV-related meningitis had higher levels of sIL-2R and sCD8 than asymptomatic HIV+ individuals, and inflammatory polyneuropathy patients had higher levels of sCD8. CSF levels of sCD8 were higher in all categories of HIV+ than in HIV- individuals. Patients with HIV-related meningitis, inflammatory neuropathy and opportunistic infections had higher levels than asymptomatic individuals. Examination of the time course showed that serum and CSF levels of sIL-2R and sCD8 increased to very high levels during acute HIV infections. Serum levels then declined over several months to relatively stable elevated levels. By 1-2 years after HIV infection sIL-2R was relatively low in CSF, while sCD8 remained elevated with a gradual decrease over the subsequent years of follow-up.

Computer-analyzed EEG (CEEG) and dynamic brain mapping in AIDS and HIV related syndrome: a pilot study

In a group of HIV positive young male patients without any significant neuropsychiatric signs, computer-analyzed EEG (CEEG) and Dynamic Brain Mapping evaluations were conducted. These patients, who only had micro-neuropsychiatric symptoms, demonstrated CEEG profiles that more closely resemble those of patients diagnosed as suffering from mild dementia than age-related normals from our CEEG data base. The CEEGs of patients diagnosed as having Acquired Immune Deficiency Syndrome (AIDS), compared to patients with HIV positive, showed greater similarity in CEEG patterns to severely demented patients than to normal control groups. The findings of this pilot study suggest that CEEG may be useful for early determination of the Central Nervous System's (CNS) involvement with the AIDS virus and monitoring the progress of the illness.

Electroencephalogram and HIV infection: a prospective study in 100 patients

In order to study the correlation between central nervous system (CNS) involvement and EEG abnormalities in HIV infection we studied 100 consecutive HIV patients. Patients were divided into 4 groups; Group I: 42 neurologically asymptomatic subjects; Group II: 6 patients with peripheral neuropathies; Group III: 28 patients with AIDS Dementia Complex; Group IV: 24 patients with secondary CNS involvement. The results of this study emphasize that abnormal EEGs are correlated with CNS involvement. Neurologically asymptomatic patients showed no abnormal tracings, but the presence of borderline EEGs (33%) in asymptomatic patients should be evaluated prospectively.

Muscle biopsy in AIDS and ARC: analysis of 50 patients

We report a large spectrum of histological muscle abnormalities in 50 homosexual men with AIDS and ARC. We encountered moth-eaten fibers in 76%, angulated fibers in 76%, type groupings in 62%, type 2 fiber atrophy in 58%, mononuclear endomysial and/or perimysial and/or perivascular infiltrates in 36%, necrosis and phagocytosis in 30% and target fibers in 6%. Two patients showed vasculitis and two others showed perifascicular atrophy. On the whole, 96% of the biopsies showed substantial abnormalities. Muscle involvement in AIDS seems more common than previously suspected.

Neurologic disorders associated with HIV infections

At least 60% of patients infected with the human immunodeficiency virus (HIV) develop neurologic disorders. These may be the direct result of human immunodeficiency virus (HIV) infection, opportunistic infections, neoplastic disorders, or cerebrovascular complications. Neurologic diseases associated with HIV infection include encephalopathy, aseptic meningitis, vacuolar myelopathy, peripheral neuropathy, and myopathy. The pathogenesis of these diseases is not known, but it is likely that they will differ. There is evidence that HIV is the etiologic agent of HIV-associated meningitis and subacute encephalitis, but to date there is little evidence to implicate HIV directly as the cause of vacuolar myelopathy, peripheral neuropathies, and myopathies. The results of preliminary clinical studies suggest that treatment with zidovudine (Retrovir) may cause improvement in some patients.

Psychiatric manifestations of HIV disease

This chapter contains a detailed description of the range of psychiatric problems likely to present in HIV patients and their relatives, and a discussion of the principles of psychiatric management. Psychosocial problems at the various disease stages are reviewed, including those at the time of HIV testing, and in asymptomatic and symptomatic individuals. Mania and schizophrenia-like syndromes are discussed, as well as neuropsychiatric disorders occurring in early and advanced HIV disease. The impact of HIV disease on relatives and professional carers is reviewed. The role of physicians and nurses in the psychological care of HIV patients is outlined, together with the role of mental health specialists. Basic information about the recognition and treatment of major psychiatric syndromes is provided. Finally, issues involved in supporting staff working with HIV patients are discussed.

