1
|
Guha D, Misra V, Yin J, Gabuzda D. CSF Inflammation Markers Associated with Asymptomatic Viral Escape in Cerebrospinal Fluid of HIV-Positive Individuals on Antiretroviral Therapy. Viruses 2023; 15:1829. [PMID: 37766236 PMCID: PMC10534549 DOI: 10.3390/v15091829] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/27/2023] [Accepted: 08/28/2023] [Indexed: 09/29/2023] Open
Abstract
HIV establishes a viral reservoir in the CNS despite viral suppression in the blood on antiretroviral therapy (ART). In a minority of people with HIV (PWH), HIV RNA is detectable in CSF when HIV RNA in plasma is undetectable or HIV RNA levels are higher in CSF compared with plasma, an event termed CSF viral escape that can occur with or without neurological symptoms. Asymptomatic CSF viral escape occurs in 3-20% of PWH on ART, yet associated biomarkers are unclear. To identify biomarkers associated with asymptomatic CSF viral escape, we performed a matched group study of PWH on ART with vs. without CSF viral escape (n = 10 and n = 60, respectively, matched for age, duration of HIV infection, nadir CD4 count, and ART regimen) and 50 HIV-negative controls. PWH were on 3 or more ART drugs for >1 year, and the group with no CSF viral escape was suppressed below 50 copies/mL in plasma and CSF. Biomarkers of inflammation (IFN-γ, IL-1β, IL-6, IL-8, IL-15, IP-10, MCP-1, VEGF), cell adhesion (ICAM-1, VCAM-1), CNS injury (NFL), and glial activation (GFAP, YKL-40) were measured in paired plasma and CSF using the Meso Scale Discovery platform. PWH with vs. without CSF viral escape had more individuals (40%) with a plasma viral load (VL) > 50 copies/mL, higher CSF VL (median 156 vs. 40 copies/mL; p < 0.0001), lower CD4 count (318 vs. 512; p = 0.045), and higher CSF WBC (median [IQR] 4 [0-22] vs. 2 [0-4] cells/µL; p = 0.15) but similar proportions with HIV-associated neurocognitive disorders (HAND) (50% vs. 47%). CSF viral escape was associated with increased IL-1β, IFN-γ, IP-10, ICAM-1, and VCAM-1 in CSF but not plasma; IP-10 had the strongest association (p = 0.0008). CSF VL and WBC correlated with IFN-γ, IP-10, ICAM-1, and VCAM-1 (p < 0.05). Although markers of CNS injury showed no significant association with asymptomatic CSF viral escape, CSF YKL-40 correlated positively with CSF IL-1β (p = 0.003), IFN-γ (p = 0.0008), IP-10 (p < 0.0001), and NFL (p = 0.06) and negatively with neurocognitive T scores (p = 0.02). These findings identify CSF inflammation and glial activation markers that may serve as surrogate measures of HIV persistence in the CNS for future studies on therapeutics targeting the CNS reservoir.
Collapse
Affiliation(s)
- Debjani Guha
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
| | - Vikas Misra
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
| | - Jun Yin
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
| | - Dana Gabuzda
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
- Department of Neurology, Harvard Medical School, Boston, MA 02115, USA
| |
Collapse
|
2
|
Killingsworth L, Spudich S. Neuropathogenesis of HIV-1: insights from across the spectrum of acute through long-term treated infection. Semin Immunopathol 2022; 44:709-724. [PMID: 35882661 PMCID: PMC10126949 DOI: 10.1007/s00281-022-00953-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 05/20/2022] [Indexed: 01/16/2023]
Abstract
This review outlines the neuropathogenesis of HIV, from initial HIV entry into the central nervous system (CNS) to chronic infection, focusing on key advancements in the last 5 years. Discoveries regarding acute HIV infection reveal timing and mechanisms of early HIV entry and replication in the CNS, early inflammatory responses, and establishment of genetically distinct viral reservoirs in the brain. Recent studies additionally explore how chronic HIV infection is maintained in the CNS, examining how the virus remains in a latent "hidden" state in diverse cells in the brain, and how this leads to sustained pathological inflammatory responses. Despite viral suppression with antiretroviral therapy, HIV can persist and even replicate in the CNS, and associate with ongoing neuropathology including CD8 + T-lymphocyte mediated encephalitis. Crucial investigation to advance our understanding of the immune mechanisms that both control viral infection and lead to pathological consequences in the brain is necessary to develop treatments to optimize long-term neurologic health in people living with HIV.
