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Chishimba LC, Chomba M, Zimba S, Asukile MT, Makai O, Saylor DR. Clinical Reasoning: Rapidly Progressive Dementia in a Man With HIV Infection and Undetectable Plasma Viral Load. Neurology 2023; 100:344-348. [PMID: 36347626 PMCID: PMC9969911 DOI: 10.1212/wnl.0000000000201576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 10/06/2022] [Indexed: 11/11/2022] Open
Abstract
Neurocognitive decline associated with HIV infection remains prevalent even in the antiretroviral therapy (ART) era, albeit usually in less severe forms. The differential diagnosis of cognitive impairment in this population is quite broad, including infectious causes such as CNS opportunistic infections, causes directly related to HIV such as HIV-associated neurocognitive disorders, and causes entirely unrelated to HIV infection such as primary dementia syndromes. In this case report, a 47-year-old man with HIV on ART with an undetectable plasma viral load presented with rapidly progressive dementia to a clinic in Zambia. He had been functioning independently and fully employed before symptom onset but had to stop working within 2 months of symptom onset because of the severity and rapidity of his cognitive decline. Initial workup led to an empiric diagnosis and initiation of an empiric treatment regimen, which was ultimately ineffective. This prompted re-evaluation, additional workup, and, ultimately, discovering the correct diagnosis. This case highlights the stepwise approach to developing a diagnosis in a resource-limited setting where there exists a high burden of HIV infection, including the necessity of empiric diagnoses of treatment plans when investigations are limited and the importance of reconsidering these diagnoses in the face of additional clinical information. In addition, it highlights both infectious and noninfectious causes of cognitive decline in people with HIV.
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Affiliation(s)
- Lorraine Chishimba Chishimba
- From the Department of Internal Medicine (L.C.C., M.C., S.Z., M.T.A., D.R.S.), University Teaching Hospital, Lusaka, Zambia; Department of Internal Medicine (S.Z., D.R.S.), University of Zambia School of Medicine, Lusaka; Department of Internal Medicine (O.M.), Infectious Diseases Unit, University of Zambia, Lusaka; and Department of Neurology (D.R.S.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mashina Chomba
- From the Department of Internal Medicine (L.C.C., M.C., S.Z., M.T.A., D.R.S.), University Teaching Hospital, Lusaka, Zambia; Department of Internal Medicine (S.Z., D.R.S.), University of Zambia School of Medicine, Lusaka; Department of Internal Medicine (O.M.), Infectious Diseases Unit, University of Zambia, Lusaka; and Department of Neurology (D.R.S.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stanley Zimba
- From the Department of Internal Medicine (L.C.C., M.C., S.Z., M.T.A., D.R.S.), University Teaching Hospital, Lusaka, Zambia; Department of Internal Medicine (S.Z., D.R.S.), University of Zambia School of Medicine, Lusaka; Department of Internal Medicine (O.M.), Infectious Diseases Unit, University of Zambia, Lusaka; and Department of Neurology (D.R.S.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Melody Tunsubilege Asukile
- From the Department of Internal Medicine (L.C.C., M.C., S.Z., M.T.A., D.R.S.), University Teaching Hospital, Lusaka, Zambia; Department of Internal Medicine (S.Z., D.R.S.), University of Zambia School of Medicine, Lusaka; Department of Internal Medicine (O.M.), Infectious Diseases Unit, University of Zambia, Lusaka; and Department of Neurology (D.R.S.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Obrie Makai
- From the Department of Internal Medicine (L.C.C., M.C., S.Z., M.T.A., D.R.S.), University Teaching Hospital, Lusaka, Zambia; Department of Internal Medicine (S.Z., D.R.S.), University of Zambia School of Medicine, Lusaka; Department of Internal Medicine (O.M.), Infectious Diseases Unit, University of Zambia, Lusaka; and Department of Neurology (D.R.S.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Deanna R Saylor
- From the Department of Internal Medicine (L.C.C., M.C., S.Z., M.T.A., D.R.S.), University Teaching Hospital, Lusaka, Zambia; Department of Internal Medicine (S.Z., D.R.S.), University of Zambia School of Medicine, Lusaka; Department of Internal Medicine (O.M.), Infectious Diseases Unit, University of Zambia, Lusaka; and Department of Neurology (D.R.S.), Johns Hopkins University School of Medicine, Baltimore, MD.
