Early Initiation of Antiretroviral Therapy is Protective Against Seizures in Children With HIV in Zambia: A Prospective Case-Control Study

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.

Global morbidity and mortality of central nervous system tuberculosis: a systematic review and meta-analysis

Background

Tuberculosis (TB) is the second most common cause of death due to a single infectious agent worldwide after COVID-19. Up to 15% of the cases are extrapulmonary, and if it is located in the central nervous system (CNS-TB), it presents high morbidity and mortality. Still, the global epidemiology of CNS-TB remains unknown.

Aim

To estimate the global prevalence and incidence of CNS-TB based on the available literature.

Methods

We systematically searched in MEDLINE, Cochrane Central, Scopus, and LILACS databases (April 2020) and included observational studies evaluating the epidemiology of CNS-TB. Two independent researchers selected and assessed the quality of the studies and extracted relevant data. We performed random-effects model meta-analysis of proportions to estimate the pooled prevalence. The protocol of this study was registered in PROSPERO (CRD 42018103946).

Results

We included 53 studies from 28 countries, representing 12,621 patients with CNS-TB. The prevalence of CNS-TB was 2 per 100,000 inhabitants. According to the clinical setting, the prevalence of CNS-TB represented the 13.91% of all cases of meningitis and 4.55% of all cases of TB. The mortality was calculated by tuberculous meningitis due to the lack of data of other presentation, and it rose up to 42.12% in hospitalized patients. The burden of countries’ TB, Human Development Index (HDI), and the prevalence of HIV were the most important prevalence moderators, especially in patients with TB. No data on incidence were found.

Conclusion

The prevalence and mortality of CNS-TB remain high, and TB meningitis is the most frequent presentation. The highest prevalence was reported in developing countries, and its main moderators were the countries’ HDI and HIV infection. Our study was limited by high heterogeneity, risk of bias, and potential data under registration from developing countries. The integration of CNS-TB early detection and management into national TB programs and population-based studies from developing countries are needed for better global estimation and response.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-022-11052-8.

Late diagnosis of human immunodeficiency virus infection is linked to higher rates of epilepsy in children in the Eastern Cape of South Africa

BACKGROUND

Human immunodeficiency virus (HIV)-positive children may present with a wide range of neurological disorders. Among these, epilepsy is of key concern because of its lifelong impact and potential for damage to the central nervous system (CNS). Few studies in developing regions have investigated the prevalence and aetiology of epilepsy in HIV-infected children as a key population.

OBJECTIVES

We describe the prevalence of epilepsy, associated neurological disabilities, immunological status, clinical stage and history of CNS infection at epilepsy diagnosis in a cohort of HIV-infected children receiving antiretroviral therapy (ART) in the Eastern Cape of South Africa.

METHODS

We conducted a retrospective study (2004-2014) at two major referral sites for HIV-infected children diagnosed with epilepsy aged 0-16 years. Eligible subjects were extracted from the electronic medicine bridging access to care in excellence (EMBRACE) Paediatric Cohort using the Paediatric ART Data Management Tool (PADMT). Fixed data fields were interrogated for exposures to antiepileptic drugs. Unstructured 'comments' fields were searched for the terms: epilepsy, seizures, fits and szs, as well as abbreviated versions of common antiepileptic drug names. Eligible subject folders were then retrieved to validate the digital data.

RESULTS

From 2139 children enrolled in the two sites, 53 children were diagnosed with epilepsy (2.48%). In these, the median CD4 count was 591 cells/mm3, and the mean viral load was 4.9 log copies/mL, with undetectable viral loads in only seven children (14.0%). World Health Organization (WHO) clinical HIV stage was available for 46 patients of the sample, with 3, 6, 26 and 11 children graded at stages 1, 2, 3 and 4, respectively. Forty percent children had a history of CNS infection prior to the epilepsy diagnosis, and 55% children were reported to have school problems.

CONCLUSIONS

In this descriptive study, the prevalence of epilepsy among children with HIV was 2.48%, mostly diagnosed in advanced HIV-disease stages. Our findings support the usefulness of early detection and initiation of ART in HIV-infected children in order to reduce the risk of epilepsy. In addition, our study demonstrates that novel techniques are effective in accessing cohort-level data that allow interrogation of both structured and unstructured clinical data.

Cognitive Function among HIV Infected Children in Pune

OBJECTIVE

To assess cognitive function of school-aged, perinatally acquired human immunodeficiency virus (HIV)-infected, antiretroviral therapy (ART) naïve children in Pune.

