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Snijders BMG, Peters MJL, van den Brink S, van Trijp MJCA, de Jong PA, Vissers LATM, Verduyn Lunel FM, Emmelot-Vonk MH, Koek HL. Infectious Diseases and Basal Ganglia Calcifications: A Cross-Sectional Study in Patients with Fahr's Disease and Systematic Review. J Clin Med 2024; 13:2365. [PMID: 38673641 PMCID: PMC11050861 DOI: 10.3390/jcm13082365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 03/26/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Background: It is unclear whether patients with basal ganglia calcifications (BGC) should undergo infectious disease testing as part of their diagnostic work-up. We investigated the occurrence of possibly associated infections in patients with BGC diagnosed with Fahr's disease or syndrome and consecutively performed a systematic review of published infectious diseases associated with BGC. Methods: In a cross-sectional study, we evaluated infections in non-immunocompromised patients aged ≥ 18 years with BGC in the Netherlands, who were diagnosed with Fahr's disease or syndrome after an extensive multidisciplinary diagnostic work-up. Pathogens that were assessed included the following: Brucella sp., cytomegalovirus, human herpesvirus type 6/8, human immunodeficiency virus (HIV), Mycobacterium tuberculosis, rubella virus, and Toxoplasma gondii. Next, a systematic review was performed using MEDLINE and Embase (2002-2023). Results: The cross-sectional study included 54 patients (median age 65 years). We did not observe any possible related infections to the BGC in this population. Prior infection with Toxoplasma gondii occurred in 28%, and in 94%, IgG rubella antibodies were present. The positive tests were considered to be incidental findings by the multidisciplinary team since these infections are only associated with BGC when congenitally contracted and all patients presented with adult-onset symptoms. The systematic search yielded 47 articles, including 24 narrative reviews/textbooks and 23 original studies (11 case series, 6 cross-sectional and 4 cohort studies, and 2 systematic reviews). Most studies reported congenital infections associated with BGC (cytomegalovirus, HIV, rubella virus, Zika virus). Only two studies reported acquired pathogens (chronic active Epstein-Barr virus and Mycobacterium tuberculosis). The quality of evidence was low. Conclusions: In our cross-sectional study and systematic review, we found no convincing evidence that acquired infections are causing BGC in adults. Therefore, we argue against routine testing for infections in non-immunocompromised adults with BGC in Western countries.
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Affiliation(s)
- Birgitta M. G. Snijders
- Department of Geriatrics, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Mike J. L. Peters
- Department of Geriatrics, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Department of Internal Medicine, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | | | | | - Pim A. de Jong
- Department of Radiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Laurens A. T. M. Vissers
- Department of Internal Medicine, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Frans M. Verduyn Lunel
- Department of Medical Microbiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | | | - Huiberdina L. Koek
- Department of Geriatrics, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
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Bearden DR, Mwanza-Kabaghe S, Bositis CM, Dallah I, Johnson BA, Siddiqi OK, Elafros MA, Gelbard HA, Okulicz JF, Kalungwana L, Musonda N, Theodore WH, Mwenechanya M, Mathews M, Sikazwe IT, Birbeck GL. Early Initiation of Antiretroviral Therapy is Protective Against Seizures in Children With HIV in Zambia: A Prospective Case-Control Study. J Acquir Immune Defic Syndr 2024; 95:291-296. [PMID: 38032746 PMCID: PMC10922319 DOI: 10.1097/qai.0000000000003357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 09/11/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Seizures are relatively common among children with HIV in low- and middle-income countries and are associated with significant morbidity and mortality. Early treatment with antiretroviral therapy (ART) may reduce this risk by decreasing rates of central nervous system infections and HIV encephalopathy. METHODS We conducted a prospective, unmatched case-control study. We enrolled children with new-onset seizure from University Teaching Hospital in Lusaka, Zambia and 2 regional hospitals in rural Zambia. Controls were children with HIV and no history of seizures. Recruitment took place from 2016 to 2019. Early treatment was defined as initiation of ART before 12 months of age, at a CD4 percentage >15% in children aged 12-60 months or a CD4 count >350 cells/mm 3 for children aged 60 months or older. Logistic regression models were used to evaluate the association between potential risk factors and seizures. RESULTS We identified 73 children with new-onset seizure and compared them with 254 control children with HIV but no seizures. Early treatment with ART was associated with a significant reduction in the odds of seizures [odds ratio (OR) 0.04, 95% confidence interval: 0.02 to 0.09; P < 0.001]. Having an undetectable viral load at the time of enrollment was strongly protective against seizures (OR 0.03, P < 0.001), whereas history of World Health Organization Stage 4 disease (OR 2.2, P = 0.05) or CD4 count <200 cells/mm 3 (OR 3.6, P < 0.001) increased risk of seizures. CONCLUSIONS Early initiation of ART and successful viral suppression would likely reduce much of the excess seizure burden in children with HIV.
