Acquired Immunodeficiency Syndrome Dementia Research Articles

Study of Clinical Spectrum of Neurological Manifestations in HIV/AIDS Seen at Tertiary Referral Hospital in India

Objectives: The pandemic caused by human immunodeficiency virus (HIV) is one of the fastest growing health problems in the world today. Neurological manifestations of HIV infection and acquired immunodeficiency syndrome (AIDS) are being seen in a frequency that is parallel to the increasing number of new cases seen the world over. The World Health Organisation (WHO) estimates that 36.7 million people in the world are infected with HIV. Neurological manifestations of HIV disease can be seen in 20% of outpatients in HIV clinics and almost half of HIV patients being treated as in-patients. Of the various subtypes of HIV, subtype C is responsible for more than 50% of HIV1 infections causing rapidly growing epidemics in India. The objectives of this study were as follows: (1) To evaluate the prevalence of neurological manifestation in HIV-positive patients admitted to a tertiary referral Hospital in India. (2) To describe the neurological manifestations documented. (3) To find the possible predictors of neurological manifestations. Material and Methods: This study was a single centre prospective cross-sectional study in which out of 200 HIV/AIDS patients, 40 patients with neurological manifestations were analysed over a period of 18 months. They were interviewed and evaluated with particular reference to neurological manifestations, and were classified using the WHO staging system. Results: Amongst the studied population of 40 patients, 16 patients (40%) manifested as tuberculous meningitis (TBM) with or without brain tuberculomas, followed by seven patients (18%) presented with peripheral neuropathy and six patients (15%) presented with central nervous system (CNS) vasculitic or multi-infarct state. Cryptococcal meningitis was seen in five patients (12%), efavirenz-induced psychosis/seizure seen in one patient, while HIV-induced polymyositis, progressive multifocal leukoencephalopathy progressive multifocal leukoencephalopathy, acute inflammatory demylinating polyradiculoneuropathy, AIDS dementia complex and CNS toxoplasmosis were seen in one patient each respectively. One patient presented with dual opportunistic infection with coexistence of cryptococcal and tuberculous meningitis. Conclusion: Headache with or without vomiting, seizures and altered sensorium were the most common neurological symptoms. Fundus abnormalities, meningeal signs, gait abnormalities, cranial nerve dysfunction and hemiplegia were the most common neurological signs. New-onset headache was a significant predictor of the occurrence of neurological complications. Opportunistic infections such as TBM and Cryptococcal meningitis were most commonly observed.

Management of Psychiatric Disorders with HIV and Dermatological Disorders.

Management of Psychiatric Disorders with HIV and Dermatological Disorders.

High level HIV-1 DNA concentrations in brain tissues differentiate patients with post-HAART AIDS dementia complex or cardiovascular disease from those with AIDS

Highly active antiretroviral treatment (HAART) has had a significant impact on survival of individuals with acquired immunodeficiency syndrome (AIDS); however, with the longer life-span of patients with AIDS, there is increasing prevalence of AIDS dementia complex (ADC) and other non-AIDS-defining illness, and cardiovascular diseases (CVD) are also common. The influence of these varied disease processes on HIV-1 DNA concentration in brain tissues has not been thoroughly assessed in the post-HAART era. The purpose of the current study is to clarify the impacts of ADC and other complications of HIV disease on the viral load in the brains in AIDS patients with post-HARRT. We examined autopsy specimens from the brains of thirteen patients who died from complications of AIDS with quantitative polymerase chain reaction (QPCR). All but one patient had received HAART prior to death since 1995. Two patients died with severe CVD, multiple cerebrovascular atherosclerosis (CVA) throughout the brain and five patients died with ADC. Six patients had no ADC/CVA. A QPCR was used to measure the presence of HIV-1 DNA in six brain tissues (meninges, frontal grey matter, frontal white matter, temporal subcortex, cerebellum and basal ganglia). In the post-HARRT era, for non-ADC/CVA patients, HIV-1 DNA concentration in brain tissues was statistically higher than that in patients with ADC. In a new finding, two patients who suffered from severe CVD, especially CVA, also had high concentrations of HIV-1 in brain compartments not showing ADC related changes. To our knowledge, this is the first report of a relationship between the CVA and HIV-1 viral burden in brain. The current observations suggest that HAART-resistant HIV reservoirs may survive within ADC lesions of the brain as well as the macrophage rich atherosclerosis, which needs to be confirmed by more AIDS cases with CVA.