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HIV drug resistance in various body compartments. Curr Opin HIV AIDS 2022; 17:205-212. [PMID: 35762375 DOI: 10.1097/coh.0000000000000741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW HIV drug resistance testing using blood plasma or dried blood spots forms part of international guidelines. However, as the clinical utility of assessing drug resistance in other body compartments is less well established, we review this for blood cells and samples from other body compartments. RECENT EVIDENCE Although clinical benefit is not clear, drug resistance testing in blood cells is often performed when patients with suppressed plasma viral loads require a treatment substitution. In patients with HIV neurocognitive disease, cerebral spinal fluid (CSF) drug resistance is rarely discordant with plasma but has nevertheless been used to guide antiretroviral drug substitutions. Cases with HIV drug resistance in genital fluids have been documented but this does not appear to indicate transmission risk when blood plasma viral loads are suppressed. SUMMARY Drug-resistant variants, which may be selected in tissues under conditions of variable adherence and drug penetration, appear to disseminate quickly, and become detectable in blood. This may explain why drug resistance discordance between plasma and these compartments is rarely found. Partial compartmentalization of HIV populations is well established for the CSF and the genital tract but other than blood plasma, evidence is lacking to support drug resistance testing in body compartments.
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Kelentse N, Moyo S, Molebatsi K, Morerinyane O, Bitsang S, Bareng OT, Lechiile K, Leeme TB, Lawrence DS, Kasvosve I, Musonda R, Mosepele M, Harrison TS, Jarvis JN, Gaseitsiwe S. Reversal of CSF HIV-1 Escape during Treatment of HIV-Associated Cryptococcal Meningitis in Botswana. Biomedicines 2022; 10:1399. [PMID: 35740421 PMCID: PMC9219642 DOI: 10.3390/biomedicines10061399] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 06/07/2022] [Accepted: 06/08/2022] [Indexed: 11/30/2022] Open
Abstract
Cerebrospinal fluid (CSF) viral escape has been poorly described among people with HIV-associated cryptococcal meningitis. We determined the prevalence of CSF viral escape and HIV-1 viral load (VL) trajectories in individuals treated for HIV-associated cryptococcal meningitis. A retrospective longitudinal study was performed using paired CSF and plasma collected prior to and during the antifungal treatment of 83 participants recruited at the Botswana site of the phase-3 AMBITION-cm trial (2018−2021). HIV-1 RNA levels were quantified then CSF viral escape (CSF HIV-1 RNA ≥ 0.5 log10 higher than plasma) and HIV-1 VL trajectories were assessed. CSF viral escape occurred in 20/62 (32.3%; 95% confidence interval [CI]: 21.9−44.6%), 13/52 (25.0%; 95% CI: 15.2−38.2%) and 1/33 (3.0%; 95% CI: 0.16−15.3%) participants at days 1, 7 and 14 respectively. CSF viral escape was significantly lower on day 14 compared to days 1 and 7, p = 0.003 and p = 0.02, respectively. HIV-1 VL decreased significantly from day 1 to day 14 post antifungal therapy in the CSF but not in the plasma (β = −0.47; 95% CI: −0.69 to −0.25; p < 0.001). CSF viral escape is high among individuals presenting with HIV-associated cryptococcal meningitis; however, antifungal therapy may reverse this, highlighting the importance of rapid initiation of antifungal therapy in these patients.
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Affiliation(s)
- Nametso Kelentse
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (K.M.); (O.M.); (O.T.B.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (M.M.); (J.N.J.)
- Department of Medical Laboratory Sciences, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana;
| | - Sikhulile Moyo
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (K.M.); (O.M.); (O.T.B.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (M.M.); (J.N.J.)
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Kesaobaka Molebatsi
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (K.M.); (O.M.); (O.T.B.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (M.M.); (J.N.J.)
- Department of Statistics, Faculty of Social Sciences, University of Botswana, Gaborone, Botswana
| | - Olorato Morerinyane
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (K.M.); (O.M.); (O.T.B.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (M.M.); (J.N.J.)
| | - Shatho Bitsang
- Botswana-University of Maryland School of Medicine Health Initiative, Gaborone, Botswana;
| | - Ontlametse T. Bareng
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (K.M.); (O.M.); (O.T.B.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (M.M.); (J.N.J.)
- Department of Medical Laboratory Sciences, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana;
| | - Kwana Lechiile
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (K.M.); (O.M.); (O.T.B.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (M.M.); (J.N.J.)
| | - Tshepo B. Leeme
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (K.M.); (O.M.); (O.T.B.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (M.M.); (J.N.J.)
| | - David S. Lawrence
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (K.M.); (O.M.); (O.T.B.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (M.M.); (J.N.J.)
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, The London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Ishmael Kasvosve
- Department of Medical Laboratory Sciences, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana;
| | - Rosemary Musonda
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (K.M.); (O.M.); (O.T.B.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (M.M.); (J.N.J.)
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Mosepele Mosepele
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (K.M.); (O.M.); (O.T.B.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (M.M.); (J.N.J.)
- Department of Internal Medicine, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Thomas S. Harrison
- Centre for Global Health, Institute for Infection and Immunity, St. George’s University of London, London SW17 0RE, UK;
| | - Joseph N. Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (K.M.); (O.M.); (O.T.B.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (M.M.); (J.N.J.)
