Abstract
Objectives: To study the differential diagnosis of HIV-infected patients with suspected central nervous system (CNS) infections and the association of CD4 counts with the final diagnosis.Methods: We analyzed HIV-infected patients from a prospective cohort study on the diagnostic accuracy of clinical and laboratory characteristics in adults with suspected CNS infections in an academic hospital in Amsterdam, the Netherlands, who underwent cerebrospinal fluid (CSF) examination.Results: Thirty-four (9.4%) out of 363 patients with suspected CNS infections were HIV-positive of whom 18 (53%) were diagnosed to have CNS infection, with median CD4 counts of 255 cells/μl. The spectrum of CNS infections consisted of progressive multifocal leukoencephalopathy in three patients (17%); cryptococcal meningoencephalitis, toxoplasma encephalitis, angiostrongylus eosinophilic meningitis, and HIV encephalitis each in two (11%); and cytomegalovirus encephalitis, neurosyphilis, tuberculous meningoencephalitis, histoplasma encephalitis, and varicella-zoster virus meningitis each in one (6%). Clinical characteristics and blood parameters did not differ between HIV-infected patients with CNS infections and other diagnoses. The best predictor for CNS infections was the CSF leukocyte count (AUC = 0.77, 95 CI% 0.61–0.94). The diagnosis of CNS infection was not associated with the CD4 count (median 205 vs. 370, p = 0.21). Two patients (11%) with CNS infections died and two (11%) had neurological sequelae.Conclusions: Half of the patients with suspected CNS infections are diagnosed with a CNS infection, and this was not related to CD4 counts. The best predictor for CNS infections was the CSF leukocyte count.
Highlights
Human immunodeficiency virus (HIV) is a neurotrophic, neuroinvasive, and neurovirulent pathogen [1], which can cause direct infection of the central nervous system (CNS) and predisposes to a variety of other neuroinfections through impaired T-cell mediated immunity [2,3,4]
Recent large observational cohorts of HIV-infected patients have reported a significant decrease in the overall incidence of the most frequent HIV-associated neurological disorders in the combination antiretroviral therapy (cART) era [6, 7], CNS infections have remained an important cause of morbidity and mortality [8]
The cause of CNS infections in HIV have been related to the CD4 lymphocyte count, of which a value below 200 has been described to predispose to cerebral toxoplasmosis, progressive multifocal leukoencephalopathy (PML), and cryptococcal meningitis [10, 11]
Summary
Human immunodeficiency virus (HIV) is a neurotrophic, neuroinvasive, and neurovirulent pathogen [1], which can cause direct infection of the central nervous system (CNS) and predisposes to a variety of other neuroinfections through impaired T-cell mediated immunity [2,3,4]. It has been estimated that in the era before the introduction of combination antiretroviral therapy (cART), around 10% of HIV-infected patients initially presented with neurological disorders, and CNS Infections in HIV. Recent large observational cohorts of HIV-infected patients have reported a significant decrease in the overall incidence of the most frequent HIV-associated neurological disorders in the cART era [6, 7], CNS infections have remained an important cause of morbidity and mortality [8]. Diagnosis of CNS infections in HIV-infected patients can be challenging as a variety of conditions should be considered in the differential diagnosis, and it may be caused by a broad spectrum of pathogens with diverse and overlapping clinical manifestations [9]. A number of studies have reported the spectrum of CNS infections in patients with a low range of CD4 count [7, 12,13,14], but the distribution of various CNS infections has not addressed in HIV-infected subgroups with a higher range of CD4 count
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