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Affiliation(s)
- David R Bearden
- Department of Neurology, University of Rochester, Rochester, NY
- University of Zambia School of Medicine, Lusaka, Zambia
- Department of Educational Psychology, University of Zambia, Lusaka, Zambia
| | | | | | - Ifunanya Dallah
- University of Rochester, Center for Health and Technology, Rochester, NY
| | - Brent A Johnson
- Department of Biostatistics, University of Rochester, Rochester, NY
| | - Omar K Siddiqi
- Department of Neurology, Beth Israel Deaconess Medical Center, Global Neurology Program, Boston, MA
- University of Zambia, University Teaching Hospitals, Lusaka, Zambia
| | | | | | - Jason F Okulicz
- San Antonio Military Medical Center, Infectious Diseases Service, HIV Medical Evaluation Unit, San Antonio, TX
| | - Lisa Kalungwana
- Department of Psychology, University of Zambia, Lusaka, Zambia
| | - Nkhoma Musonda
- Department of Neurology, University of Rochester, Rochester, NY
- University of Rochester, Center for Health and Technology, Rochester, NY
| | | | | | - Manoj Mathews
- University of Zambia, University Teaching Hospitals, Lusaka, Zambia
| | | | - Gretchen L Birbeck
- Department of Neurology, University of Rochester, Rochester, NY
- University of Zambia School of Medicine, Lusaka, Zambia
- University of Rochester, Center for Health and Technology, Rochester, NY
- University of Zambia, University Teaching Hospitals, Lusaka, Zambia
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Ravishankar M, Dallah I, Mathews M, Bositis CM, Mwenechanya M, Kalungwana‐Mambwe L, Bearden D, Navis A, Elafros MA, Gelbard H, Theodore WH, Koralnik IJ, Okulicz JF, Johnson BA, Belessiotis C, Ciccone O, Thornton N, Tsuboyama M, Siddiqi OK, Potchen MJ, Sikazwe I, Birbeck GL. Clinical characteristics and outcomes after new-onset seizure among Zambian children with HIV during the antiretroviral therapy era. Epilepsia Open 2022; 7:315-324. [PMID: 35305291 PMCID: PMC9159241 DOI: 10.1002/epi4.12595] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/10/2022] [Accepted: 03/12/2022] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE This study describes clinical profiles including human immunodeficiency virus (HIV) disease history and seizure etiology among children living with HIV presenting with new-onset seizure during the era of antiretroviral therapy (ART) in Zambia. 30-day mortality and cause of death are also reported. METHODS Children living with HIV (CLWHIV) with new-onset seizures were prospectively evaluated at one large urban teaching hospital and two non-urban healthcare facilities. Interviews with family members, review of medical records, and where needed, verbal autopsies were undertaken. Two clinicians who were not responsible for the patients' care independently reviewed all records and assigned seizure etiology and cause of death with adjudication as needed. RESULTS From April 2016 to June 2019, 73 children (49 urban, 24 rural) were identified. Median age was 6 years (IQR 2.2-10.0) and 39 (53%) were male children. Seizures were focal in 36 (49%) and were often severe, with 37% presenting with multiple recurrent seizures in the 24 hours before admission or in status epilepticus. Although 36 (49%) were on ART at enrollment, only 7 of 36 (19%) were virally suppressed. Seizure etiologies were infectious in over half (54%), with HIV encephalitis, bacterial meningitis, and tuberculous meningitis being the most common. Metabolic causes (19%) included renal failure and hypoglycemia. Structural lesions identified on imaging accounted for 10% of etiologies and included stroke and non-accidental trauma. No etiology could be identified in 12 (16%) children, most of whom died before the completion of clinical investigations. Twenty-two (30%) children died within 30 days of the index seizure. SIGNIFICANCE Despite widespread ART roll out in Zambia, new-onset seizure in CLWHIV occurs in the setting of advanced, active HIV disease. Seizure severity/burden is high as is early mortality. Enhanced programs to assure early ART initiation, improve adherence, and address ART failure are needed to reduce the burden of neurological injury and premature death in CLWHIV.