The Aging of Human-Immunodeficiency-Virus-Associated Neurocognitive Disorders

This special issue proposes a new era for studies of the humanimmunodeficiency-virus-type-one (HIV-1) -associated neurological disorders serving to highlight cognitive abnormalities in infected aging patients. It has been 15 years since the “Third Workshop on NeuroAIDS” was held (Black and Sager 1994). At that time, NeuroAIDS (or the AIDS dementia complex) was the principal manifestation of cognitive, behavioral, and motor abnormalities in patients with the acquired immunodeficiency syndrome (AIDS). This has all but changed. Indeed, after introduction of highly active antiretroviral therapy (HAART) in 1996 and1997, the prevalence of severe manifestations of NeuroAIDS was significantly reduced, and the HIV patients show reduced disease morbidities and mortality. According to the Centers for Disease Control, the number of people 50 years and older infected with HIV has increased from 77% from 2001 to 2005. As HIV disease becomes a treatable medical disorder, morbidities in the HAART era abound including those linked to antiretroviral toxicities and viral infection per se as well as common disorders that all aging patients face, such as chronic obstructive pulmonary disease, diabetes, atherosclerosis-linked heart, vascular and kidney failure, bleeding ulcers, depression, cancers, and osteoporosis. Recent studies on aged HIV patient brain suggest a new type of neurological disorders distinct from HIV-1-associated dementia (HAD) and now termed HIV-associated neurocognitive disorders (HAND). HAND in aged population is linked, in part, to early signs of beta-amyloidosis or microtubule-associated tau aggregation commonly seen in Alzheimer’s disease (AD) or tauopathy brain. However, whereas extracellular amyloid plaques (senile plaques) are the major amyloid pathology in AD, HAND brains show intraneuronal amyloid accumulation or perivascular diffuse amyloid deposition, indicating distinct mechanisms and brain disease development. Considering the increase in the aged HIV population, this issue of the Journal of Neuroimmune Pharmacology will specifically focus for the first time on age-associated neurodegeneration in HIV patients. Special emphasis was made on beta-amyloidosis contributed by an outstanding line of seven investigators representing the cutting edge of HAND research activities. Peer-reviewed original research and review articles provide clear direction for forthcoming HAND research directives. The issue is lead by a comprehensive review of neurodegeneration and aging in the HAART era (Brew et al. 2009). This review discusses the history of NeuroAIDS, HAART, and persistent neurodegeneration in HAARTtreated patients. The implication of neurodegeneration in post-HAART patients is provocative and highlighted in its association with HIV, aging, and inflammation. Potential mechanisms common to specific diseases, such as AD and Parkinson’s disease, and therapeutic inventions are proposed. HAND pathogenesis, in the context of selective vulnerability of specific neuronal populations, epidemiology, and risk factors, is reviewed by Jayadev and Garden (2009). This article discusses a variety of host and viral factors that are associated with increased risk of developing HAND, and some of which are associated with the development of AD. Here, they propose a different view of how viral J Neuroimmune Pharmacol (2009) 4:161–162 DOI 10.1007/s11481-009-9155-5

Variable Impact on Mortality of AIDS‐Defining Events Diagnosed during Combination Antiretroviral Therapy: Not All AIDS‐Defining Conditions Are Created Equal

