HIV/AIDS: Neuropsychiatric Disease

Rudolf J. Kotula, MD

Private Practice in Infectious Diseases
Methodist Hospital, Omaha, Nebraska
Peer Review Status: Externally Peer Reviewed by Mosby

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1. General. About 60% of individuals with AIDS have some neuropsychiatric manifestations of the illness. This may be because macrophages and monocytes carry the HIV into the CNS. The virus may also gain direct access because many CNS components are CD4+. It is critical to ascertain that neurologic manifestations are not attributable to infectious causes (other than HIV) or CNS lymphoma before attributing symptoms to the direct effects of the AIDS virus. Individuals with AIDS or HIV infection are undergoing a major stress, and psychologic support is critical to the successful management of their illness. Drug therapies are helpful, but social and psychologic support is important to their overall care.
2. Terminology. Subacute encephalitis (AIDS encephalopathy, AIDS dementia complex).
1. Defined by progressive dementia, psychomotor retardation, focal motor abnormalities, behavioral changes, and short-term memory deficits.
2. May manifest headache with problems of coordination, apathy, and affective blunting. Later manifestations include inappropriate behavior, emotional lability, seizures, aphasia, and psychotic manifestations.
3. Advanced cases develop global cognitive deterioration, incontinence, sensory loss, and visual disturbances.
4. 75% of AIDS patients manifest these symptoms, but 90% show pathologic changes on autopsy.
3. Testing.
1. Useful tests include the Symbol Digit Modalities Test and Parts A & B of the Trail Making Test, which test psychomotor function. A newly developed screening instrument, the HIV Dementia Scale, is a reliable and quantitative scale superior to the Minimental Status Exam and the Grooved Pegboard in identifying HIV dementia.
2. Double-dose contrast-enhanced CT alone cannot provide a definitive diagnosis. The most common abnormality reported on CT scans of these patients is cerebral atrophy. Radiographically, MRI is best at demonstrating degeneration. The most common white matter lesions are diffuse over a wide area, typically in the centrum semiovale and periventricular white matter. Less commonly, there is localized involvement with patchy or punctate lesions.
3. In atypical aseptic meningitis, there is an increase in the ICP and in the CSF mononuclear pleocytosis, multinucleated giant cells, protein content, and oligoclonal bands.
4. EEG is not particularly helpful.
4. Differential diagnosis of neuropsychiatric disorders in HIV disease once one has excluded infectious and other medical causes.
1. Most common are affective disorders.
2. Dementia.
1. Responds to some degree to high doses of ARV therapy (especially AZT).
2. Some experimental agents are being investigated to treat AIDS dementia, including nimodipine, pentoxyphylline, memantine, delavirdine and peptide-T.
1. Do not use in patients with florid psychosis.
2. Document changes with tests noted above.
3. Agitation secondary to delirium may be treated by lorazepam 0.5 mg IV slow push.
4. Treat psychotic symptoms with haloperidol 0.5 to 1 mg PO QID.
5. Depression can be treated with standard antidepressants. Some patients respond rapidly to methylphenidate 5mg Q AM up to 20-60 mg divided TID. Patients may be sensitive to anticholinergic side effects late in HIV illness. MAO inhibitors are contraindicated.
6. AIDS patients can get a manic syndrome related to the use of ganciclovir, zidovudine, and fluoxetine, which may respond to lithium. Treat agitation as above.
7. Anxiety can be treated with standard drugs. See Chapter 18.

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University of Iowa Family Practice Handbook, Fourth Edition, Chapter 11

HIV/AIDS: Dermatologic Manifestations

Rudolf J. Kotula, MD
Private Practice in Infectious Diseases
Methodist Hospital, Omaha, Nebraska
Peer Review Status: Externally Peer Reviewed by Mosby

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1. Cutaneous Infections.
1. Viral. Herpesviruses produce disseminated, extensive, or chronic herpetic ulcers. Treat with acyclovir 400 mg PO 5 x a day or 5 mg/kg IV Q8h x 7 to 14 days if severe. Maintenance dose acyclovir 400 mg PO BID.
2. Fungal.
1. Dermatophytosis (tinea) by fungi of the genera Trichophyton, Microsporum, and Epidermophyton. For treatment, see Chapter 17.
2. Yeasts and mucosal candidiasis. Treat with systemic antifungals (see section on candidiasis above).
3. Rarely: histoplasmosis and cryptococcosis.
3. Bacterial.
1. Bacterial folliculitis, impetigo. For treatment, see Chapter 17.
1. Mycobacteriosis. Treatment involves systemic antibiotics; see previous section on Mycobacterium.
2. Bacillary angiomatosis. Treat with erythromycin 250 to 500 mg PO QID until lesions resolve or doxycycline 100 mg PO BID.
2. Cutaneous Neoplasms
1. Kaposi’s sarcoma. Human herpes virus-8 (HHV-8) has been implicated as the probable agent of this skin neoplasm. Clinically appear as purplish macules, papules, plaques, nodules, tumors. Histopathologic analysis reveals immunostain to type IV collagen. Therapy includes observation, cryotherapy, laser surgery, excisional surgery, radiation therapy or systemic chemotherapy. Anecdotal reports of remissions have been reported with foscarnet.
2. Lymphoma cutis. Skin is rarely involved, usually B cell in origin.
3. Possible increased incidence of melanoma, basal cell carcinoma, and squamous cell carcinoma
4. Oral hairy leukoplakia. Well-demarcated verrucous plaque with an irregular, corrugated, or hairy surface, most commonly on the lateral or inferior surface of the tongue, or on the buccal and soft palatal mucosa.
3. Inflammatory Dermatitides
1. Seborrheic dermatitis, psoriasis, eczematous dermatitis, and folliculitis. See Chapter 17 for treatment options. Avoid the use of methotrexate.
2. Pruritus, prurigo, eosinophilic folliculitis.
1. Extremely common and extremely debilitating with 3 to 5 mm edematous, follicular papules, and pustules.
2. Treatment is often unsatisfactory. Antihistamines, potent topical fluorinated corticosteroids (such as clobetasol propionate BID), photo-therapy with natural sunlight or UVB radiation.

Cutaneous eruption of HIV. Presents as erythematous non-pruritic macules soon after infection.


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