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, The London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Simani Gaseitsiwe
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; (N.K.); (S.M.); (K.M.); (O.M.); (O.T.B.); (K.L.); (T.B.L.); (D.S.L.); (R.M.); (M.M.); (J.N.J.)
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
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Biotypes of HIV-associated neurocognitive disorders based on viral and immune pathogenesis. Curr Opin Infect Dis 2022; 35:223-230. [PMID: 35665716 PMCID: PMC9179892 DOI: 10.1097/qco.0000000000000825] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW HIV-associated neurocognitive disorders (HAND) continues to be prevalent in people living with HIV despite antiretroviral therapy. However, understanding disease mechanisms and identifying therapeutic avenues has been challenging. One of the challenges is that HAND is a heterogeneous disease and that patients identified with similar impairments phenotypically may have very different underlying disease processes. As the NeuroAIDS field is re-evaluating the approaches used to identify patients with HIV-associated neurological impairments, we propose the subtyping of patients into biotypes based on viral and immune pathogenesis. RECENT FINDINGS Here we review the evidence supporting subtyping patients with HIV-associated neurological complications into four biotypes: macrophage-mediated HIV encephalitis, CNS viral escape, T-cell-mediated HIV encephalitis, and HIV protein-associated encephalopathy. SUMMARY Subtyping patients into subgroups based on biotypes has emerged as a useful approach for studying heterogeneous diseases. Understanding biotypes of HIV-associated neurocognitive impairments may therefore enable better understanding of disease mechanisms, allow for the development of prognostic and diagnostic markers, and could ultimately guide therapeutic decisions.
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Ferretti F, De Zan V, Gerevini S, Turrini F, Boeri E, Gianotti N, Hasson H, Lazzarin A, Cinque P. Relapse of Symptomatic Cerebrospinal Fluid HIV Escape. Curr HIV/AIDS Rep 2021; 17:522-528. [PMID: 32875516 DOI: 10.1007/s11904-020-00526-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Symptomatic cerebrospinal fluid (CSF) HIV escape defines the presence of neurological disease in combination antiretroviral therapy (cART)-treated persons due to HIV replication in CSF despite systemic suppression or to higher viral replication in CSF than in plasma. The aim was to search for cases of recurrent symptomatic CSF escape and to define their characteristics. RECENT FINDINGS By review of the literature, we identified symptomatic CSF escape relapses in three patients who had shown clinical remission of a first escape episode following cART optimization. By examination of our cohort of 21 patients with symptomatic CSF escape, we identified five additional patients. In the latter, viral escape relapsed over a median follow-up of 108 months because of low adherence or upon treatment simplification of a previously optimized regimen. cART reoptimization based on resistance profile and potential drug neuropenetration and efficacy led to relapse resolution with no further episodes after a median follow-up of 50 months from relapse. The observation that CSF escape may relapse highlights the importance of long-term neuro-suppressive regimens after a first episode and supports the role of the brain as a reservoir for HIV.
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Affiliation(s)
- Francesca Ferretti
- Department of Infectious Diseases, San Raffaele Scientific Institute and San Raffaele Vita-Salute University, Via Stamira d'Ancona 20, 20127, Milan, Italy.,Chelsea and Westminster Hospital NHS Trust, London, UK
| | - Valentina De Zan
- Department of Infectious Diseases, San Raffaele Scientific Institute and San Raffaele Vita-Salute University, Via Stamira d'Ancona 20, 20127, Milan, Italy
| | - Simonetta Gerevini
- Unit of Neuroradiology, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.,Unit of Neuroradiology, Ospedali Riuniti, Bergamo, Italy
| | - Filippo Turrini
- Department of Infectious Diseases, San Raffaele Scientific Institute and San Raffaele Vita-Salute University, Via Stamira d'Ancona 20, 20127, Milan, Italy
| | - Enzo Boeri
- Laboratory of Microbiology, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Nicola Gianotti
- Department of Infectious Diseases, San Raffaele Scientific Institute and San Raffaele Vita-Salute University, Via Stamira d'Ancona 20, 20127, Milan, Italy
| | - Hamid Hasson
- Department of Infectious Diseases, San Raffaele Scientific Institute and San Raffaele Vita-Salute University, Via Stamira d'Ancona 20, 20127, Milan, Italy
| | - Adriano Lazzarin
- Department of Infectious Diseases, San Raffaele Scientific Institute and San Raffaele Vita-Salute University, Via Stamira d'Ancona 20, 20127, Milan, Italy
| | - Paola Cinque
- Department of Infectious Diseases, San Raffaele Scientific Institute and San Raffaele Vita-Salute University, Via Stamira d'Ancona 20, 20127, Milan, Italy.
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