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Ciccarelli N. Considerations on nosology for HIV-associated neurocognitive disorders: it is time to update? Infection 2019; 48:37-42. [PMID: 31691905 DOI: 10.1007/s15010-019-01373-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 10/24/2019] [Indexed: 02/07/2023]
Abstract
AIMS The prognosis and the clinical manifestations of HIV infection have changed with the introduction of the potent combination antiretroviral therapy (cART); however, up to 50% of patients meet research criteria for "HIV-associated neurocognitive disorders" (HAND) according with current nosology. The majority of patients affected by HAND, especially in cohorts with suppressed plasma viremia, showed an Asymptomatic Neurocognitive Impairment (ANI), without any functional impairment. After more than 10 years from the introduction of the current so-called "Frascati criteria", this mini-review aimed to address the emerging limitations in current diagnosis procedures. METHODS We discussed the most relevant literature on HAND prevalence, etiology, and diagnosis. RESULTS We addressed three main emerging issues: (1) the unclear clinical relevance of ANI entity; (2) the evidences that Frascati criteria could produce a significant overestimation of HAND; (3) the need to better identify patients with a higher risk to develop HAND requiring routine neuropsychological examinations. CONCLUSIONS Frascati criteria should be updated to better respond to the present characteristics of HIV + cohorts and to help clinicians in their cognitive and global management.
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Affiliation(s)
- Nicoletta Ciccarelli
- Department of Psychology, Catholic University, Largo Agostino Gemelli 1, 20123, Milan, Italy.
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Abstract
Human immunodeficiency virus (HIV)-associated neurocognitive disorder (HAND) affects roughly half the HIV-positive population. The symptoms of cognitive slowing, poor concentration, and memory problems can impact on everyday life. Its diagnosis is validated where possible by identifying deficits in two cognitive domains on neuropsychologic testing in patients either with or without symptoms. Corroborating evidence may be found on imaging, blood tests, and cerebrospinal fluid analysis, though sensitive and specific biomarkers are currently lacking. The introduction of combined antiretroviral therapy in the 1990s has generated a therapeutic paradox whereby the number of severe cases of HAND has fallen, yet milder forms continue to rise in prevalence. New emphasis has been placed on identifying the cause of apparent ongoing HIV infection and inflammation of the central nervous system (CNS) in the face of durable systemic viral suppression, and how this equates to the neuronal dysfunction underlying HAND. The interaction with aging and comorbidities is becoming increasingly common as the HIV-positive population enters older adulthood, with neurodegenerative, metabolic, and vascular causes of cognitive impairment combining and probably accelerating in the context of chronic HIV infection. Therapies targeted to the CNS, but without neurotoxic side-effects, are being investigated to attempt to reduce the likelihood of developing, and improving, HAND.
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Affiliation(s)
| | - Bruce James Brew
- Departments of Neurology and HIV Medicine, St. Vincent's Hospital and Peter Duncan Neurosciences Unit, St. Vincent's Centre for Applied Medical Research, St. Vincent's Hospital, Sydney, NSW, Australia.
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Abstract
Human immunodeficiency virus (HIV) enters the brain early after infecting humans and may remain in the central nervous system despite successful antiretroviral treatment. Many neuroimaging techniques were used to study HIV+ patients with or without opportunistic infections. These techniques assessed abnormalities in brain structures (using computed tomography, structural magnetic resonance imaging (MRI), diffusion MRI) and function (using functional MRI at rest or during a task, and perfusion MRI with or without a contrast agent). In addition, single-photon emission computed tomography with various tracers (e.g., thallium-201, Tc99-HMPAO) and positron emission tomography with various agents (e.g., [18F]-dexoyglucose, [11C]-PiB, and [11C]-TSPO tracers), were applied to study opportunistic infections or HIV-associated neurocognitive disorders. Neuroimaging provides diagnoses and biomarkers to quantitate the severity of brain injury or to monitor treatment effects, and may yield insights into the pathophysiology of HIV infection. As the majority of antiretroviral-stable HIV+ patients are living longer, age-related comorbid disorders (e.g., additional neuroinflammation, cerebrovascular disorders, or other dementias) will need to be considered. Other highly prevalent conditions, such as substance use disorders, psychiatric illnesses, and the long-term effects of combined antiretroviral therapy, all may lead to additional brain injury. Neuroimaging studies could provide knowledge regarding how these comorbid conditions impact the HIV-infected brain. Lastly, specific molecular imaging agents may be needed to assess the central nervous system viral reservoir.
