REVIEW ARTICLE Clinical Profile of HIV Positive Patients with Neurological Manifestations Sharma, Asso. M. D. Solu, Vinod Dandge, Parika Kalra, Riesh Prajapati, Akash Joshi Keywords : HIV, Cryptococcal Meningitis, Toxoplasmosis

ABSTRACT The nervous system is among the most frequent and serious target of HIV infection and is most frequently occur in pt with profound immunosupression. 40 to 70 percent persons with HIV have neurological disorder 6. In 10 to 20 percent it is AIDS defining illness. It has higher mortality and morbidity than other infections. In assessment of neurological symptoms, it should be kept in mind that (1) multiple HIV associated disorders may coexist in a patient simultaneously. (2) Even in absence of specific complains careful neurological examination frequently reveals evidence of CNS or PNS dysfunction. Use of various drugs in patients having HIV with nervous system disorders is an important aspect to be studied. Effectiveness and side effects of various drugs and their cost effectiveness cause a great challenge to the physician and also require study in depth. Considering these facts we have decided to study the incidence and clinical profile of various neurological manifestations in HIV patients. Neurological abnormalities are sometime the first manifestation in symptomatic HIV p atients High index of suspicion of neurological involvement in HIV patients at all stages helps in early diagnosis and early institution of specific therapeutic treatment which in turn considerably decreases morbidity and mortality. There is no specific diagnostic test for AIDS Dementia Complex but decline in MMSE score give objective clue for ADC if previous score is available. So it is recommended to do baseline MMSE score in all HIV patients. INTRODUCTION

of poverty and illiteracy as patient either doesn’t take ART or become ART defaulter.

Acquired Immunodeficiency Syndrome (AIDS) is caused by Human Immunodeficiency Virus (HIV). It is a serious disorder of immune system in which normal defense of body breaks against infection leading to life threatening conditions.

The AIDS epidemic in India is in the early ascending phase, with doubling time of one year 1. The number of HIV positive individuals and AIDS cases will become enormous in coming few years, this will affect our already over burdened economy and Health Services.

Since the first detection of Acquired lmmunodeficiency Syndrome (AIDS) cases in summer of 1981 among Homosexuals in USA, the number of Human Immunodeficiency Virus (HIV) positive individuals and AIDS cases has increased explosively.

Although extensive studies on HIV and AIDS have been done in West, there is pressing need for elaborate studies in India owing to the differences in social, economic, cultural and educational background.

India appears to be fertile soil for HIV infection because of poverty, illiteracy, malnutrition, lack of sex education and high prevalence of STDs. In India also HIV pt has more chances to manifest full blown AIDS and developing extra pulmonary TB including neurotuberculosis because Correspondence address :

GMJ

MATERIALS AND METHODS In present study we have studied HIV infected patients (admitted or OPD based treatment) from our hospial showing clinical evidence of nervous system involvement.

Dr. M. G. Solu 94, Amrapali Bunlgow, Nr. Gayatri Temple, Udhana, Surat. Email : [email protected]

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Detail clinical history was noted in each patient with special emphasis on past history of major surgery, blood transfusion, penile ulcer, multiple sexual partners, drug abuse, and history of TB, unconsciousness, convulsion or headache.

Table - II : Primary Neurological Illness

Detail physical examination was carried out in each patient looking especially for opportunistic infection in other systems also. Fundus examination in dilated eyes is carried out in each patient. Routine hematological, biochemical, bacteriological, CD4 test and radiological examination was carried out in each patient. Special tests like CT, MRI, EMG-NCV and CSF examination was carried out in indicated patient. HBsAg and VDRL done in all patients.

Primary neurological illness

In present study

In NIMS study45

DSPN (Distal Sensory Polyneuropathy)

11(22%)

10%

ADC (AIDS Dementia Complex)

2(4%)

8%

AIDP (Acute Inflammatory Demye linating Polyneuropathy)

2(4%)

1%

Total

15(30%)

19%

All the patients were treated according to their opportunistic infection and indicated patients received ART also. Patients were followed up regularly for change in the clinical condition and change in value of CD4. OBSERVATIONS AND DISCUSSION DSPN was most common primary neurological illness. DSPN was found in 22% cases accounting most common primary HIV illness. ADC and AIDP both were found in 4% of cases. Our results are comparable with results of NIMS study.

