Módulo 3 – Curso pós-graduado – VIH e Envelhecimento

Neurocognitive Disorders in HIV Infected Patients

Clinical management of HIV-related neurological disorders

Autor: Prof. Doutor Richard W. Price, MD PhD (San Francisco General Hospital, University of California, San Francisco, USA)

Clinical evaluation of neurological disorders

As one of the first steps, it is important to evaluate systemic HIV disease and treatment history, along with current treatment status. This provides important context and neurological disease risk. Evaluation includes:

  • Systemic disease progression, in terms of current and past (nadir) blood TCD4+ counts. While the current TCD4+ count is an important indicator of disease risk, the nadir TCD4+ may also provide risk information for some conditions (for example, CNS escape).
  • Treatment history, including the current ART regimen and plasma viral load (VL) as an index of adherence and efficacy, but also the past regimens and past resistance (especially if considering any adjustment of ART).

The clinical evaluation should also consider the competing risks, including:

  • AIDS related conditions, which are now uncommon and confined largely to late presenters. These opportunistic infections relate to immunosuppression and are most common in those with blood TCD4+ counts below 50 per µL. An exception is progressive multifocal leukoencephalopathy (PML) that develops with some frequency at higher TCD4+ counts. These conditions have been well-defined in the older literature. Non-AIDS related conditions have increased in importance with treatment success. These are conditions that affect the normal immunocompetent population but are more common in HIV-infected patients, likely related to heightened immune activation in concert with other risk factors: age, drug use, psychiatric disease, cardiovascular risk factors, past infections, and family history.

Neurological examinations should then be conducted, with the purpose of establishing the presence and character of the neurological abnormalities; this is the first step to formulating a differential diagnosis. Neurology deals with localization of lesions; first establishing whether the problem is in the brain, in the spinal cord or peripheral nerves, because the localization of the problem provides an important key to identify of the underlying disease. Information about the time course of symptoms should also be collected. Did it develop abruptly like a stroke or more gradually like an infection or neurodegenerative disease? Regarding neuropsychological testing, this is more important in the research setting, to follow and quantify change over time and to screen for or document subclinical or equivocal disease, than when patients present with a new neurological deficit.

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