Lymphoma and other HIV-associated malignancies

The immunodeficient state that evolves in persons infected with the human immunodeficiency virus (HIV) appears to increase their risk of certain types of cancer. Among these are primary lymphoma of the central nervous system, undifferentiated non-Hodgkin's lymphoma, squamous cell carcinoma, anorectal carcinoma, and cutaneous malignancies. These malignancies are similar in incidence to those seen in other immunodeficient patients. Lymphoma, in particular, is associated with a more aggressive disease state. In HIV-infected patients, the disease is usually diagnosed at a more advanced stage, frequently has extranodal involvement, and usually responds poorly to chemotherapy. Viruses, such as Epstein-Barr virus and papillomavirus, have been implicated in the pathogenesis of lymphoma and other malignancies in immunosuppressed patients, including those with HIV infection.

Trans-activation of the JC virus late promoter by the tat protein of type 1 human immunodeficiency virus in glial cells

Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system caused by the JC virus (JCV), a human papovavirus. PML is a relatively rare disease seen predominantly in immunocompromised individuals and is a frequent complication observed in AIDS patients. The significantly higher incidence of PML in AIDS patients than in other immunosuppressive disorders has suggested that the presence of human immunodeficiency virus type 1 (HIV-1) in the brain may directly or indirectly contribute to the pathogenesis of this disease. In the present study we have examined the expression of the JCV genome in both glial and non-glial cells in the presence of HIV-1 regulatory proteins. We find that the HIV-1-encoded trans-regulatory protein tat increases the basal activity of the JCV late promoter, JCVL, in glial cells. In a reciprocal experiment, the JCV early protein, the large tumor antigen, stimulates expression from JCVL and HIV-1 long terminal repeat promoter in both glial and non-glial cells. This trans-activation occurs at the level of RNA synthesis, as measured by the rate of transcription, stability of the message, and translation. We conclude that the presence of the HIV-1-encoded tat protein may positively affect the JCV lytic cycle in glial cells by stimulating JCV gene expression. Our results suggest a mechanism for the relatively high incidence of PML in AIDS patients than in other immunosuppressive disorders. Furthermore, our findings indicate that the HIV-1 regulatory protein tat may stimulate other viral and perhaps cellular promoters, in addition to its own.

Cultured human brain capillary endothelial cells are permissive for infection by human cytomegalovirus

Human cytomegalovirus (HCMV) infection is associated with a variety of systemic and neurologic diseases. In vitro HCMV growth is usually studied in fibroblasts, while in vivo HCMV growth is frequently observed in a wide variety of cell types including glia, neurons, and human brain capillary endothelial (HBCE) cells. To examine the biology of HCMV in HBCE cells, we have established a procedure for isolating these cells from human brain temporal lobectomies. Greater than 99.0% of these cultured cells were identified as HBCE cells on the basis of positive staining for factor VIII-related antigen-Von Willebrand's factor (F VIII) and Ulex Europaeus agglutinin I (UEA I). HCMV antigens were detected by immunocytochemistry in HBCE cells after infection with strain AD 169. Intracellular virions were observed in infected cells by electron microscopy and infectious virus was released from HBCE cells. In addition, infected cells were confirmed as endothelial cells by double staining with antibodies to F VIII and HCMV.

Human immunodeficiency virus type 1 expression in the central nervous system correlates directly with extent of disease

To investigate human immunodeficiency virus type 1 (HIV-1) pathogenesis in infected individuals and examine the correlation of HIV-1 expression with extent of clinical and pathologic disease, we studied spinal cords from acquired immunodeficiency syndrome patients with a wide range of spinal cord pathology. By performing in situ hybridization with HIV-1-specific riboprobes, we detected HIV-1 RNA in all 10 cords from acquired immunodeficiency syndrome patients with a common, characteristic pathologic entity called vacuolar myelopathy but not in 10 control cords from HIV-1-infected and uninfected patients. In the cords from individuals with vacuolar myelopathy, the level of HIV-1 RNA expression correlated directly with extent of spinal cord pathology and clinical findings. These data support a role for HIV-1 in the pathogenesis of tissue damage and related clinical disease in infected individuals.