The extent to which mortality differs following individual acquired immunodeficiency syndrome (AIDS)-defining events (ADEs) has not been assessed among patients initiating combination antiretroviral therapy.We analyzed data from 31,620 patients with no prior ADEs who started combination antiretroviral therapy. Cox proportional hazards models were used to estimate mortality hazard ratios for each ADE that occurred in >50 patients, after stratification by cohort and adjustment for sex, HIV transmission group, number of antiretroviral drugs initiated, regimen, age, date of starting combination antiretroviral therapy, and CD4+ cell count and HIV RNA load at initiation of combination antiretroviral therapy. ADEs that occurred in <50 patients were grouped together to form a "rare ADEs" category.During a median follow-up period of 43 months (interquartile range, 19-70 months), 2880 ADEs were diagnosed in 2262 patients; 1146 patients died. The most common ADEs were esophageal candidiasis (in 360 patients), Pneumocystis jiroveci pneumonia (320 patients), and Kaposi sarcoma (308 patients). The greatest mortality hazard ratio was associated with non-Hodgkin's lymphoma (hazard ratio, 17.59; 95% confidence interval, 13.84-22.35) and progressive multifocal leukoencephalopathy (hazard ratio, 10.0; 95% confidence interval, 6.70-14.92). Three groups of ADEs were identified on the basis of the ranked hazard ratios with bootstrapped confidence intervals: severe (non-Hodgkin's lymphoma and progressive multifocal leukoencephalopathy [hazard ratio, 7.26; 95% confidence interval, 5.55-9.48]), moderate (cryptococcosis, cerebral toxoplasmosis, AIDS dementia complex, disseminated Mycobacterium avium complex, and rare ADEs [hazard ratio, 2.35; 95% confidence interval, 1.76-3.13]), and mild (all other ADEs [hazard ratio, 1.47; 95% confidence interval, 1.08-2.00]).In the combination antiretroviral therapy era, mortality rates subsequent to an ADE depend on the specific diagnosis. The proposed classification of ADEs may be useful in clinical end point trials, prognostic studies, and patient management.

Reduced Expression of Excitatory Amino Acid Transporter 2 and Diffuse Microglial Activation in the Cerebral Cortex in AIDS Cases With or Without HIV Encephalitis

To determine the relationship between the human immunodeficiency virus type 1 (HIV-1) encephalitis (HIVE) and diffuse poliodystrophy in the acquired immunodeficiency syndrome dementia complex, we examined the neuropathologic features in brain autopsy tissue specimens of HIV-1-infected patients with (n = 11) or without HIVE (n = 9). The brains were free of opportunistic diseases and major cerebrovascular lesions. In both groups, there was diffuse microglial activation, astrocytic gliosis, and decreased excitatory amino acid transporter 2 (EAAT-2) immunoreactivity. These changes did not correlate either with the severity of encephalitis or local HIV-1 infection as detected by p24 immunostaining. Some activated microglia expressed EAAT-2; interleukin-1beta and tumor necrosis factor were detected only in microglial nodules of HIVE cases but not in areas with diffusely activated microglia. There was a significant negative correlation between the areas of EAAT-2 expression and numbers of activated microglia (p < 0.01) in cases with decreased EAAT-2. These data indicate that diffuse cortical changes may occur independently of HIVE in acquired immunodeficiency syndrome patients. The expression of EAAT-2 by activated microglia suggests that they might exert a compensatory effect that protects neurons from glutamate neurotoxicity.

Expression of proinflammatory cytokines and its relationship with virus infection in the brain of macaques inoculated with macrophage‐tropic simian immunodeficiency virus

The pathogenesis of acquired immunodeficiency syndrome dementia complex (ADC) is still poorly understood. Many studies suggest that proinflammatory cytokines such as IL-1beta and TNF-alpha released by microglia/macrophages or astrocytes play a role in CNS injury. A microscopic finding of a microglial nodule with multinucleated giant cells (MNGCs) is a histopathologic hallmark of ADC and named HIV encephalitis. However, in vivo expression of these cytokines in this microenvironment of HIV encephalitis is not yet clarified. One of the main reasons is complexities of brain pathology in patients who have died from terminal AIDS. In this study, we infected two macaques with macrophage-tropic Simian immunodeficiency virus SIV239env/MERT and examined expression of TNF-alpha and IL-1beta in inflammatory lesions with MNGCs and its relation to virus-infected cells using immunohistochemistry. One macaque showed typical inflammatory lesions with MNGCs in the frontal white matter. Small microglial nodules were also detected in the basal ganglia and the spinal cord. SIVenv positive cells were detected mainly in inflammatory lesions, and seemed to be microglia/macrophages and MNGCs based on their morphology. Expression of IL-1beta and TNF-alpha were detected in the inflammatory lesions with MNGCs, and these positive cells were found to be negative for SIVenv by double-labeling immunohistochemistry or immunohistochemistry of serial sections. There were a few TNF-alpha positive cells and almost no IL-1beta positive cells in the area other than inflammatory lesions. Another macaque showed scattered CD3+ cells and CD68+ cells in the perivascular regions of the white matter. SIVenv and TNF-alpha was demonstrated in a few perivascular macrophages. These findings indicate that virus-infected microglia/macrophages do not always express IL-1beta and TNF-alpha, which suggests an indirect role of HIV-1-infected cells in cytokine-mediated pathogenesis of ADC. Our macaque model for human ADC may be useful for better understanding of its pathogenesis.