Following observations were noted during this study. Table - I : Distribution of Neurological Illness in 50 HIV Positive Patients Studied Neurological illness.

No of cases

percentages

Primary

15

30%

Secondary

35

70%

Total

50

100%

ADC is another common primary neurological manifestation. 4% of our patients had ADC which is diagnosed by MMSE (mini mental status examination) score which included questions for assessment of orientation, memory, attention, concentration ability, recall, language, etc. TABLE III : Secondary Neurological Illness Secondary

No. of Cases

% in

AKD

in present study

present

study47

TBM

18

36%

10%

Cry. Meningitis

8

16%

21%

Toxoplasmosis

5

10%

26%

PML

4

8%

8%

Neurosyphilis

0

0

0%

Neurological Illness study

From above Table it is concluded that among 50 HIV positive patients with neurological manifestation studied 15 had primary neurological illness while 35 had secondary illness. GMJ

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Out of 50 patients with neurological manifestation, 32 patients (64%) presented with history of fever. 16 (32%) patients presented with history of convulsion. 28 patients (44%) presented with history of headache. 26 patients (52%) presented with altered sensorium, Vomiting was found in 12 patients (24%). Tingling and numbness was found in 13 patients (26%). 18% of patients Tuberculous meningitis was the commonest neurological illness in the present study followed by cryptococcal meningitis in 16%, toxoplasmosis in 10%, PMLE in 8% and Neurosyphilis was found in 0% cases. TBM is most common secondary neurological illness. Overall TBM is most common neurological illness. In the study by ALAKA K. DESPANDE et al, TBM as found in 10% cases, cryptococcal meningitis in 21% cases, Toxoplasmosis in 26% and PML in 8% of patients. The possible reason for the difference between the present study and study by ALAKA K. DESPANDE et al might be due to small sample size. TABLE - IV : Presenting Symptoms in Cases of HIV with Neurological Manifestation Presenting Symptoms

No. of Cases

Percentage

Fever

32

64%

Altered consciousness

26

52%

Headache

28

56%

Convulsion

16

32%

Vomiting

12

24%

Focal weakness

9

18%

Tingling Numbness

13

26%

Forgetfulness

13

26%

Bowel/bladder disturbances

20

40%

Cough

11

22%

presented with focal deficits. 11 patients (22%) has H/ O cough. Bowel/bladder incontinence was found in 20 patients (40%). Above figure indicate that most common presenting symptom is fever; altered sensorium, headache, and convulsion. Table - V : Abnormal Physical Signs on Neurological Examination Clinical Findings

No. of Cases

Percentage

Altered sensorium

26

52%

Sign of meningeal irritation

17

34%

Hemi paresis (CV stroke)

4

8%

Quadruparesis

3

6%

3rd Nerve palsy

1

2%

6rd Nerve palsy

2

4%

52% patients had altered consciousness of which most of patients were only drowsy, signs of meningeal irritation were found in 34%, hemi paresis in 8%, monoparesis in 2% and Quadruparesis in 6% patients. 2 patients had 6th nerve palsy while 1 patient had 3 rd nerve palsy. GMJ

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SUMMARY AND CONCLUSION SUMMARY: -

·

Commonest presenting symptom in patients with Tuberculous meningitis was fever (88%) followed by Headache (82%), altered consciousness (64%) and convulsion (35%).

·

Commonest presenting symptom in patients with cryptococcal meningitis was headache (71%) and altered sensorium (71%), followed by fever (57%) and sign of meningeal irritation (57%).

·

Maximum numbers of patients were in age group 21-40 years (78%).

·

Male: Female ratio in patients with neurological involvement is 2.9:1.

·

Commonest mode of acquiring HIV infection is heterosexual (64%)

·

HIV related primary neurological illness was present in 30% cases, while secondary neurological illness was present in 70% cases.

·

In Toxoplasmosis most common presenting symptom was headache (80%) and altered sensorium (80%), followed by convulsion (60%).

·

Most common HIV related primary neurological illness is DSPN which is present in 22% of HIV positive patients presenting with neurological manifestation, followed by AIDP (4%), and ADC (4%).

·

·

Most common secondary neurological illness in HIV is TBM which is present in 34% HIV positive patients presenting with neurological manifestation, followed by Cryptococcal meningitis (14%) and Toxoplasmosis (10%) .

Low CD4 count (