[The neuropathology of HIV infection in the era of highly active antiretroviral therapy].

Introduction of Highly Active Antiretroviral Treatment (HAART) which is available for most AIDS patients in France since 1996, has resulted in a dramatic improvement of the disease course. From the survey of our autopsy series of (AIDS) cases and the review of other neuropathological studies from different developed countries, we found quantitative and qualitative changes in the pattern of human immunodeficiency virus (HIV) neuropathology. Quantitatively, there was a dramatic decrease in the number of autopsy cases but brain involvement remained a major cause of death in AIDS patients. There was an overall decrease of cerebral toxoplasmosis, cytomegalovirus encephalitis (CMVE) and HIV encephalitis (HIVE) for which successful treatment is available. This contrasted with the unchanged incidence of progressive multifocal leucoencephalopathy (PML) and primary malignant non Hodgkin brain lymphomas (PMBL). However, when looking closer at the last three years, the incidence of diseases affecting patients with severe immunodepression (CMVE, PML, PMBL) decreased in 2000-2002, whereas infections occurring in patients with milder immunodeficiency (toxoplasmosis, varicella-zoster encephalitis (VZVE) or herpes simplex virus encephalitis (HSVE) became more frequent. Qualitatively, there were uncommon types of brain infections, such as BK virus encephalitis or general paresis. Finally, new forms of HIVE were reported: severe leukoencephalopathy with intense perivascular macrophage and lymphocyte infiltration possibly due to an exaggerated response from a newly reconstituted immune system; and also chronic "burnt out" forms of HIVE as VZVE, toxoplasmosis, or PML in which no inflammation and no infectious agent could be detected, likely due to prolonged survival.