Seizures in HIV: The case for special consideration

Outcomes of patients in Chagas disease of the central nervous system: a systematic review

Chagas disease is a parasitic infection caused by the protozoan Trypanosoma cruzi. One of the complications of the disease is the infection of the central nervous system (CNS), as it can result from either the acute phase or by reactivation during the chronic phase, exhibiting high mortality in immunocompromised patients. This systematic review aimed to determine clinical and paraclinical characteristics of patients with Chagas disease in the CNS. Articles were searched from PubMed, Scopus and LILACS until January 2023. From 2325 articles, 59 case reports and 13 case series of patients with Chagas in the CNS were retrieved from which 138 patients were identified. In this population, 77% of the patients were male, with a median age of 35 years old, from which most of them came from Argentina and Brazil. Most of the individuals were immunocompromised from which 89% were HIV-positive, and 54 patients had an average of 48 cells per mm3 CD4+ T cells. Motor deficits and seizures were the most common manifestation of CNS compromise. Furthermore, 90 patients had a documented CNS lesion by imaging from which 89% were supratentorial and 86% were in the anterior/middle cranial fossa. The overall mortality was of 74%. Among patients who were empirically treated with anti-toxoplasma drugs, 70% died. This review shows how Chagas disease in the CNS is a devastating complication requiring prompt diagnosis and treatment to improve patients’ outcomes.

Clinical factors predictive of new-onset seizure in patients with AIDS-related brain parenchymal lesion

PURPOSE

This study aimed to determine the clinical characteristics and risk factors of new-onset seizure in patients with AIDS-related brain parenchymal lesion.

METHODS

A retrospective case-control study from January 2015 to December 2021 was conducted to determine the clinical characteristics and etiology of seizures in patients with AIDS-related brain parenchymal lesion. Univariate and multivariate logistic regression analyses were used to identify risk factors associated with seizures. Receiver operating characteristic (ROC) curve was used to analyze seizure prediction efficiency.

RESULTS

Among a total of 343 patients with AIDS-related brain lesions, 222 had brain parenchymal lesions. Of the 222 patients in the series (range: 16-81 y), 69 reported an episode of at least one seizure. A logistic regression analysis showed that tuberculoma, cortex involvement, and lesions in parietal lobe were found to have a strong association with higher incidence of seizures, whereas lesions in the periventricular area was less prone to seizure. The area under the ROC curve of these factors was 0.733, indicating these factors could predict seizure effectively. Amongst the 69 patients with seizures in multivariate analysis using logistic regression, multiple lesions significantly associated with focal to bilateral tonic-clonic seizures, and lesions in temporal lobe independently associated with focal impaired awareness seizure.

CONCLUSIONS

Our study identified the underlying predictors between seizures and the clinical characteristics in a large population of patients with AIDS-related brain parenchymal lesions. These findings would provide further insights into developing effective prevention and treatment strategies aimed at improving the quality of life in the HIV population.

New-onset focal seizure as a presenting feature of HIV infection: a case report and mini review to the challenge in resource-limited settings

Background

The frequency of new-onset HIV-associated seizure in the HIV-infected patient is estimated to be between 2 and 11%. Identifying the underlying etiology of new-onset seizure will have a vital impact on the mortality and morbidity of patients living with HIV infection.

Case presentation

We report a 34-year old newly diagnosed HIV+ male patient presented with abnormal body movement (ABM) involving his right hemibody associated with loss of consciousness lasting few minutes of two weeks duration. The ABM occurred frequently (> five times per week) and associated with frothy and excessive salivation. He reported headache following each spells. Brain magnetic resonance imaging (MRI) showed bilateral frontal T2 and FLAIR hyperintensity and T1 hypointensity; post contrast study showed bilateral small ring enhancing lesion with perilesional oedema, the biggest one on the left hemisphere, with a 10 mm diameter; considering patient advanced immunosuppression and underlying HIV infection, the brain MRI findings were consistent with cerebral toxoplasmosis. Bipolar montage electroencephalography (EEG) study showed generalized background slowing, prominent in the left fronto-centeral region. Patient was managed with combination antiretroviral therapy, anti-toxoplasmosis medication, and anticonvulsant. On follow up, the frequency of seizure attack has significantly reduced.

Conclusion

Considering the high prevalence of HIV infection and associated seizure among people living with HIV in sub-Saharan Africa, this case fairly highlights on the importance of utilizing advanced imaging techniques such as MRI and EEG in identifying the underlying causes of HIV-associated seizures.