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Affiliation(s)
| | - Ifunanya Dallah
- Center for Health + TechnologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Manoj Mathews
- University Teaching Hospitals Children's HospitalLusakaZambia
| | | | | | | | - David Bearden
- University of Rochester Medical CenterRochesterNew YorkUSA
| | | | | | - Harris Gelbard
- University of Rochester Medical CenterRochesterNew YorkUSA
| | | | - Igor J. Koralnik
- Northwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | | | | | | | - Ornella Ciccone
- University Teaching Hospitals Children's HospitalLusakaZambia
- University of ZambiaLusakaZambia
| | | | | | | | - Michael J. Potchen
- University of Rochester Medical CenterRochesterNew YorkUSA
- Zambian College of Medicine & SurgeryLusakaZambia
| | | | - Gretchen L. Birbeck
- University Teaching Hospitals Children's HospitalLusakaZambia
- Epilepsy DivisionDepartment of NeurologyUniversity of RochesterRochesterNew YorkUSA
- Epilepsy Care TeamChikankata HospitalMazabukaZambia
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Cerebrovascular Disease in Children Perinatally Infected With Human Immunodeficiency Virus in Zambia. Pediatr Neurol 2020; 112:14-21. [PMID: 32871411 PMCID: PMC7554106 DOI: 10.1016/j.pediatrneurol.2020.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/31/2020] [Accepted: 08/01/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND High rates of cerebrovascular disease (CVD) have previously been described in pediatric human immunodeficiency virus (HIV). However, little is known about pediatric CVD in the era of antiretroviral therapy or about the contribution of CVD to HIV-associated neurocognitive disorders. METHODS We completed a neuroimaging substudy of the HIV-Associated Neurocognitive Disorders in Zambia study, a prospective cohort study of neurocognitive complications of pediatric HIV. Brain magnetic resonance imaging (1.5 T) was acquired for 34 HIV+ children on antiretroviral therapy and 17 HIV-exposed uninfected children (aged eight to 17 years). Demographics, medical history, neurological examination, and neuropsychologic testing results were collected. Two neuroradiologists, unaware of HIV status and clinical course, read the scans. RESULTS CVD was identified in seven of 34 children with HIV (HIV+ CVD+) and no HIV-exposed uninfected children (21% vs 0%, P = 0.05). Three participants had white matter changes suggestive of small vessel disease, four had infarcts, and two had evidence of intracranial artery stenosis. Age of antiretroviral therapy initiation and exposure to protease inhibitors or efavirenz was not significantly different between children with and without CVD. HIV+ CVD+ children had significantly worse scores on a summary measure of cognition than the HIV+ CVD- group (NPZ8 score -0.57 vs 0.33, P = 0.04). CONCLUSIONS This study demonstrates high rates of CVD in children with HIV despite antiretroviral therapy, and worse cognitive performance in children with CVD. Longitudinal studies are necessary to determine the mechanisms and incidence of new-onset CVD in children with HIV.