Collapse
Affiliation(s)
- Lauren Killingsworth
- Department of Neurology, Yale University School of Medicine, 300 George Street, Room 8300c, New Haven, CT, 06520, USA
| | - Serena Spudich
- Department of Neurology, Yale University School of Medicine, 300 George Street, Room 8300c, New Haven, CT, 06520, USA.
| |
Collapse
|
3
|
Muir RT, Suthiphosuwan S, Bharatha A, Lin A, Munoz D, Ostrowski M, Schneider R. Reversible Small Vessel Vasculitis and Encephalitis in HIV Antiretroviral Resistance. J Neuropathol Exp Neurol 2021; 80:89-92. [PMID: 33212472 PMCID: PMC7749715 DOI: 10.1093/jnen/nlaa106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Ryan T Muir
- Adult Neurology Residency Training Program, Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Neurology, Department of Medicine
| | | | | | - Amy Lin
- Division of Neuroradiology, Department of Radiology
| | - David Munoz
- Department of Laboratory Medicine, Division of Pathology
| | - Mario Ostrowski
- Division of Infectious Diseases, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | |
Collapse
|
4
|
Eisenmenger LB, Sawatzky BD, Manunga JM, Sosman JM, Rowley HA, Kuner AD. Progressive Neurologic Symptoms in the Setting of HIV: A Rare Case of Neurosymptomatic CSF HIV Escape. Neurology 2021; 97:389-390. [PMID: 34039732 PMCID: PMC8397590 DOI: 10.1212/wnl.0000000000012238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Laura B Eisenmenger
- From the Departments of Radiology (L.B.E., H.A.R., A.D.K.) and Medicine (J.M.S.), University of Wisconsin, Madison; Department of Radiology (B.D.S.), University of Vermont, Burlington; and Division of Vascular and Endovascular Surgery (J.M.M.), Minneapolis Heart Institute, Abbott Northwestern Hospital, MN.
| | - Benjamin D Sawatzky
- From the Departments of Radiology (L.B.E., H.A.R., A.D.K.) and Medicine (J.M.S.), University of Wisconsin, Madison; Department of Radiology (B.D.S.), University of Vermont, Burlington; and Division of Vascular and Endovascular Surgery (J.M.M.), Minneapolis Heart Institute, Abbott Northwestern Hospital, MN
| | - Jesse M Manunga
- From the Departments of Radiology (L.B.E., H.A.R., A.D.K.) and Medicine (J.M.S.), University of Wisconsin, Madison; Department of Radiology (B.D.S.), University of Vermont, Burlington; and Division of Vascular and Endovascular Surgery (J.M.M.), Minneapolis Heart Institute, Abbott Northwestern Hospital, MN
| | - James M Sosman
- From the Departments of Radiology (L.B.E., H.A.R., A.D.K.) and Medicine (J.M.S.), University of Wisconsin, Madison; Department of Radiology (B.D.S.), University of Vermont, Burlington; and Division of Vascular and Endovascular Surgery (J.M.M.), Minneapolis Heart Institute, Abbott Northwestern Hospital, MN
| | - Howard A Rowley
- From the Departments of Radiology (L.B.E., H.A.R., A.D.K.) and Medicine (J.M.S.), University of Wisconsin, Madison; Department of Radiology (B.D.S.), University of Vermont, Burlington; and Division of Vascular and Endovascular Surgery (J.M.M.), Minneapolis Heart Institute, Abbott Northwestern Hospital, MN
| | - Anthony D Kuner
- From the Departments of Radiology (L.B.E., H.A.R., A.D.K.) and Medicine (J.M.S.), University of Wisconsin, Madison; Department of Radiology (B.D.S.), University of Vermont, Burlington; and Division of Vascular and Endovascular Surgery (J.M.M.), Minneapolis Heart Institute, Abbott Northwestern Hospital, MN
| |
Collapse
|
5
|
Lucas SB, Wong KT, Nightingale S, Miller RF. HIV-Associated CD8 Encephalitis: A UK Case Series and Review of Histopathologically Confirmed Cases. Front Neurol 2021; 12:628296. [PMID: 33868143 PMCID: PMC8047670 DOI: 10.3389/fneur.2021.628296] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/11/2021] [Indexed: 11/30/2022] Open
Abstract