CT findings in different stages of HIV infection: a prospective study

In the acquired immunodeficiency syndrome (AIDS), different patterns of CT findings have been described. In a prospective and unselected CT study we examined 200 patients in different stages of HIV-1 infection, 14% of whom had focal lesions, 37% atrophic changes and 49% normal findings. The differential diagnosis is discussed. Depending on the patient's complaints and clinical findings, even when the CT scan is normal there may be treatable complications that must be detected by other diagnostic techniques, such as lumbar puncture.

Antigens of Toxoplasma gondii recognized by sera of AIDS patients before, during, and after clinically important infections

A longitudinal study of different parameters of the immune responses to Toxoplasma gondii was performed with sera of AIDS patients taken during and after clinically important Toxoplasma infections. Follow-up of patients lasted for 9 months on an average. The titres of the specific IgG and IgM antibodies were measured by an indirect fluorescent antibody test (IFAT), and the appearance of circulating antigens of Toxoplasma gondii was determined in 88 sera of 18 patients with CNS (6 cases), pulmonary (1), lymph-node toxoplasmosis (1), or asymptomatic primary infections (2), respectively. The profile of the IgG antibodies reacting with a lytic antigen originating from a pool of trophozoites of six different Toxoplasma strains were examined by means of an SDS-PAGE followed by an immunoblot. Although numerous antigen bands were recognized by the sera of patients with clinically important infections, an antigen pattern characteristic of an acute infection could not be discovered. The majority of these sera, however, recognized bands at 27 and 57 kd; proteins of these molecular weights are components of the circulating antigens. In patients without any indication of a Toxoplasma infection, small amounts of antibodies reacting with 34-38 kd antigens were detected. The results of this study demonstrate that seropositivity to Toxoplasma gondii in AIDS patients determined by routine serological methods (e.g. IFAT) may be very heterogeneous even if identical titres are found; it simply results from different combinations of various antibodies which can only be detected by the immunoblotting technique.

Long latency event-related potentials in patients infected with human immunodeficiency virus

Long latency auditory evoked potentials were recorded in 55 homosexual men infected with human immunodeficiency virus (HIV). Forty-one of these patients were asymptomatic from the infection and 14 had clinical signs of illness. Nine of the symptomatic patients were demented and 8 (6 of whom were demented) met other diagnostic criteria for acquired immunodeficiency syndrome (AIDS). Cerebral responses were recorded from Fz, Cz, and Pz electrode placements referred to linked mastoids and averaged separately to rare (2,000 Hz) and frequent (1,000 Hz) tones presented in a pseudorandom sequence. Electroencephalography (EEG) was performed in 54 of the patients and magnetic resonance imaging (MRI) or computed tomography (CT) was done in 14 (13 of whom were symptomatic from the infection). The latency of N1, P2, N2, and P3 components was delayed in HIV-positive patients compared to normal and this was particularly so for the N1, N2, and P3 components. These changes were more marked in those patients who were symptomatic from their infection, especially in those who were demented. They were, however, present to a lesser degree even in asymptomatic (Class II) patients. Thus, 78% of the demented patients and 28% of nondemented patients had a delay in latency of at least one of the evoked potential components beyond the upper limit of our normal population. By contrast, the EEG was normal in all patients with asymptomatic HIV infection and most symptomatic patients, although 5 patients in this latter group had mild generalized slowing. MRI and CT findings were similarly nonspecific, particularly in the nondemented group.(ABSTRACT TRUNCATED AT 250 WORDS)

Mood and behavioral disturbances in hospitalized AIDS patients

A retrospective chart review of 127 patients with acquired immune deficiency syndrome (AIDS) was undertaken to determine the rate of requests for psychiatric consultation. Thirty-six patients (28.3%) had received psychiatric consultations. This is similar to the rate of consultations seen in other studies. Patients who were not intravenous (iv) drug abusers were more likely to be seen for mood disturbances; iv drug users were more likely to be seen for behavior disturbances. The implications of these findings for future demands on consultation-liaison services for AIDS patients are discussed.