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Ciccone O, Mathews M, Birbeck GL. Management of acute seizures in children: A review with special consideration of care in resource-limited settings. Afr J Emerg Med 2017; 7:S3-S9. [PMID: 30505668 PMCID: PMC6246874 DOI: 10.1016/j.afjem.2017.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 08/14/2017] [Accepted: 09/15/2017] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION We sought to review recent evidence-based guidelines and where applicable, primary data to extrapolate insights into the appropriate management of acute seizures in children in resource-limited settings. METHODS PubMed and Google scholar searches were conducted with attention to publications from the last three to five years, including a focused search for acute seizure management guidelines relevant to resource limited settings. Since all guidelines to date, except the World Health Organization's, assume ready access to invasive ventilation and advanced diagnostic testing, guidelines and primary data were used to propose management appropriate for resource-limited settings where respiratory suppression from treatment presents a major challenge in management. RESULTS Acute seizures are among the commonest medical emergencies encountered in the African settings. Seizure management must occur simultaneously with the diagnostic assessment, which should include addressing life threatening causes (e.g. hypoglycaemia, malaria) and with attention given to the most likely aetiology in a particular region or setting. For ongoing seizures, initial treatment with benzodiazepines is indicated. There is evidence of efficacy for several agents and delivery modes. Longer-acting antiepileptic drugs (AEDs) should be on hand if acute seizures fail to respond to two doses of benzodiazepines. There is little direct evidence comparing the relative efficacy of different long-acting AEDs for acute seizure management in African children. Findings suggest that generalising data from Western settings, where different aetiologies and risk factors for seizures prevail, may be inappropriate. DISCUSSION Though treatment options and diagnostics may be dictated by available medications and capacity, it is possible for virtually any healthcare setting to develop a relevant and feasible local guideline for seizure management. Clear specifications on when to refer to a higher level of care should be part of the care plan.
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Affiliation(s)
- Ornella Ciccone
- The University of Zambia, School of Medicine, Lusaka, Zambia
- University Teaching Hospital, 1 Nationalist Road, P.O. Box 50440, Ridgeway, Lusaka, Zambia
| | - Manoj Mathews
- University Teaching Hospital, 1 Nationalist Road, P.O. Box 50440, Ridgeway, Lusaka, Zambia
| | - Gretchen L. Birbeck
- Chikankata Epilepsy Care Team, Chikankata Hospital, Private Bag S2, Mazabuka, Zambia
- Strong Epilepsy Center, Department of Neurology, University of Rochester, 265 Crittenden Blvd, Rochester, NY 14641, United States
- Corresponding author.
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Jensen BK, Monnerie H, Mannell MV, Gannon PJ, Espinoza CA, Erickson MA, Bruce-Keller AJ, Gelman BB, Briand LA, Pierce RC, Jordan-Sciutto KL, Grinspan JB. Altered Oligodendrocyte Maturation and Myelin Maintenance: The Role of Antiretrovirals in HIV-Associated Neurocognitive Disorders. J Neuropathol Exp Neurol 2015; 74:1093-118. [PMID: 26469251 PMCID: PMC4608376 DOI: 10.1097/nen.0000000000000255] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Despite effective viral suppression through combined antiretroviral therapy (cART), approximately half of HIV-positive individuals have HIV-associated neurocognitive disorders (HAND). Studies of antiretroviral-treated patients have revealed persistent white matter abnormalities including diffuse myelin pallor, diminished white matter tracts, and decreased myelin protein mRNAs. Loss of myelin can contribute to neurocognitive dysfunction because the myelin membrane generated by oligodendrocytes is essential for rapid signal transduction and axonal maintenance. We hypothesized that myelin changes in HAND are partly due to effects of antiretroviral drugs on oligodendrocyte survival and/or maturation. We showed that primary mouse oligodendrocyte precursor cell cultures treated with therapeutic concentrations of HIV protease inhibitors ritonavir or lopinavir displayed dose-dependent decreases in oligodendrocyte maturation; however, this effect was rapidly reversed after drug removal. Conversely, nucleoside reverse transcriptase inhibitor zidovudine had no effect. Furthermore, in vivo ritonavir administration to adult mice reduced frontal cortex myelin protein levels. Finally, prefrontal cortex tissue from HIV-positive individuals with HAND on cART showed a significant decrease in myelin basic protein compared with untreated HIV-positive individuals with HAND or HIV-negative controls. These findings demonstrate that antiretrovirals can impact myelin integrity and have implications for myelination in juvenile HIV patients and myelin maintenance in adults on lifelong therapy.
