CNS infection in HIV

Presentation
Change mental states/abnormal neurologic exam
Risk factor
CD4>500 benign/Malignant brain tumors & Metastases
CD4 200-500 cognitive/motor disorders are common
CD4 <200 opportunistic & AIDS associated tumors
Ex - Toxoplasma encephalitis
- Primary CNS lymphoma
- Progressive multifocal leukoencephalopathy
- HIV encephalopathy
- CMV encephalitis
Imaging (Radio)
CT/MRI
MRI > CT sensitive
Mass เจอได้ 2 แบบ Presence/ absence of Mass effect
CNS lesions with mass effect swelling, edema
if located in posterior fossa
Cerebral herniation
usually enhance after contrast
Patient c Mass effect can present c headache, N/V
confusion, lethargy
มักพบใน Toxoplasma encephalitis & primary central system
lymphoma
Toxoplasma encep
Present with fever headache AOC, Focal neurologic
complaints seizure

Positive Toxoplasma Antibodies Lesion multiple localized in

parietal / frontal lobes thalamus/ basal ganglia
With ring enchancement
Can be seen in single lesion < 4cm
Primary central nervous system lymphoma
Present with confusion, lethargy, memoryloss, hemiparesis
aphasia,seizure + constitutional symptom
(fever,night sweat,weight lassi)
Other opportunistic
brain abscess secondary to staphylocuccus, streptocoocus,
salmanella, aspergillus, nocardia listeria. ….
CNS lesion without mass effect
usually not enhance after inject contrast
Ex. Progressive multifocal leukoenphalpathy
Or HIV associated encephalopathy
Progressive multifocal leukoencephalopathy
-Is a myelination disease by JC virus papova virus
- usually multifocal areas of demyelination bilateral, asymmetric
usually not enhancing
Ddx of PML
- HIV encephalopathy
- CMV encephalitis
HIV Incephalonathy (HIVE)
Classical triad
-Subcortical dementia
Memory & Psychomotor speed impairment
Depressive symptoms
Movement disorder
CMV encephalitis
- Found in patient who CD4 < 50 Cell
- Present with delirium, confusion, focal neuralgic
abnormalities
Empiric toxoplasma therapy
A trial empiric therapy for possible TE may be
considered as an alternative to brain biopsy
Corticosteroids should be considered in the presence
of mess effect since these patient are at increased
risk of herniation
Gold standard for diagnosis is brain biopsy