Psychological aspects of HIV infection and AIDS. What have we learned?

Publications on the acquired immunodeficiency syndrome (AIDS) have reached such a pitch that leading medical journals have received letters of protest (Kubin, 1989), and some have been forced to defend themselves for the space they devote to the subject (Lock, 1989). While some consider that their problems have been ignored and that AIDS is attracting too much money and publicity (Adler, 1987), others believe AIDS research and clinical services are grossly underfunded (Rogers, 1989). Perhaps because modern medicine has rarely encountered such a completely ‘new’ disorder the fascination is great, no less in psychiatry than in other fields. An editorial in the Lancet (1989), just before the annual International Conference on AIDS, reminded us bluntly of the crucial questions: how many cases of HIV infection had been prevented in the year since the previous conference, and how many would be prevented before the next?

Spinal cord lesions in the acquired immune deficiency syndrome (AIDS)

Spinal cord involvement in AIDS is not uncommon. Different types of lesions corresponding to varying pathogenetic mechanisms have been reported. Vacuolar myelopathy is the most frequently found. The symptoms and pathological changes resemble those of subacute combined degeneration; however, cobalamine or folate levels have always been found normal. Its frequent association with the multi-nucleated giant cells characteristic of HIV encephalitis makes it likely that the virus plays a role in its pathogenesis. Cytomegalovirus may be responsible for acute myeloradiculitis involving the spinal roots of the cauda equina and inferior part of the spinal cord. In cases of Herpes simplex virus myelitis has been reported; they are usually associated with cytomegalovirus infection and are due to herpes simplex virus type II. Secondary spread from systemic lymphomas may involve the subarachnoid space of the cord and the spinal roots. Compression of the spinal cord by epidural lymphomatous masses has also been described. Spinal infarcts may be secondary to acute or chronic vasculitis or to less specific vascular processes such as disseminated intravascular coagulation.

The many faces of AIDS: opportunities for intervention

Social and cultural issues may have a profound impact on different populations' responses to the AIDS epidemic. To maximize their own effectiveness, clinicians need to be aware of special needs and concerns.

Multimodal evoked potentials in HIV infected patients

We studied 126 HIV seropositive patients (106 men, 20 women; mean age: 32 years): 45 had neurological signs, 81 had none. Multimodal evoked potential (MEP) assessment included: visual EPs by flash and reversal checkerboard; brain-stem auditory EPs; somatosensory EPs by stimulation of the median nerve. Evaluation also included: electroencephalography, electromyography with measurement of conduction velocities, neuroimaging (CT scan and MRI). We found abnormal MEPs for all modalities. The prevalence of abnormal results was high in neurologically symptomatic patients; in non-neurological subjects, the changes were more dramatic as HIV infection progressed. Whatever the stage of the disease, the modalities were equally affected. MEPs were abnormal in 54.7% of patients: in 41.8% of those without neurological signs vs. 85.7% of those with these signs. Comparison of MEPs and other electrophysiological procedures and neuroimaging techniques showed the high sensitivity of MEPs at all stages of the disease. EMG was sensitive and complementary to MEPs. EEG and neuroimaging showed abnormalities principally at the neurological symptomatic stage. Our results agree with those found in the literature. Abnormal MEPs may: (1) indicate latent neurological involvement of the visual, auditory and somatosensory pathways, (2) help diagnose an encephalitis suspected on neuropsychological, non-quantifiable testing.

Human immunodeficiency virus: infection of the nervous system

Cynics would say it has taken the scientific community a long time to achieve very little progress in our understanding of HIV-mediated CNS damage. We cannot yet say with surity how neuronal function is affected. However, when viewed through the perspective that retroviral diseases of the human nervous system are newly recognized diseases, significant progress has been made in the 3 years since HIV infection was noted within the CNS. We have a lot to learn about how retroviruses damage the CNS, but at least the questions are better defined.