Central Nervous System Infections Associated with Human Immunodeficiency Virus Infection: Radiologic-Pathologic Correlation

Diseases of the central nervous system (CNS) in patients infected with the human immunodeficiency virus (HIV) result directly from HIV itself or from a variety of opportunistic agents. These infections include progressive multifocal leukoencephalopathy, toxoplasmosis, and cryptococcosis. A resurgence of tuberculosis and neurosyphilis has also been documented. Mass lesions, meningoencephalitis, demyelination, atrophy, and vascular lesions are the commonly encountered imaging findings. The introduction of highly active antiretroviral therapy (HAART) has improved both the clinical and radiologic findings in HIV-infected patients and reduced the number of opportunistic infections. In countries that use HAART, AIDS (acquired immunodeficiency syndrome) dementia complex is becoming the most common neurologic complication of HIV infection, whereas opportunistic infections are still the major cause of neurologic complications in patients from countries that do not commonly use HAART. Immune reconstitution inflammatory syndrome, which occurs in some patients in the weeks to months after the institution of HAART, may alter the typical imaging appearance of infectious diseases involving the CNS. Knowledge of the spectrum of imaging findings of these infectious diseases, as well as the effect that treatment has on imaging appearances, is important in the evaluation of HIV-infected patients.

Gender Differences in HIV Progression to AIDS and Death in Industrialized Countries: Slower Disease Progression Following HIV Seroconversion in Women

To evaluate sex differences in human immunodeficiency virus (HIV) disease progression before (pre-1997) and after (1997-2006) introduction of highly active antiretroviral therapy, the authors used data from a collaboration of 23 HIV seroconverter cohort studies from Europe, Australia, and Canada restricted to the 6,923 seroconverters infected through injecting drug use and sex between men and women. Within a competing risk framework, they used Cox proportional hazards models allowing for late entry to evaluate sex differences in time from HIV seroconversion to death, to acquired immunodeficiency syndrome (AIDS), and to each first AIDS-defining disease and death without AIDS. While no significant sex differences were found before 1997, from 1997 onward, women had a lower risk of AIDS (adjusted cumulative relative risk (aCRR) = 0.76, 95% confidence interval (CI): 0.63, 0.90) and death (adjusted hazard ratio = 0.68, 95% CI: 0.56, 0.82) than men did. Compared with men, women also had lower risks of AIDS dementia complex (aCRR = 0.23, 95% CI: 0.07, 0.74), tuberculosis (aCRR = 0.60, 95% CI: 0.39, 0.92), Kaposi's sarcoma (aCRR = 0.27, 95% CI: 0.07, 0.99), lymphomas (aCRR = 0.47, 95% CI: 0.23, 0.96), and death without AIDS (aCRR = 0.74, 95% CI: 0.56, 0.98). Sex differences in HIV disease progression have become larger and statistically significant in the era of highly active antiretroviral therapy, supporting a stronger impact of health interventions among women.

Impaired Astrocytes and Diffuse Activation of Microglia in the Cerebral Cortex in Simian Immunodeficiency Virus-Infected Macaques Without Simian Immunodeficiency Virus Encephalitis

Various types of neuronal damage have been reported in acquired immunodeficiency syndrome (AIDS) dementia. We previously demonstrated that inflammation and cortical damage occur independently according to viral tropism in a simian immunodeficiency virus (SIV)-infected macaque model of AIDS dementia. To elucidate the pathogenesis of cortical degeneration, we examined the frontal cortex of SIV-infected macaques and found apoptosis and decreased expression of the excitatory amino acid transporter 2 in astrocytes and diffuse activation of microglia in association with limited neuronal damage. Some activated microglia also expressed excitatory amino acid transporter 2 but not proinflammatory cytokines. No inflammatory changes were seen in the cortex or the white matter, and SIV-infected cells were not detected in or around cortical lesions either by immunohistochemistry or by the polymerase chain reaction detection of SIV genomes of extracted DNA from microdissected tissue samples. These results indicate that an astrocytic abnormality and a compensatory activation of microglia might provide a protective effect against neuronal degeneration in the frontal cortex of SIV-infected macaques without SIV encephalitis.