METHODS

HIV infected ART naïve children (n = 50) between 6 and 12 y attending outpatient clinic were administered the Indian Child Intelligence Test (ICIT) after their clinical evaluation. Age and gender matched HIV uninfected children (n = 50) were enrolled as controls. The test battery included measures of perception of form (Gestalt), concept formation, memory span, learning and remembering, associative memory span, transformation of visual field, quantitative concepts, spatial visualization and visual motor coordination. The information on adaptive behavior was obtained from the care giver and a brief interview with the child using Vineland Social Maturity Scale (VSMS).

RESULTS

Mean age of the children was 9.3 y (SD: 1.3) and mean education was 4.3 y (SD: 1.3). The mean CD4 count of HIV infected children was 588 cells/mm(3) (SD: 324.4). There was no significant difference in the overall ICIT scores between HIV infected and uninfected children (p 0.209). The adaptive behavior (VSMS) scores were significantly less in HIV infected children as compared to others (p 0.028).

CONCLUSIONS

There was no significant difference in the overall cognitive abilities in HIV infected children using ICIT as compared to HIV uninfected children, although significant difference in the adaptive behavior between the two groups was observed. It is important to conduct larger prospective studies using standardized test batteries that are inclusive of multiple cognitive domains sensitive to HIV effects in Indian children.

Neonatal intrahippocampal HIV-1 protein Tat(1-86) injection: neurobehavioral alterations in the absence of increased inflammatory cytokine activation

Pediatric AIDS caused by human immunodeficiency virus type 1 (HIV-1) remains one of the leading worldwide causes of childhood morbidity and mortality. HIV-1 proteins, such as Tat and gp120, are believed to play a crucial role in the neurotoxicity of pediatric HIV-1 infection. Detrimental effects on development, behavior, and neuroanatomy follow neonatal exposure to the HIV-1 viral toxins Tat1-72 and gp120. The present study investigated the neurobehavioral effects induced by the HIV-1 neurotoxic protein Tat1-86, which encodes the first and second exons of the Tat protein. In addition, the potential effects of HIV-1 toxic proteins Tat1-86 and gp120 on inflammatory pathways were examined in neonatal brains. Vehicle, 25 μg Tat1-86 or 100 ng gp120 was injected into the hippocampus of male Sprague-Dawley pups on postnatal day 1 (PD1). Tat1-86 induced developmental neurotoxic effects, as witnessed by delays in eye opening, delays in early reflex development and alterations in prepulse inhibition (PPI) and between-session habituation of locomotor activity. Overall, the neurotoxic profile of Tat1-86 appeared more profound in the developing nervous system in vivo relative to that seen with the first exon encoded Tat1-72 (Fitting et al., 2008b), as noted on measures of eye opening, righting reflex, and PPI. Neither the direct PD1 CNS injection of the viral HIV-1 protein variant Tat1-86, nor the HIV-1 envelope protein gp120, at doses sufficient to induce neurotoxicity, necessarily induced significant expression of the inflammatory cytokine IL-1β or inflammatory factors NF-κβ and I-κβ. The findings agree well with clinical observations that indicate delays in developmental milestones of pediatric HIV-1 patients, and suggest that activation of inflammatory pathways is not an obligatory response to viral protein-induced neurotoxicity that is detectable with behavioral assessments. Moreover, the amino acids encoded by the second tat exon may have unique actions on the developing hippocampus.

Prevalence of seizures in children infected with human immunodeficiency virus

A retrospective study of 354 human immunodeficiency virus (HIV)-infected patients identified a subgroup of 27 children with seizures (7.6%, 95% confidence interval: 5.1%-10.9%). Of the total group, 13% (n = 46) had identifiable neurologic deficits and 30% (n = 107) had developmental delay. Both observations were significantly more frequent in the subgroup of patients with seizures (P < .001). The median age of patients with seizures was 20 months (range, 8-87 months) and the median baseline CD4 percentage was 13.5% (interquartile range, 8%-23%). Seizures were treated with sodium valproate (n = 11), phenobarbital (n = 3), diazepam (n = 2), lamotrigine (n = 1), and carbamazepine (n = 1). Combination therapy was required for 5 children. Suboptimal valproic acid levels were recorded for 3 patients. When resources are available, antiepileptic drug level monitoring is advised for children who require both antiepileptic and antiretroviral medications to facilitate optimal seizure management.