Coadministration of ARV (Atripla) and Topiramate disrupts quail cardiac neural crest cell migration

INTRODUCTION

Congenital anomalies such as ventricular septal defects and truncus communis have been reported with the prenatal use of antiretroviral therapy. The mechanism of antiretroviral therapy teratogenicity is unclear and is therefore the focus of this study. Some human immunodeficiency virus patients on antiretrovirals are placed on antiepileptic drugs which are also teratogenic. The interactive effects arising from this therapeutic combination may affect their teratogenic propensity through their effects on neural crest cell migration.

METHODS

Appropriately cultured neural crest cells from dissected neural tubes of 32-hr old quail embryos exposed to culture media containing peak plasma levels of Atripla, Topiramate and the combination of both were studied. Distance of migration of neural crest cells was measured using the migration assay and the cells were stained with rhodamine phalloidin to evaluate the cell actin. Also quail neural crest cells were brought into suspension and microinjected into chick hosts to determine the migration of the cells to the interventricular septum.

RESULTS

Migration of cultured neural crest cells was extensive in the control cultures, but inhibited in the treated groups. The experimental cultures showed a disarray of actin cytoskeleton contrary to normal distribution of actin filaments in controls. Significantly, few quail neural crest cells migrated to the interventricular septum of chick host embryos compared to the control cultures. The coadministration of topiramate with antiretroviral therapy does not seem to affect the activity of the antiretroviral drug.

CONCLUSION

These results indicate that Atripla and Topiramate cause ventricular septal defects by inhibiting the migration of cardiac neural crest cells.

Current epidemiological and etiological characteristics and treatment of seizures or epilepsy in patients with HIV infection

Seizures or epilepsy is one of the common serious complications in patients with advanced human immunodeficiency virus (HIV) infection or diagnosed with immune deficiency syndrome, with higher incidence and prevalence than in the general population. Generalized seizures are the most common type in the patients. Opportunistic infections are a stereotypical predisposing factor for seizures in HIV patients, but a variety of pathogenic factors can also be found in these patients, such as metabolic perturbation and drug-drug interactions. The diagnostic criteria for seizures in these patients are the same as those in the general population. As HIV patients with seizures need to take both antivirals and antiepileptic drugs, the risk of drug-drug interactions is greatly increased, and the side effects of drugs may also become more prominent. At present, most experience in antiepileptic drug usage has come from the general population, and there is still a lack of guidance of antiepileptic drug use in special groups such as the HIV-infected people. Unlike the old-generation drugs that involve metabolisms through CYP450, the first-line antiepileptic drugs usually bypass CYP450, thus having less drug-drug interactions. In this review, we summarize the recent research progress on the above-mentioned widely discussed topics and make a prospect on future research direction.

Prevalence and incidence of new-onset seizures and epilepsy in patients with human immunodeficiency virus (HIV): Systematic review and meta-analysis

BACKGROUND

The prevalence and incidence of seizures are substantially higher in patients with human immunodeficiency virus (HIV) compared with the general population and is associated with higher mortality rates. Despite this, the condition remains poorly understood, and there is variation in reported epidemiological studies. The aim of this systematic review and meta-analysis was to investigate the risk factors associated with seizures in the population with HIV, explore the source of variations, and describe management plans that can aid clinicians in the acute and long-term treatment of these patients.

METHODS

A structured electronic database search of MEDLINE, EMBASE, and Cochrane Library was conducted. Studies were included if they described clinical details of patients with HIV with seizures or epilepsy. We extracted select variables from each included study, and we estimated pooled estimates of the incidence and prevalence of seizures using random-effects meta-analysis of proportions.

RESULTS

Information on 6639 cases of patients with HIV was extracted from 9 included studies. These comprised of 2 studies from the United States of America (USA), 3 from Europe, 3 from Asia, and 1 from Africa. The pooled prevalence and incidence rate of seizures in HIV were 62 per 1000 population and 60 per 1000 population respectively. Among those who presented with new-onset seizures, 63% had seizure recurrence. At the time of first seizure, 82.3% had acquired immunodeficiency syndrome (AIDS). Factors that appeared to be linked to seizures in HIV included advanced HIV disease, opportunistic infections particularly toxoplasmosis, and metabolic derangement. Most seizures were effectively controlled by common antiepileptic drugs (AEDs).

CONCLUSIONS

The prevalence and incidence of seizures and epilepsy in the population with HIV are substantially higher than the general population. Our results suggest that advanced HIV and opportunistic infections are associated with the majority of the seizures. Early initiation of highly active antiretroviral therapy (HAART), prophylactic use of cotrimoxazole (trimethoprim-sulfamethoxazole) and routine electroencephalogram (EEG) in patients with HIV may reduce seizure incidence and frequency and help in early diagnosis of nonconvulsive seizures in this population. We recommend long-term seizure management with AED, and for patients on HAART, enzyme-inducing AED should be avoided when possible.