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Affiliation(s)
- Brigid K. Jensen
- Department of Neuroscience, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Neurology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pathology, School of Dental Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hubert Monnerie
- Department of Neurology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Maggie V. Mannell
- Department of Neuroscience, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick J. Gannon
- Department of Pathology, School of Dental Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cagla Akay Espinoza
- Department of Pathology, School of Dental Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle A. Erickson
- Department of Pathology, School of Dental Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Annadora J. Bruce-Keller
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, Louisiana
| | - Benjamin B. Gelman
- Department of Pathology, University of Texas Medical Branch, Galveston, Texas
| | - Lisa A. Briand
- Department of Psychology, College of Liberal Arts, Temple University, Philadelphia, Pennsylvania
| | - R. Christopher Pierce
- Center for Neurobiology and Behavior, Department of Psychiatry, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kelly L. Jordan-Sciutto
- Department of Pathology, School of Dental Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Judith B. Grinspan
- Department of Neurology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Update on the key developments of the neurologic complications in children infected with HIV. Curr Opin HIV AIDS 2015; 9:533-8. [PMID: 25188807 DOI: 10.1097/coh.0000000000000101] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To discuss recent research findings of neurologic complications in HIV-infected children, specifically addressing neuroinfections, cerebrovascular disease, epilepsy and neurocognitive complications. The range of neurologic childhood onset complications is diverse and often overlaps diseases previously considered only to manifest in adults. In the pediatric population, these complications frequently have their own unique disease identity, which may be related to maturational patterns evident in the developing brain. RECENT FINDINGS Developments regarding the pathogenesis of neuroAIDS, treatment of tuberculous meningitis and prevention of bacterial meningitis are described. With the advent of neuroimaging, there is greater insight into silent cerebrovascular events and the progression of vasculopathy in HIV-infected children. The role of surgical intervention for affected cases is a novel area that could alter the otherwise poor prognosis. Epilepsy, although common as a burden of disease, carries its own additional complications with regard to cross reactivity with various antiretroviral therapies. Increased risk of low bone mineral density supports a role for supplementation with vitamin D in people receiving antiretroviral therapy and antiepileptic drugs. Recognition of the early neurobiological, as well as spectrum of neurocognitive effects of the HIV on the developing brain, is evolving, as greater numbers of children are treated early. Developments in these critical areas are described. SUMMARY Recent research reflects the need for improved strategies to prevent neuroinfections, more effective screening and interventions for vasculopathy and better antiepileptic drugs for HIV-infected children. Furthermore, our understanding of the timing and spectrum of neurocognitive complications is evolving.
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Wyllie E, Rincon SP, Pierce VM. Case records of the Massachusetts General Hospital. Case 16-2015. A 9-year-old girl with loss of consciousness and seizures. N Engl J Med 2015; 372:2050-8. [PMID: 25992750 DOI: 10.1056/nejmcpc1501149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Potchen MJ, Siddiqi OK, Elafros MA, Koralnik IJ, Theodore WH, Sikazwe I, Kalungwana L, Bositis CM, Birbeck GL. Neuroimaging abnormalities and seizure recurrence in a prospective cohort study of zambians with human immunodeficiency virus and first seizure. Neurol Int 2014; 6:5547. [PMID: 25568738 PMCID: PMC4274408 DOI: 10.4081/ni.2014.5547] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 08/11/2014] [Indexed: 02/06/2023] Open
Abstract
In HIV-positive individuals with first seizure, we describe neuroimaging findings, detail clinical and demographic risk factors for imaging abnormalities, and evaluate the relationship between imaging abnormalities and seizure recurrence to determine if imaging abnormalities predict recurrent seizures. Among 43 participants (mean 37.4 years, 56% were male), 16 (37%) were on antiretroviral drugs, 32 (79%) had advanced HIV disease, and (28) 66% had multiple seizures and/or status epilepticus at enrollment. Among those with cerebrospinal fluid studies, 14/31 (44%) had opportunistic infections (OIs). During follow-up, 9 (21%) died and 15 (35%) experienced recurrent seizures. Edema was associated with OIs (odds ratio: 8.79; confidence interval: 1.03-236) and subcortical atrophy with poorer scores on the International HIV Dementia Scale) (5.2 vs. 9.3; P=0.002). Imaging abnormalities were not associated with seizure recurrence or death (P>0.05). Seizure recurrence occurred in at least a third and over 20% died during follow-up. Imaging was not predictive of recurrent seizure or death, but imaging abnormalities may offer additional diagnostic insights in terms of OI risk and cognitive impairment.