Neurotropic viral infections leading to epilepsy: focus on Theiler's murine encephalomyelitis virus

Neurotropic viruses cause viral encephalitis and are associated with the development of seizures/epilepsy. The first infection-driven animal model for epilepsy, the Theiler's murine encephalomyelitis virus-induced seizure model is described herein. Intracerebral infection of C57BL/6 mice with Theiler's murine encephalomyelitis virus induces acute seizures from which the animals recover. However, once the virus is cleared, a significant portion of the animals that experienced acute seizures later develop epilepsy. Components of the innate immune response to viral infection, including IL-6 and complement component 3, have been implicated in the development of acute seizures. Multiple mechanisms, including neuronal cell destruction and cytokine activation, play a role in the development of acute seizures. Future studies targeting the innate immune response will lead to new therapies for seizures/epilepsy.

Infectious causes of seizures and epilepsy in the developing world

Central nervous system (CNS) infections are the main cause of seizures and acquired epilepsy in the developing world. Geographical variations determine the common causes in a particular region. Acute seizures are common in severe meningitis, viral encephalitis, malaria, and neurocysticercosis, and in most cases are associated with increased mortality and morbidity, including subsequent epilepsy. Neuronal excitability secondary to proinflammatory signals induced by CNS infections are an important common mechanism for the generation of seizures, in addition to various other specific mechanisms. Newer insights into the neurobiology of these infections and the associated epilepsy could help in developing neuroprotective interventions. Management issues include prompt treatment of acute seizures and the underlying CNS infection, correction of associated predisposing factors, and decisions regarding the appropriate choice and duration of antiepileptic therapy. Strategies for the prevention of epilepsy in CNS infections such as early anti-infective and anti-inflammatory therapy need scientific exploration. Prevention of CNS infections is the only definitive way forward to reduce the burden of epilepsy in developing countries.

Neurological complications in late-stage hospitalized patients with HIV disease

BACKGROUND AND OBJECTIVE

The nervous system is the most frequent and serious targets of human immunodeficiency virus (HIV) infection. In spite of a wide prevalence of neurological manifestations in HIV there are not many studies to look into it, especially from this part of the world. We investigated various neurological manifestations of HIV and their association with CD4 and CD8 counts at the time of presentation.

MATERIALS AND METHODS

All HIV-infected patients who presented to 750 bedded teaching hospital in North India were subjected to thorough neurological and neuropsychological evaluation. Wherever indicated, neuroimaging, cerebrospinal fluid study, electromyography, and nerve-conduction studies were performed to confirm the diagnosis. CD4 and CD8 counts were calculated.

RESULTS

A total of 416 HIV-positive patients were seen. Of them 269 were males. A total of 312 neurological events were identified in 268 patients having evidence of neurological involvement. HIV-associated dementia (HAD) was the most common cause of morbidity (33.65%), followed by CNS infections (21.63%). Most common CNS infection was tuberculosis (65.56%). CD4 counts in CNS infections and HAD were 64.8/μl and 83.52/μl, respectively. Most of the patients in our study had low scores on MMSE (22.32).

CONCLUSIONS

Even in the absence of overt neurological disease, subclinical involvement in the form of subtle cognitive and motor decline is found to occur with greater frequency. Most of these patients have lower CD4 and CD8 counts, thus substantiating the proposition that neuroAIDS is a late manifestation. Significant correlation exists between CD4 counts and type of neurological manifestation. We concluded that neuropsychological assessment should be mandatory for all HIV-positive patients.

Human immunodeficiency virus (HIV) infection in a child presenting as acute disseminated encephalomyelitis

Acute disseminated encephalomyelitis is an extremely rare occurrence in human immunodeficiency virus (HIV) infection. We describe an 8-year-old male child who presented with weakness of both lower limbs for 10 days and focal convulsions for 2 days. The child had left, upper motor neuron facial palsy, lower limb hypotonia, and exaggerated deep tendon reflexes. Enzyme-linked immunosorbent assay antibodies for HIV tested positive and the CD4 count was 109 cells/µL. The magnetic resonance imaging (MRI, brain) revealed extensive confluent hyperintensities (on T2-weighted images) in left parietal, right temporal, and right occipital regions of the white matter, and similar signals were seen in right lentiform nucleus and right posterior thalami, suggesting acute disseminated encephalomyelitis. There was transient improvement with intravenous methyl prednisolone. The patient succumbed to the illness. Perinatally transmitted pediatric HIV infection presenting with acute disseminated encephalomyelitis has not yet been reported in the medical literature.