HIV-associated dementia: A diagnostic dilemma.

BACKGROUND: Considerable clinical research has been conducted to increase our knowledge in understanding the underlying neuropathological significance of HIV viral infection. AIM: To find the incidence of HIV Associated Dementia in a suburban part of India.
MATERIALS AND METHODS: 6135 prospective cases from January 2008 to August 2010 were subjected to pretest counseling. Those willing were tested for HIV status using western blot test.
RESULTS: 5688 (92.71%) underwent for detection of HIV.273 (4.8%) were tested positive. 246 out of these (90.10%) were put on ART. 1 (0.37%) was detected to have HAD stage II.38 cases (18.92%) had varied psychiatric symptoms.
CONCLUSION: HAART has considerably reduced morbidity in HIV infection.

HIV/AIDS have been the scourge of present century. The virus enters the CNS early in the course of disease and causes both direct and indirect CNS effects.[1] Maharashtra was one of the earliest States in the country to register AIDS cases. The first case was recorded in Mumbai in 1986. Out of 98,697 reported HIV/AIDS cases during the period, Pune district alone accounted for 17,258 cases. 741 have died during this period.[2] As per the report, of the total of 7,263 deaths due to AIDS in the State so far, as many as 1,138 occurred between January and September 2010. Workers in Hotel and tourism industry had the highest HIV prevalence among groups tested in the State followed by drivers and the unemployed. Truck drivers, who travel long distances, bring the infection with them to the places where the disease has not penetrated. A total of 9732 HIV/AID cases have been reported during January to September 2010.

Ever since Navia et al, in 1986, described a triad of clinical symptoms which were categorized as AIDS dementia complex (ADC), the occurrence of dementic symptoms in an established case of HIV were considered to be common neurologic disorder affecting 6% to 30% of all infected persons with HIV.[3-5] In 1990, the WHO recommended a new diagnostic term, HIV-associated dementia (HAD) to replace ADC.[6] With the introduction of HAART, the incidence of HAD has reduced and the median survival rate from 6 months has increased considerably. The early detection of HAD in the presence of behavioral abnormality poses considerable diagnostic problems. Hence, this present study was undertaken with the aim to estimate the incidence of HAD in HIV cases in a semi urban industrial area.

MATERIALS AND METHODS

Those who registered for HIV pre-test counseling from January 2008 to August 2010 in a prestigious Medical College Hospital formed the basis of the study. Those tested positive in 2010 were interviewed in detail. They were followed till the development of any Psychiatric problems. A comprehensive schedule was evolved for counseling of the positive cases as a preventive measure and the importance of initiating ART to reduce morbidity as per norms.

RESULTS

A total of 6135 who were subjected to Pre-test Counseling from January 2008 to August 2010. A total of 5688 (92.71%) underwent tests for HIV status. Out of these, 5297 (93.12%) were subjected to Post-test Counseling. 273 (4.80%) cases were found positive for HIV by western blot. 246 (90.10%) cases were put on ART. One case (0.37%) was detected to be HAD stage II. 38 cases (13.92%) had varied symptoms of anxiety, irritability, sleeplessness, agitation, unprovoked aggressive behavior, and mild depression following the detection of HIV positivity Table 1.

Table 1

HIV seropositive status and psychological symptoms

A detailed analysis of the seropositive cases from Jan 2010 to Aug 2010 revealed that out of 1977 cases 74 (3.74%) were found positive and almost all the cases had symptoms of anxiety, irritability, depressive symptoms, and agitation [Table 2]. A closer look of the positive cases revealed that the rate of positivity was higher in females than males.

Table 2

Detailed analysis of seropositive cases during the months of january to august 2010

DISCUSSION

A total of 6135 who were subjected to Pre-test Counseling from Jan 2008 to Aug 2010.

A total of 5688 (92.71%) underwent tests for HIV Status [Table 1]. Out of these, 5297 (93.12%) were subjected to Post-test Counseling. Significance of the test was explained to the cases and if they found positive what steps they ultimately take to get themselves treated with antiretroviral therapy, testing of family members, and the universal precautions that they have to resort to were highlighted. 273 (4.80%) cases were found positive for HIV by western blot, 246 (90.10%) cases were put on ART, and 1 case (0.37%) was detected to have developed HAD stage II [Figures 1–4].

Figure 1

MRI brain showing hyper intense areas in frontal and temporo-parietal areas

Figure 4

MRI brain showing subcortical lesions in frontal and temporal regions

MRI brain showing hyper intense areas in internal capsule and thalamus

38 cases (13.92%) had varied psychiatric symptoms of anxiety, irritability, sleeplessness, agitation, unprovoked aggressive behavior, and mild depression following the detection of HIV positivity.

Neuropsychiatric manifestations following detection of HIV virus has been described since the earliest reports on AIDS. It is now recognized that neuropsychiatric signs and symptoms can result from direct effects of HIV on the brain and CNS[7] or from indirect effects such as opportunistic infections or tumors associated with immunosuppression, cerebrovascular disease, systemic toxicity, and complications of antiretroviral therapy. As understanding of the broad range of neuropsychiatric manifestations of HIV has grown, new classification and diagnostic criteria has replaced the earlier more inexact terms such as HIV encephalopathy and ADC. HIV virus enters the CNS early in the course of illness and induces neural injury/inflammation. Although HIV does not productively infect neurons, replication of the perivascular macrophages and microglia alters the usual functioning through cascade of neurotoxic molecular events. Histologically major changes are seen in the subcortical areas of the brain and include pallor and gliosis; multinucleated giant cell encephalitis, and vacuolar myelopathy [Ref Figures 1–4 vide infra of the HAD Stage II case]. HIV RNA may be present throughout the CNS and HIV-associated neuropathies are consequently observed in many brain regions including white matter tracts, neo-cortex, basal ganglia, and limbic system.

The preferential impact of HIV infection on fronto-striatal circuits results in prototypical pattern of deficits, including slowed information processing efficiency, executive dysfunction, and deficient episodic memory encoding and retrieval. Clinically, impaired ability to concentrate, increased forgetfulness, difficulty in reading, increased difficulty in performing complex tasks especially dual tasks or divided attention paradigm, deficits in working memory, verbal and spatial working memory process, apathy, reduced spontaneity, inertia, irritability, lack of initiative, and social withdrawal. Among the motor deficits are unsteady gait, poor balance, tremor, and difficulty with rapid alternating movements. Increased tone and deep tendon reflexes are mostly found in cases with spinal cord involvement. These features occur without significant changes in the level of alertness.

CONCLUSION

Although HAD is the initial AIDS defining illness in 3% of HIV +ve patients, it is a clinical dilemma in undiagnosed HIV cases in the early stages. The incidence of HAD has significantly reduced after the introduction of HAART. The HIV patients can hope for a better living with the easy availability of drugs made available by the Government. Education of the ill effects of the HIV remains the mainstay with regard to control of this dreaded infection.