HIV-associated CD8-encephalitis (HIV-CD8E) is a severe inflammatory disorder dominated by infiltration of the brain by CD8+ T-lymphocytes. It occurs in people with HIV, typically when the virus is apparently well-controlled by antiretroviral treatment (ART). HIV-CD8E presents with symptoms and signs related to marked cerebral inflammation and swelling, and can lead to coma and death unless treated promptly with corticosteroids. Risk events such as intercurrent infection, antiretroviral therapy interruption, immune reconstitution inflammatory syndrome (IRIS) after starting ART, and concomitant associations such as cerebrospinal fluid (CSF) HIV viral escape have been identified, but the pathogenesis of the disorder is not known. We present the largest case series of HIV-CD8E to date (n = 23), representing histopathologically confirmed cases in the UK. We also summarize the global literature representing all previously published cases with histopathological confirmation (n = 30). A new variant of HIV-CD8E is described, occurring on a background of HIV encephalitis (HIVE).Together these series, totalling 53 patients, provide new insights. CSF HIV viral escape was a frequent finding in HIV-CD8E occurring in 68% of those with CSF available and tested; ART interruption and IRIS were important, both occurring in 27%. Black ethnicity appeared to be a key risk factor; all but two UK cases were African, as were the majority of the previously published cases in which ethnicity was stated. We discuss potential pathogenic mechanisms, but there is no unifying explanation over all the HIV-CD8E scenarios.
Collapse
Affiliation(s)
- Sebastian B. Lucas
- Department of Cellular Pathology, Guys and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Kum T. Wong
- Department of Pathology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Sam Nightingale
- Department of Neurology, University of Cape Town, Cape Town, South Africa
| | - Robert F. Miller
- Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, United Kingdom
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, United Kingdom
| |
Collapse
|
6
|
Symptomatic cerebrospinal fluid HIV escape syndrome in a patient on highly active antiretroviral therapy and suppressed plasma viral load. AIDS 2019; 33:2444-2446. [PMID: 31764112 DOI: 10.1097/qad.0000000000002370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
7
|
Abstract
: Cerebrospinal fluid (CSF) viral escape is defined by detectable HIV-RNA in CSF despite undetectable or lower-than-CSF level in plasma of patients receiving combination antiretroviral therapy (cART). This condition may occasionally be associated with neurological problems, consisting of new and progressive cognitive decline and/or focal symptoms and signs, defining the 'symptomatic CSF escape'. Brain MRI usually shows diffuse white matter hyperintensities that recall the presentation of HIV encephalopathy in the precART era. However, patients develop symptomatic CSF escape with relatively high CD4 cell counts and suppressed or low systemic virus replication. In addition, the frequent CSF pleocytosis and the pathological demonstration of CD8 T-cell brain infiltrates in some cases of symptomatic escape indicate that inflammation is an important component in the pathogenesis of this condition. Low nadir CD4 cells are common, likely reflecting the establishment of a HIV reservoir in the central nervous system (CNS). CSF escape seems to result from reactivation of CNS infection when cART potency is lowered, because of low patient's adherence, drug resistance, or use of drug combinations that are poorly effective in the CNS and cART optimization is key to revert escape and neurological disease in the great majority of cases.
Collapse
|
8
|
HIV Cerebrospinal Fluid Escape and Neurocognitive Pathology in the Era of Combined Antiretroviral Therapy: What Lies Beneath the Tip of the Iceberg in Sub-Saharan Africa? Brain Sci 2018; 8:brainsci8100190. [PMID: 30347806 PMCID: PMC6211092 DOI: 10.3390/brainsci8100190] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 10/16/2018] [Accepted: 10/17/2018] [Indexed: 11/17/2022] Open
Abstract
Neurocognitive impairment remains an important HIV-associated comorbidity despite combination antiretroviral therapy (ART). Since the advent of ART, the spectrum of HIV-associated neurocognitive disorder (HAND) has shifted from the most severe form to milder forms. Independent replication of HIV in the central nervous system despite ART, so-called cerebrospinal fluid (CSF) escape is now recognised in the context of individuals with a reconstituted immune system. This review describes the global prevalence and clinical spectrum of CSF escape, it role in the pathogenesis of HAND and current advances in the diagnosis and management. It highlights gaps in knowledge in sub-Saharan Africa where the HIV burden is greatest and discusses the implications for this region in the context of the global HIV treatment scale up.
Collapse
|