Antiretroviral Therapy and Central Nervous System HIV Type 1 Infection

Central nervous system (CNS) human immunodeficiency virus type 1 (HIV-1) infection begins during primary viremia and continues throughout the course of untreated systemic infection. Although frequently accompanied by local inflammatory reactions detectable in cerebrospinal fluid (CSF), CNS HIV-1 infection usually is not clinically apparent. In a minority of patients, CNS HIV-1 infection evolves into encephalitis during the late stages of systemic infection, which compromises brain function and presents clinically as acquired immunodeficiency syndrome dementia complex (ADC). Combination antiretroviral therapy (ART) has had a major impact on all aspects of CNS HIV-1 infection and disease. In those with asymptomatic infection, ART usually effectively suppresses HIV-1 in CSF and markedly reduces the incidence of symptomatic ADC. In those presenting with ADC, ART characteristically prevents neurological progression and leads to variable, and at times substantial, recovery. Similarly, treatment has reduced CNS opportunistic infections. With better control of these severe disorders, attention has turned to the possible consequences of chronic silent infection and the issue of whether indolent, low-grade brain injury might require earlier treatment intervention.

Frontal-Subcortical Dementias

Frontal-subcortical dementias are a heterogeneous group of disorders that share primary pathology in subcortical structure and a characteristic pattern of neuropsychologic impairment. Their clinical presentation is characterized by memory disorders, an impaired ability to manipulate acquired knowledge, important changes of personality (apathy, inertia, or depression), and slowed thought processes (or bradyphrenia). It also has marked frontal dysfunction. Classic frontal-subcortical dementias include Huntington chorea, Parkinson disease dementia, progressive supranuclear palsy, thalamic degeneration, subcortical vascular dementia, multiple sclerosis, the acquired immunodeficiency syndrome dementia complex, depressive pseudodementia, and some other rare dementias like spinocerebellar degenerative syndromes, Hallervorden-Spatz disease, choreoacanthocytosis, idiopathic basal ganglia calcification, Guamanian parkinsonism-dementia complex, corticobasal degeneration multiple system atrophy, Wilson disease, metachromatic leukodystrophy, adrenoleukodystrophy, hypoparathyroidism, sarcoidosis, and other CNS inflammatory disorders. Anatomic data suggest that the frontal signs result from a disconnection of the frontal cortex from the basal ganglia. However, most frontal-subcortical dementias show cortical atrophy in later stages, and cortical dementias have subcortical pathology at some point. In fact, the concept might be seen as a continuum, and only the 2 extremes would be represented by pure cortical or subcortical pathology. Anyway, subcortical disorders may still be more similar to one another than they are to AD. Possibly, frontal-subcortical and cortical dementias are the description of the prior main target of the disease process, ending up in both cases in a global dementia. Although the dichotomy cortical versus frontal-subcortical dementia is not strict, the 2 concepts still seem to have advantages.

Elevated Cerebrospinal Fluid Neurofilament Light Protein Concentrations Predict the Development of AIDS Dementia Complex

The light subunit of neurofilament protein (NFL) is a sensitive indicator of central nervous system axonal injury. We retrospectively identified 9 subjects participating in a longitudinal cohort study who developed acquired immunodeficiency syndrome dementia complex (ADC) and who had had a lumbar puncture performed within 2 years before presentation. Elevated cerebrospinal fluid (CSF) NFL concentrations were found in 7 (78%) of the 9 case patients who later developed ADC, compared with 9 (33%) of 27 CD4 cell count-matched HIV-1-infected control subjects. By contrast, no differences were found in CSF HIV-1 RNA or neopterin concentrations between the 2 groups. CSF NFL may prove to be a useful predictive marker for ADC.

