HIV/AIDS

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Cryptococcal Meningitis
Cryptococcus is a fungus that lives in the soil and gets into the body when a person breathes in contaminated dust. Cryptococcal meningitis is an infection of the lining of the spinal cord and brain that occurs in patients who have HIV and CD4+ counts lower than 100. Patients who are on antiretroviral therapy rarely develop cryptococcal meningitis.

Symptoms include headache, fever, fatigue, stiff neck, nausea, vomiting, confusion, and vision problems. Headache, which is usually very mild at first, becomes increasingly severe over days or weeks and eventually is present 24 hours a day. Often, pain medications do not relieve the headache.

Cryptococcal meningitis is treated with a potent antibiotic called amphotericin (Fungizone®). In severe cases, a second antibiotic called flucytosine (Ancobon®) is used as well. These antibiotics have many side effects, including kidney problems and an imbalance of salts in the body. Unfortunately, less toxic medications do not effectively treat the infection.

After initial treatment, most patients take a secondary prophylaxis (e.g., fluconazole, itraconazole) to prevent a recurrence of the infection. A patient who has had cryptococcal meningitis, is taking antiretrovirals, and has a CD4 count above 100 to 200 cells per cc may be able to stop taking the secondary prophylaxis. However, medication should not be discontinued without consulting a physician or other health care provider. Discontinuing the secondary prophylaxis for cryptococcus is not considered standard treatment.

Toxoplasmic Encephalitis
Toxoplasmic encephalitis, also called toxoplasmosis, is an infection of the brain tissue caused by the protozoan parasite Toxoplasma gondii. T. gondii is commonly found in cat feces, raw meat, raw vegetables, and soil. Approximately 50% of the population is infected with T. gondii, which normally does not cause illness. In patients whose CD4+ is below 100 cells per cc, however, infection can cause encephalitis, which, if left untreated, can lead to coma and death.

People who are infected with HIV should not clean cat boxes or eat undercooked meat, particularly pork, lamb, and venison. They should thoroughly wash all vegetables before eating and should be sure to wash their hands after gardening or handling soil.

Signs of toxoplasmosis in people who have HIV/AIDS are focal weakness (weakness in one part of the body) and paralysis. Seizures, fatigue, and fever also may occur. All patients who have HIV should be tested for toxoplasmosis.

Patients on antiretroviral therapy rarely develop toxoplasmic encephalitis. Treatment usually involves several medications, including pyrimethamine (Diaprim®), folinic acid, and sulfadiazine or trisulfapyrimidine. Other medications may be used in the initial treatment as well.

Following initial treatment, as with cryptococcal meningitis, secondary prophylactic medication is necessary to prevent recurrence. Secondary prophylaxis should not be discontinued without consulting a physician or other health care provider. It is not known yet if patients on antiretroviral therapy can safely discontinue secondary prophylaxis.

Progressive Multifocal Leukoencephalopathy (PML)
Progressive multifocal leukoencephalopathy, or PML, is a progressive demyelinating disease of the central nervous system caused by a virus known as "JCV," or "the JC virus." Scientists estimate that as much as half of the human population is infected with the common JC virus, but only patients with severely suppressed immune systems become ill from it. Before HIV/AIDS, PML was a very rare disorder that appeared most often in association with leukemia and lymphoma. Currently, PML is a fatal consequence of untreated late stage AIDS as well. It occurs in patients with less than 100 and, more commonly, 50 CD4 cells per cc.

Symptoms include generalized or localized weakness or paralysis (inability to move) on one side of the body, speech problems, blurred vision or loss of vision in one eye, lethargy, cognitive impairments (e.g., memory loss, confusion), and loss of balance. Symptoms progress rapidly, and in most cases, PML causes death within 3 to 6 months. There is no specific treatment for this condition. PML is rare with effective antiretroviral therapy.

Neuropathy
Painful neuropathy, also called peripheral neuropathy or painful peripheral neuropathy, is a common complication of HIV infection. It is a condition that is related to damaged peripheral nerves and can cause pain ranging from minor discomfort to disabling weakness. For a complete description of neuropathy, please visit neurologychannel.com.

The AIDS virus, as well as many of the HIV-associated infections (e.g., herpes, cytomegalovirus [CMV]), can cause peripheral neuropathy. Fortunately, the use of antiretroviral therapy has greatly reduced the incidence of painful neuropathy resulting from HIV or HIV-associated conditions. However, neuropathy remains an HIV-related problem, as it is a common side effect of antiretroviral medication, especially stavudine, didanosine, and zalcitabine.

In some cases, changing antiretrovirals can help relieve neuropathy or the condition can be treated medically, depending on the exact cause. Antidepressants (e.g., amitryptaline, desipramine, doxepin) have proven to be effective, as have several anti-seizure agents (e.g., gabapentin, lamotrigene, carbamazepine, valproic acid). Anti-seizure drugs usually have fewer side effects than antidepressants.

In addition to changing antiretrovirals and/or prescribing medication, there are a number of other ways to relieve neuropathy pain, including the following:

• Do not wear tight shoe or socks.
• Do not walk or stand for too long.
• Soak the feet or hands in cold water for 15 minutes twice a day, and use a moisturizer.
• Hand and foot massage can increase circulation and help relieve pain.
• Exercise to increase circulation to the hands and feet.

Dementia
HIV infection can lead to AIDS-related dementia. Fortunately, this condition is much less common since the advent of potent combination antiretroviral therapy. When AIDS dementia does develop, the complex usually involves cognitive (e.g., inability to pay attention, loss of memory), motor (e.g., clumsiness, slowed movements), and behavioral (e.g., changed personality) dysfunction and typically develops in the later stages of HIV infection. Most HIV patients who are not on antiretroviral therapy experience dementia at some point during the illness.

There is no specific treatment for AIDS dementia, other than antiretroviral therapy. Patients with dementia who do not respond to antiretroviral therapy may benefit from treatment with tranquilizers such as haloperidol, respirdal, or zyprexa. These patients should seek treatment from a neurologist or psychiatrist who is experienced in treating AIDS-related dementia.

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