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Affiliation(s)
- Linda Chang
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States; Department of Medicine and Department of Neurology, John A. Burns School of Medicine, University of Hawaii, Manoa, United States.
| | - Dinesh K Shukla
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
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Nguyen KL, Yoshida T, Han F, Ayad I, Reemtsen BL, Salusky IB, Satou GM, Hu P, Finn JP. MRI with ferumoxytol: A single center experience of safety across the age spectrum. J Magn Reson Imaging 2016; 45:804-812. [PMID: 27480885 PMCID: PMC5290274 DOI: 10.1002/jmri.25412] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 07/19/2016] [Indexed: 12/23/2022] Open
Abstract
Purpose To summarize our single‐center safety experience with the off‐label use of ferumoxytol for magnetic resonance imaging (MRI) and to compare the effects of ferumoxytol on monitored physiologic indices in patients under anesthesia with those of gadofosveset trisodium. Materials and Methods Consecutive patients who underwent ferumoxytol‐enhanced (FE) MRI exams were included. Adverse events (AEs) were classified according to the Common Terminology Criteria for Adverse Events v4.0. In a subgroup of patients examined under general anesthesia, recording of blood pressure, heart rate, oxygen saturation, and end‐tidal CO2 was performed. A comparable group of 23 patients who underwent gadofosveset‐enhanced (GE) MRI under anesthesia with similar monitoring was also analyzed. Results In all, 217 unique patients, ages 3 days to 94 years, underwent FE‐MRI. No ferumoxytol‐related severe, life‐threatening, or fatal AEs occurred acutely or at follow‐up. Two patients developed ferumoxytol‐related nausea. Between‐group (FE‐ vs. GE‐MRI) comparisons showed no statistical difference in heart rate (P = 0.69, 95% confidence interval [CI] 96–113 bpm), mean arterial blood pressure (MAP) (P = 0.74, 95% CI 44–52 mmHg), oxygen saturation (P = 0.76, 95% CI 94–98%), and end‐tidal CO2 (P = 0.73, 95% CI 31–37 mmHg). No significant change in MAP (P = 0.12, 95% CI 50–58 mmHg) or heart rate (P = 0.25, 95% CI 91–105 bpm) was noted between slow infusion of ferumoxytol (n = 113) vs. bolus injection (n = 104). Conclusion In our single‐center experience, no serious AEs occurred with the diagnostic use of ferumoxytol across a wide spectrum of age, renal function, and indications. Because of the limited sample size, firm conclusions cannot be drawn about the generalizability of our results. Thus, vigilance and monitoring are recommended to mitigate potential rare adverse reactions. Level of Evidence: 2 J. Magn. Reson. Imaging 2017;45:804–812.
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Affiliation(s)
- Kim-Lien Nguyen
- Diagnostic Cardiovascular Imaging Laboratory, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Takegawa Yoshida
- Diagnostic Cardiovascular Imaging Laboratory, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Fei Han
- Diagnostic Cardiovascular Imaging Laboratory, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Ihab Ayad
- Department of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Brian L Reemtsen
- Division of Cardiothoracic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Isidro B Salusky
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Gary M Satou
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Peng Hu
- Diagnostic Cardiovascular Imaging Laboratory, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - J Paul Finn
- Diagnostic Cardiovascular Imaging Laboratory, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Abstract
PURPOSE OF REVIEW The purpose of this study is to summarize recent advances in ageing and neuroAIDS by reviewing relevant articles from the preceding 18 months from PubMed and PsycINFO databases. RECENT FINDINGS The success of combination antiretroviral therapy (cART) has led to ageing of the HIV-infected population, which in turn contributes to the prevalence of HIV-associated neurocognitive disorder (HAND). Biomedical advances continue to clarify the pathophysiology of HAND despite effective cART, including chronic inflammatory and neurovascular causes. In recent months, associations between HAND and nonneurological medical diseases have been identified, as well as linkage to neuroimaging in those ageing with HIV. Developing effective screening tools to detect impairment remains an important scientific gap, although promoting factors associated with successful cognitive ageing is emerging as a possible means of enhancing quality of life. SUMMARY A greater understanding of HAND pathophysiology among treated individuals with suppressed virus will aid in explaining the high prevalence of HAND despite effective cART and allow for development of novel targeted interventions. Neuroimaging and other biomarkers show promise in discerning HAND from age-associated cognitive disorders. Effective screening tools remain critically needed. Together, this work will inform promising strategies needed to address issues pertinent to an expanding group of older patients living with HIV.
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