Atherosclerosis and Central Adiposity in a Pediatric Patient with AIDS Treated with HAART: Autopsy Findings

Several types of cardiovascular lesions may develop in pediatric human immunodeficiency virus-positive (HIV+)/acquired immunodeficiency syndrome (AIDS) patients, namely myocarditis, dilated cardiomyopathy, pericardial effusion, pericarditis, left ventricle hypertrophy, fibrocalcific arteriopathy, and aneurysms. Additional lesions may be discovered by histological examination. These include fibrocalcific lesions in medium-sized arteries and small vessels, mainly of the heart and brain, and vasculitis. In the large arteries the vasa vasorum may present chronic inflammatory infiltrates or leukocytoclastic vasculitis, resulting in aneurysms. We are reporting the case of a 14-year-old girl with mother-to-infant HIV transmission with a long history of several central nervous system infections and AIDS dementia, who received treatment with the HAART protocol (including a protease inhibitor) for 3 years. A year after beginning this treatment, cholesterol serum levels were 2.8 g/L and 3.8 g/L. Autopsy findings showed gross and microscopic features of adult-type atherosclerosis involving the whole thoracic aorta, its main branches, and the coronary arteries. Remarkably, the abdominal aorta and all its branches were almost completely devoid of these lesions. At the same time, although the body presented extreme cachexia, there were obvious subepericardial, periadrenal, and peripancreatic fat deposits. The referred findings may have resulted from the well-known metabolic-dyslipemic syndrome induced by the HAART therapy and have not been specifically mentioned previously in the literature in the particular setting observed in the case of this patient.

Human immunodeficiency virus infection and acquired immunodeficiency syndrome dementia complex: Role of cells of monocyte-macrophage lineage

The entry of human immunodeficiency virus (HIV) into the central nervous system (CNS) causes both the establishment of a lifelong viral reservoir in the brain and symptoms of neurological dysfunction that have an AIDS dementia complex (ADC) clinical appearance. Neurological dysfunction in ADC patients still remains an unresolved problem. However, ADC pathogenesis may be a multistep process that starts with HIV invasion of CNS by crossing the blood-brain barrier (BBB). It progresses by developing a chronic inflammatory status that can cause dysfunction in neurons and astrocytes that result in apoptotic death. Monocytes-macrophages (M/M) may play an important role by concealing the HIV transfer across the BBB. Furthermore, HIV-infected M/M could produce and release neurotoxic factors. In this review the main mediators and cells involved in pathogenesis and development of ADC are highlighted. A better understanding of the mechanisms involved in this process may help in a successful therapeutic approach to the neuropathogenesis of HIV infection.

Toxoplasma gondii Prevents Neuron Degeneration by Interferon-γ-Activated Microglia in a Mechanism Involving Inhibition of Inducible Nitric Oxide Synthase and Transforming Growth Factor-β1 Production by Infected Microglia

Interferon (IFN)-gamma, the main cytokine responsible for immunological defense against Toxoplasma gondii, is essential in all infected tissues, including the central nervous system. However, IFN-gamma-activated microglia may cause tissue injury through production of toxic metabolites such as nitric oxide (NO), a potent inducer of central nervous system pathologies related to inflammatory neuronal disturbances. Despite potential NO toxicity, neurodegeneration is not commonly found during chronic T. gondii infection. In this study, we describe decreased NO production by IFN-gamma-activated microglial cells infected by T. gondii. This effect involved strong inhibition of iNOS expression in IFN-gamma-activated, infected microglia but not in uninfected neighboring cells. The inhibition of NO production and iNOS expression were parallel with recovery of neurite outgrowth when neurons were co-cultured with T. gondii-infected, IFN-gamma-activated microglia. In the presence of transforming growth factor (TGF)-beta1-neutralizing antibodies, the beneficial effect of the parasite on neurons was abrogated, and NO production reverted to levels similar to IFN-gamma-activated uninfected co-cultures. In addition, we observed Smad-2 nuclear translocation, a hallmark of TGF-beta1 downstream signaling, in infected microglial cultures, emphasizing an autocrine effect restricted to infected cells. Together, these data may explain a neuropreservation pattern observed during immunocompetent host infection that is dependent on T. gondii-triggered TGF-beta1 secretion by infected microglia.