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Affiliation(s)
- Michael J. Potchen
- Neuroradiology Division Department of Imaging Sciences, University of Rochester, NY, USA
| | - Omar K. Siddiqi
- Department of Internal Medicine, University of Zambia, Lusaka, Zambia,Division of NeuroVirology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Melissa A. Elafros
- College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - Igor J. Koralnik
- Division of NeuroVirology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - William H. Theodore
- Clinical Epilepsy Section, United States National Institutes of Health, Bethesda, MD, USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Lisa Kalungwana
- Department of Psychology, University of Zambia, Lusaka, Zambia
| | | | - Gretchen L. Birbeck
- Epilepsy Division, Department of Neurology, University of Rochester, NY, USA,Chikankata Epilepsy Care Team, Mazabuka, Zambia,Epilepsy Division, Department of Neurology, University of Rochester, 265 Crittenden Blvd, Rochester, NY 14624, USA. +1.585.273.4265 - +1.517.507.5440.
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Abstract
Progressive multifocal leukoencephalopathy is a rare, demyelinating disease of the central nervous system caused by JC virus. Fewer than 30 cases have been reported in HIV- and non-infected children. We report the case of a 15-year-old girl with progressive multifocal leukoencephalopathy and AIDS who presented with nystagmus, dysarthria and ataxia. Following combined antiretroviral therapy, she developed immune reconstitution inflammatory syndrome, which proved fatal.
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Donald KA, Hoare J, Eley B, Wilmshurst JM. Neurologic complications of pediatric human immunodeficiency virus: implications for clinical practice and management challenges in the African setting. Semin Pediatr Neurol 2014; 21:3-11. [PMID: 24655398 DOI: 10.1016/j.spen.2014.01.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Approximately 3.4 million children worldwide are affected with human immunodeficiency virus (HIV)/AIDS with more than 90% of them residing in sub-Saharan Africa, according to the World Health Organization. A significant proportion of the children eligible for treatment with antiretroviral therapy are not currently receiving it. Neurologic manifestations of HIV are common in both adults and children. There is a large spectrum of neurologic conditions that may be caused by the virus; however, early invasion of the central nervous system by the virus, affecting the developing fetal and infant brain, is believed to result in the most common primary HIV-related central nervous system complication, HIV encephalopathy. This article summarizes the spectrum of neuro-HIV in children, focuses on the neurocognitive and behavioral sequelae, reviews the effects of treatment on the primary neurologic effects of the disease, and discusses the specific challenges of identifying and managing these problems in resource-limited contexts, such as those found on the African continent.
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Affiliation(s)
- Kirsten Ann Donald
- Division of Developmental Paediatrics, School of Child and Adolescent Health, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa.