HIV infection: psychiatric findings in The Netherlands

A psychiatric consultation was requested in 51 in-patient cases of HIV infection. Reasons for referral included counselling, the evaluation of depressive symptoms, and the treatment of delirium. The most common DSM-III diagnoses included: delirium (n = 13), major depressive disorders (n = 12), dementia (n = 5), and adjustment disorders with depressive or anxious mood (n = 5). The psychiatric treatment of patients with HIV infection does not differ fundamentally from that of other medically ill patients with similar psychiatric symptoms. However, the psychiatric treatment of patients with HIV infection can be hampered by the fear of contagion, negative attitudes towards homosexuals and drug users, and over-identification or avoidance reactions.

Brainstem Viral‐like Encephalitis as a Possible Cause of a Gastroduodenal Motility Disorder: A Case Report

The case of a 36‐year‐old caucasiun woman who suffered for many years from gastric retention and duodenogastric reflux due to gastroduodenal motor dysfunction resistant to therapy with prokinetic drugs is described. As the patient died suddenly of an unexplained cardiocirculatory collapse a few hours after a low‐risk operation, an autopsy examination was carried out to clarify the cause of death. No alterations were found in the heart, lungs, and central nervous system with the exception of a subacute viral‐like brainstem encephalitis involving the dorsal motor nucleus of the nervus vagus, the nucleus XII, the nucleus tractus solitaruis, and the nucleus ambiguus. A clinico‐pathologic correlate between the clinical alterations and the lesions of the brainstem centers, which modulate gastrointestinal and cardiovascular functions, is surmised.

The spectrum of polyneuropathies in patients infected with HIV

Twenty five patients with peripheral neuropathy at different stages of human immunodeficiency virus (HIV) infection are reported. Cerebrospinal fluid (CSF) findings were available in 17 cases, electrophysiology in all and a neuromuscular biopsy in 11. Of six otherwise asymptomatic HIV+ patients, five had chronic inflammatory demyelinating polyneuropathy (CIDP) and one acute inflammatory demyelinating polyneuropathy (AIDP). CSF showed pleocytosis in all cases. Infiltration of the endoneurium and/or the epineurium by mononuclear cells was seen in biopsies from three cases. These six patients recovered either spontaneously, or with corticosteroids or plasmaphereses. Of five patients with AIDS related complex (ARC), three had distal predominantly sensory peripheral neuropathy (DSPN), one CIDP and one mixed neuropathy. Of 14 patients with AIDS, one had mononeuropathy multiplex and 13 painful DSPN. Electrophysiological studies were consistent with an axonopathy. Nerve biopsies in six cases showed axonal changes but surprisingly associated with marked segmental demyelination in two cases. Cell infiltration was present in nerve samples in two cases. Five patients died within six months after the onset of the neuropathy.

Cytomembranous inclusions in the peripheral nerves in AIDS

We report finding tubuloreticular inclusions (TRI) in the endothelial cells of endo- and epineurial vessels in the sural nerve of 11 patients with AIDS. Six patients had a painful peripheral neuropathy, one a non-painful sensory neuropathy, one an acute inflammatory demyelinating polyradiculoneuropathy and one a thalidomide-related neuropathy. Two patients had no clinical evidence of neuropathy. The TRI are not specific to one neuropathy and are unlikely to contribute to the pathogenesis of peripheral nerve syndromes in AIDS.

Biological characterization of paired human immunodeficiency virus type 1 isolates from blood and cerebrospinal fluid

Virus has been isolated from the blood and cerebrospinal fluid (CSF) of eight subjects with varying severity of human immunodeficiency virus type 1 (HIV-1) infection and from the frontal lobe of one patient with AIDS. The five patients with AIDS-related complex (ARC) and AIDS also showed neurological/psychiatric complications. With the exception of one isolate from the CSF of an asymptomatic carrier, all isolates replicated in peripheral blood mononuclear cells and monocytes after cell-free transmission. Isolates obtained from the blood of patients in late stages of HIV infection replicated in 3 (of 4) cases in H9 cells, whereas none of the blood isolates from patients in the early stages did so. The capacity of CSF isolates to replicate in H9 cells was low (only 2 of 12). Paired virus isolates from blood and CSF of the same patient could be distinguished by their replicative capacity in different cell lines, type of cytopathic effect, and protein profile as tested by radioimmunoprecipitation. The results indicate that variant viruses with distinct biological characteristics may be isolated from the blood and CSF of the same patient.