HIV‐1 Chemokine Coreceptor Utilization in Paired Cerebrospinal Fluid and Plasma Samples: A Survey of Subjects with Viremia

Chemokine receptors serve as coreceptors for human immunodeficiency virus type 1 (HIV-1) entry, influence cell tropism, and may critically determine central nervous system infection pathogenesis. Using an in vitro functional entry assay, we examined utilization of 2 principal coreceptors in cerebrospinal fluid (CSF) and plasma in 46 subjects. Paired CSF and plasma samples were selected from subjects with a range of CD4 T cell counts. Amplified populations of env sequences were characterized as using CCR5 (R5), CXCR4 (X4), or both receptors (R5+X4). Individual clones derived from 3 subjects were analyzed for viral tropism and phylogeny. CSF and plasma pairs were mainly concordant for R5 (36/46) or R5+X4 (5/46) viruses. However, 5 pairs were discordant, 2 of which had the R5+X4 phenotype in CSF despite having the R5 phenotype in plasma. Although R5+X4 tropism was associated with advanced immunodeficiency, all 4 subjects with acquired immunodeficiency syndrome dementia complex had R5 tropism in CSF. Clones derived from R5+X4-tropic populations revealed mixtures of R5 and X4 viruses and viruses able to utilize either coreceptor, suggesting both virus exchange between compartments and autonomous CSF virus evolution. Although R5 viruses predominate in the CSF, HIV-1 populations able to utilize CXCR4 are also present. Discordant tropism in CSF and plasma may have implications for R5 inhibitor therapy.

Rapidly Progressed Acquired Immunodeficiency Syndrome Dementia Complex as an Initial Manifestation

We report a patient with acquired immunodeficiency syndrome dementia complex (ADC) that presented human immunodeficiency virus infection as an initial manifestation. A 34-year-old man developed disturbance of consciousness and severe abulia over 3 months. The CD4 lymphocyte count was 7.9/microl, while human immunodeficiency virus RNA in blood amounted to 4.2 x 10(4) copies/ml. T2-weighted magnetic resonance imaging showed diffusely high signal intensity in the deep white matter of both cerebral hemispheres. On the 20th hospital day, the patient died of sepsis caused by methicillin-resistant Staphylococcus aureus. Autopsy findings in the brain included increased glial cells and multinucleated giant cells in cerebral white matter and subcortical gray matter. These features were compatible with ADC.

A novel action of minocycline: inhibition of human immunodeficiency virus type 1 infection in microglia.

Human immunodeficiency virus type 1 (HIV-1) infection of the brain produces a characteristic disease called acquired immunodeficiency syndrome (AIDS) dementia in which productive infection and inflammatory activation of microglia and macrophages play a central role. In this report, the authors demonstrate that minocycline (MC), a second-generation tetracycline with proven safety and penetration to the central nervous system, potently inhibited viral production from microglia. Inhibition of viral release was sustained through the entire course of infection and even when the drug exposure was limited to the first day of infection. Minocycline was effective even at low viral doses, and against R5- and X4R5-HIV, as well as in single-cycle reporter virus assays. Electrophoretic mobility shift analysis showed that minocycline inhibited nuclear factor (NF)-kappaB activation in microglia. HIV-1 long terminal repeat (LTR)-promoter activity in U38 cells was also inhibited. These results, combined with recently demonstrated in vivo anti-inflammatory effects of MC on microglia, suggest a potential utility for MC as an effective adjunct therapy for AIDS dementia.

Prothrombotic states in HIV disease and stroke complications

Thirty to 40% of patients with acquired immunodeficiency syndrome (AIDS) have symptoms and signs of neurologic dysfunction. Radiographic and pathologic studies reveal evidence of neurologic involvement in 75% to 90% of cases of advanced-stage human immunodeficiency virus-1 (HIV) disease. Before the introduction of highly active antiretroviral therapies, AIDS dementia complex and opportunistic infections of the central nervous system were frequent causes of global cerebral dysfunction. Focal neurological deficits were most commonly due to toxoplasmosis, primary central nervous system (CNS) lymphoma, or progressive multifocal leukoencephalopathy. Thrombotic events including cerebral infarction and venous thrombosis have been reported in patients with HIV/AIDS. Various hematologic abnormalities have been described that could lead to a hypercoagulable state, including antiphospholipid antibodies; deficiencies of antithrombin III, protein C, and protein S; and increased levels of von Willebrand factor and D-dimer. In the majority of cases of cerebral infarction, there is an associated precipitating event such as opportunistic infection or malignancy. However, vasculopathy has also been described in both adults and children. Furthermore, there are reports of HIV patients with cerebral infarction in whom an HIV-related coagulopathy is identified and other cases where no explanation is found, but only a limited hematologic evaluation has been performed.