Neuropsychiatric Aspects of HIV and AIDS

8/6/2019 Neuropsychiatric Aspects of HIV and AIDS

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Case Summary

42 years old Vietnamese man, who is a known case ofAIDS for 3 years, currently on HAART treatment,presented with a 2 months history of worsening memory,keep forgetting things associated with motor dysfunction(unable to carry out daily routine activities). Patient alsohas been feeling depressed for the past 2monthsassociated with lose of appetite and insomnia. He is

unable to concentrate and becomes tired easily. Past medical history of Pneumocystic carinni infection

and is a substance abuser.

No other significant history


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Physical examination nothing significant

MSE Appearance : dress appropriately, good eye contact, co-

operative with some degree of psychomotor retardation

Speech : rate was slow, normal quantity.

Mood & Affect : Depressed, affect was restricted.

Thought & Perception: No obsession or delusion. Feelingworthless/guilt. Suicidal ideation. No hallucination.

Cognition: MMSE score 13 (unable to draw the clock, nogood concentration with impaired short and long termmemory)

Judgement & Insight : Poor judgement and partial insight.


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Investigation

FBC

U&E

Urine FEME and Urine toxicology

LFT

LP CXR

CT and MRI of brain

Blood Culture

Tests for herpes simplex, CMV, cryptococcal and VDRL

HIV viral load and CD4 count

Results : everything was normal, except very high viral load and CD4 was


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Diagnosis

HIV associated Dementia / AIDS dementia complex

Major Depressive Disorder?

To rule out other general medical conditions due toAIDS.


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NEUROPSYCHIATRICASPECTS OF HIV & AIDS


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Introduction

HIV epidemic was identified in the 1980s, and

neurologists described several HIV related CNS

syndromes within the first several years of the

epidemic.

These include acquired immunodeficiency syndrome

(AIDS) dementia, the associated AIDS mania,

increased rates of depression, and psychiatricconsequences of CNS injuries


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HIV transmission

HIV is a retrovirus. HIV-1 is the primary causative agent for most HIV

related disorders

HIV is present in blood, semen, cervical and vaginal

secretions, and, to a lesser extent, saliva, tears, breastmilk, and the cerebrospinal fluid of those who areinfected.

Modes of transmission include Heterosexual and homosexual intercourse

Needles Blood products

Vertical transmission

The risk for transmission is higher with higher viral loadsand with the coexistence of sexually transmitteddiseases that compromise skin or mucosal integrity.


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AIDS develops 8 11 years after infection

The virus binds to the CD4 receptor on T4

lymphocytes

The virus injects ribonucleic acid (RNA) into the

lymphocyte

HIV pathophysiological mechanisms gradually

disable all T4 lymphocytes and destroy cellmediated immunity, and opportunistic infections

develop


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Epidemiology

Estimated 33 million people have been infected withHIV worldwide

More than 12 million deaths as result

The chance of becoming infected after a singleexposure to an HIV infected person is relatively low:

0.8 3.2% for unprotected receptive anal intercourse

0.05 0.15% with unprotected vaginal sex

0.32% after puncture with an HIV contaminated needle

0.67% after using a contaminated needle to inject

drugs


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Classification

The Center of Disease Control (CDC) classifies AIDS

based on CD4+ counts and the presence or

absence of HIV associated clinical conditions


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Clinical manifestation About 30% of person infected with HIV experience a flulikesyndrome 3 6 weeks after becoming infected

Most never notice any symptoms immediately or shortly aftertheir infection

The flulike symdrome include Fever Myalgia

Headaches

Fatigue

Gastrointestinal symptoms

Rash Splenomegaly

Lymphadenopathy

The two most common coinfections in person infected with HIVwho have AIDS are Pneumocystis carinii pneumonia andKaposis sarcoma


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Investigations

Serum testing

Enzyme linked immunosorbent assay (ELISA)

Western blot The ELISA is the initial screen. The western blot is more

specific and is used to confirm positive ELISA results

Seroconversion is the change after HIV infection

from a negative HIV antibody test result to apositive HIV antibody test result

Usually occurs 6 12 weeks after infection but maytake 6 12 months


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HIV In Psychiatric

Primary HIV neurocognitive disorders: Asympomatic neurocognitive impairment

HIV mild neurocognitive disorder

HIV associated dementia

Other primary HIV neurobiological complications: Meningitis

Vacuolar myelopathy

Neuropathies and myopathy

Secondary neurobiological complications: Infections Neoplasia

CVS

Drugs/nutritional/metabolic


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HIV In Psychiatric

Presentations:

Delirium

Dementia

Minor cognitive motor disorder

Major Depressive Disorder

Anxiety Disorders

Sleep Disorders


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HIV Associated Dementia / AIDS

Dementia Complex

The cumulative prevalence of HIV dementia in the

lifetime of an infected adult has been reported to be

near 15 percent, although the incidence has decreased

by about 50 percent since the introduction of HAART. HIV-associated dementia is generally seen in late stages

of HIV illness, usually in patients who have had a CD4+

count under 200 cells per microliter.

Furthermore, certain risk factors have been associated

with eventual development of HIV dementia, namely,

higher HIV RNA viral load, lower educational level,

older age, anemia, illicit drug use, and female sex.


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Clinically, the dementia presents with the typicaltriad of symptoms seen in other subcorticaldementias

memory and psychomotor speed impairments,

depressive symptoms,

movement disorders.

Initially, patients may notice slight problems withreading, comprehension, memory, and mathematicalskills, but since these symptoms are subtle, they maybe overlooked or discounted as fatigue and illness.

Later, patients develop more global dementia, withmarked impairments in naming, language, andpraxis.


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Motor symptoms are also often subtle in early

stages, including

occasional stumbling while walking or running slowing of fine repetitive movements

slight tremor.

In late stages, motor symptoms may be quite severe,

with marked difficulty in smooth limb movements,

especially in the lower extremities.


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Apathy is a common early symptom of HIV-associated dementia

A frank depressive syndrome also commonly

develops, typically with irritable mood andanhedonia instead of sadness and crying spells

Sleep disturbances are common, as is weight loss

Psychosis develops in a significant number of

patients, typically with paranoid ideas

Overall, HIV-associated dementia is rapidly

progressive, usually ending in death within two

years.


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Criteria (Grants & Atkinson)

HIV-1 associated Dementia

Marked acquired impairment in cognitive functioning,

involving at least 2 ability domains (memory, attention).

The impairment produces marked interference with dayto day functioning.

Has been present for at least 1 month.

Pattern of cognitive impairment does not meet criteria

for delirium.

There is no evidence of another cause that could

explain the dementia.


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HIV-1 associated Mild Neurocognitive Disorder (MND)

acquired impairment in cognitive functioning, involving atleast 2 ability domains (memory, attention), at least 1.0standard deviation below the mean for age and educationappropriate norms using neuropsychological tests.

The impairment produces at least mild interference in dailyfunctioning at least one of these: self report, observation byothers.

Present for at least 1 month. Does not meet criteria for dementia or delirium

No evidence of another preexisting cause.


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Major depression is a risk factor for HIV infectionby virtue of its impact on behavior, intensification of

substance abuse, exacerbation of self-destructivebehaviors, and promotion of poor partner choice inrelationships.

Depression can be seen as a vector of HIV

transmission. So, HIV is a causal factor in depression and that

depression is a causal factor in HIV transmission andits morbidity.


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Conclusion

Important role for mental

health care in HIV treatmentand prevention


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Documents

Neuropsychiatric Aspects of HIV and AIDS