CNS toxoplasmosis as the initial presentation of the acquired immunodeficiency syndrome

Neurological manifestations are present in 30% to 60% of patients with acquired immunodeficiency syndrome (AIDS) and may be the initial presentation in 10% to 20% of cases. Central nervous system toxoplasmosis now represents the most common focal brain lesion in patients with AIDS and possibly the most common opportunistic infection. A case of fulminant central nervous system toxoplasmosis as the initial presentation of AIDS is presented. Emergency physicians will be confronted with neurological complications of AIDS with increasing frequency in the future and should maintain a high index of suspicion for human immunodeficiency virus infection in young patients with neurological dysfunction.

Myelopathy: an unusual presentation of toxoplasmosis

Central nervous system toxoplasmosis is a well known disease of immunocompromised patients. Neuropathologic examinations have only rarely demonstrated spinal cord involvement. This report describes a fatal case of toxoplasmosis that presented with a subacute myelopathy. Toxoplasmosis should be considered in immuno-compromised patients, including patients with the acquired immune deficiency syndrome, that develop intramedullary lesions of the spinal cord.

Low prevalence of neuro-psychiatric clinical manifestations in central African patients with acquired immune deficiency syndrome

In order to evaluate the frequency of neurological and psychiatric disorders in central African patients with acquired immune deficiency syndrome (AIDS), 93 inpatients at the National Hospital Centre of Bangui were selected according to the World Health Organization (Bangui) clinical definition of AIDS and were confirmed to be serologically positive for human immunodeficiency virus (HIV) 1 (92/93) or HIV 2 (1/93) by Western blot. Neurological (11/15) and psychiatric (4/15) abnormalities were clinically detected in 16% (15/93) of African patients with AIDS. In this series, the prevalence of neuro-psychiatric disorders appeared to be lower than in Europe and North America.

Neurological and neuropsychological manifestations of HIV-1 infection: association with AIDS-related complex but not asymptomatic HIV-1 infection

To determine whether neurological and neuropsychological abnormalities are associated with clinical manifestations of human immunodeficiency virus type 1 (HIV-1) infection in men who do not have acquired immunodeficiency syndrome (AIDS), we performed a historical prospective and cross-sectional study. One hundred HIV-1 seropositive homosexual or bisexual men, of whom 26 had AIDS-related complex, 31 had generalized lymphadenopathy, and 43 had no signs or symptoms of HIV-1 infection, and 157 HIV-1 seronegative men were enrolled from a cohort of 6,701 men who were originally recruited between 1978 and 1980 for studies of hepatitis B virus infection. Evaluation included medical history, physical examination, and neuropsychological tests. Of 26 HIV-1 seropositive subjects with AIDS-related complex, 11 (42%) reported neurological, cognitive, or affective symptoms compared with 30 (19%) of 157 HIV-1 seronegative subjects (relative risk = 2.2, p = 0.02). On neuropsychological testing, subjects with AIDS-related complex performed at a significantly lower level than the HIV-1 seronegative group (p = 0.001). A significantly higher percentage of subjects with AIDS-related complex (8[31%]of 26) than HIV-1 seronegative subjects (19 [12%] of 157) had abnormal results on two or more neuropsychological tests (rate ratio = 2.5, p = 0.03). Symptoms and impairment on neuropsychological tests were correlated only within the group who had AIDS-related complex. Subjects with generalized lymphadenopathy and subjects who had no signs or symptoms of HIV-1 infection were not different from HIV-1 seronegative subjects with respect to symptoms or performance on neuropsychological tests.(ABSTRACT TRUNCATED AT 250 WORDS)