| | - Jackie Hoare
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Brian Eley
- Paediatric Infectious Diseases Unit, School of Child and Adolescent Health, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Jo M Wilmshurst
- Division of Paediatric Neurology, School of Child and Adolescent Health, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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van Arnhem LA, Bunders MJ, Scherpbier HJ, Majoie CBLM, Reneman L, Frinking O, Poll-The BT, Kuijpers TW, Pajkrt D. Neurologic abnormalities in HIV-1 infected children in the era of combination antiretroviral therapy. PLoS One 2013; 8:e64398. [PMID: 23691211 PMCID: PMC3654960 DOI: 10.1371/journal.pone.0064398] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 04/13/2013] [Indexed: 12/05/2022] Open
Abstract
Background Pediatric HIV-1 infection is associated with neurologic abnormalities. In recent years, the neurological outcome of HIV-1 infected children has substantially improved with combination antiretroviral therapy (cART). However, data regarding the long-term effect of cART and neurologic outcome are limited. Methods In the Pediatric Amsterdam Cohort on HIV-1 study, 59 perinatally HIV-1 infected children were evaluated from 1992–2010. All children underwent neurological examination and neuro-imaging studies, including CT-scan and/or MRI imaging. Fisher exact and Kruskal-Wallis tests were used to compare clinical deviations of neuro-imaging studies with HIV-1 related parameters, including CD4+ T cell count, HIV-1 viral load in blood and cerebrospinal fluid (CSF), and duration of cART as well as neurological examination. Results Abnormal neurologic examinations in these HIV-1 infected children included language impairment (22%), abnormal muscle tone (hyper/hypotonia) (14%) and delay in reaching developmental milestones (12%). Ventricular enlargement and sulcal widening (29%) and white matter lesions (38%) were prominent findings. White matter lesions were positively correlated with HIV-1 viral load levels. In a small follow-up sub study white matter lesions did not improve while children with ventricular enlargement and sulcal widening showed improvements whilst being treated with cART. Conclusions In the current era of cART HIV-1 infected children still frequently show neurological impairments together with abnormal neuro-imaging.
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Affiliation(s)
- Lotus A van Arnhem
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Centre (AMC), Amsterdam, The Netherlands
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13
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Wilmshurst JM. Diagnosis and management of pediatric peripheral neuropathies in resource-poor settings. FUTURE NEUROLOGY 2013. [DOI: 10.2217/fnl.12.97] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The diagnosis of a peripheral neuropathy in a child who resides in the majority of resource-poor settings is based on the history taken and the clinical examination. The majority of children, unless they demonstrate additional clinical markers, will lack a more definitive diagnosis beyond the label ‘peripheral neuropathy’. The treatable, typically acquired conditions, which are prevalent in these settings, are the priority to identify. This would include neuroinfections, neuroinflammation, toxins and vitamin deficiencies. The management of children with peripheral neuropathies in resource-poor settings must be approached in a different manner to that of more ‘resource-equipped’ settings. Secondary or tertiary centers are scarce, often significant distances away from the patient, and this leads to long delays before access is possible. Most children present to primary healthcare settings and are seen by practitioners with little training in the features suggestive of a peripheral neuropathy. As such, basic aids to assist the healthcare worker in the early recognition and interventions of a child with a peripheral neuropathy are important. In addition, there must be recognition of the child with a rapidly progressive neuropathy where a life-threatening condition is present, and urgent referral to a tertiary setting made wherever possible.
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Affiliation(s)
- Jo M Wilmshurst
- Pediatric Neurology Department, Red Cross War Memorial Children’s Hospital, University of Cape Town, 7700, Cape Town, South Africa
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Govender R, Eley B, Walker K, Petersen R, Wilmshurst JM. Neurologic and neurobehavioral sequelae in children with human immunodeficiency virus (HIV-1) infection. J Child Neurol 2011; 26:1355-64. [PMID: 21616924 DOI: 10.1177/0883073811405203] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The range and extent of neurologic and neurobehavioral complications of human immunodeficiency virus (HIV-1) infection in children are under-described. Seventy-eight children with HIV-1 infection (32 females) were assessed for neurologic complications. Forty-six children had abnormal neurology examinations. Thirty-three children had global pyramidal tract signs, 5 had a hemiparesis, 4 had peripheral neuropathy, 18 had visual impairment, and 5 had hearing impairment. Thirty-nine of 63 children over 1 year of age had neurobehavioral problems. Of 24 children with HIV encephalopathy, 74% had severe immunosuppression and 45% were not receiving antiretroviral therapy. Twelve children had prior opportunistic central nervous system infections, and 9 had epilepsy. Diverse neurologic and neurobehavioral deficits are common in children with HIV-1 infection. Children with severe immunosuppression, who were not receiving antiretroviral therapy, were growth impaired and less than 1 year of age, were at greatest risk for developing neurologic complications.
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Affiliation(s)
- Rajeshree Govender
- Department of Paediatric Neurology, Red Cross Children's Hospital, School of Child and Adolescent Health, University of Cape Town, South Africa.
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