AIDS Dementia Complex

AIDS dementia complex is a term used in literature to describe the most severe complication of human immunodeficiency virus (HIV) infection when it comes to the central nervous system (CNS) and is also known as HIV-associated dementia (HAD). Various cognitive, motor and behavioral symptoms are described. The diagnosis can be achieved through an extensive workup and findings from physical examination.

  • Processes: infectious

Overview

Etiology

Epidemiology

Pathophysiology

Prognosis

Presentation

Acquired immunodeficiency syndrome (AIDS) dementia complex, now more frequently termed HIV- associated dementia (HAD), is the most severe CNS complication of HIV infection [1] [2]. Despite the introduction of antiretroviral therapy (ART) in recent decades and marked success in therapy that led to a reduction in CNS complications, the increased life expectancy of patients suffering from this viral infection has actually increased the rate of HAD according to certain reports [1] [3] [4]. Failure to comply with therapy is the single most important risk factor, and the clinical presentation is distinguished by the onset of subcortical dementia, due to the fact that aphasia, apraxia and other signs of cortical damage are absent [5]. The clinical hallmarks of AIDS dementia complex is a slowly progressive deceleration in, motor, cognitive and behavioral functions over the course of weeks or months [4] [6] [7]. In the initial stages, only minor symptoms, such as difficulties performing complex tasks and memory loss, may be observed [5]. Over time, however, more pronounced signs include psychomotor decline, mood changes (depression, apathy, but also mania), anxiety (and even psychosis), reduced capacity to process information, as well as more severe memory, but also language and attention deficits, which are rather common and can significantly impair daily life [3] [4] [5] [8]. Olfactory senses are also reduced [3], and notable neurologic symptoms can be paraparesis, spasticity of the lower extremities, less pronounced reflexes, postural tremor, ataxia and gait disturbances [5] [9].

Workup

The diagnosis of AIDS dementia complex requires a comprehensive workup, starting with a meticulous patient history that will confirm the presence of an HIV infection and exclude other potential causes of such symptoms (for eg. recent substance abuse, Alzheimer disease, Parkinson's disease, CNS infections or other disorders) [4] [8]. In addition to the patient interview, the onset and course of symptoms should be assessed with the family of the patient, as they can provide vital information. Compliance with therapy and possible coinfections must be noted as well, after which a thorough physical examination, considered as the essential component of the workup, is performed. The diagnosis of AIDS dementia complex primarily rests on findings obtained during a physical exam, and a full physical and neurologic exam followed by a complete cognitive assessment are imperative [1] [2] [4] [6]. The HIV dementia scale and other proposed criteria roughly divide patients suffering from HIV-associated dementia (HAD) into 3 categories: HAD with motor symptoms, HAD with either psychosocial or behavioral symptoms and HAD with both motor and behavioral/psychosocial signs [5] [6] [9]. Regardless of the stage and severity of symptoms, determination of CD4+ T-cell counts is recommended in all HIV+ patients who exhibit such complaints, and HAD is often diagnosed in individuals with a CD4+ T-cell count of < 200/mm3 [8]. A polymerase chain reaction (PCR) testing to detect the viral load of HIV RNA in serum and cerebrospinal fluid (obtained through a lumbar puncture) must be carried out [5] [9]. Imaging studies are also an important part of the diagnosis of AIDS dementia complex [9]. Computed tomography (CT), but more commonly magnetic resonance imaging (MRI), can show atrophy of the subcortical, but also cortical structures in the advanced stages of the disease [4] [5].

Treatment

Prevention

Patient Information

References

  1. Kaul M. HIV-1 associated dementia: update on pathological mechanisms and therapeutic approaches. Curr Opin Neurol. 2009;22(3):315-320.
  2. Ghafouri M, Amini S, Khalili K, Sawaya BE. HIV-1 associated dementia: symptoms and causes. Retrovirology. 2006;3:28.
  3. Lindl KA, Marks DR, Kolson DL, Jordan-Sciutto KL. HIV-Associated Neurocognitive Disorder: Pathogenesis and Therapeutic Opportunities. J Neuroimmune Pharmacol. 2010;5(3):294-309.
  4. Alfahad TB, Nath A. Update on HIV-associated Neurocognitive Disorders. Curr Neurol Neurosci Rep 2013;13(10):387.
  5. Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J; 2011.
  6. Antinori A, Arendt G, Becker JT, et al. Updated research nosology for HIV-associated neurocognitive disorders. Neurology. 2007;69(18):1789-1799.
  7. Zhou L, Saksena NK. HIV Associated Neurocognitive Disorders. Infect Dis Rep. 2013;5(1):e8. Mandell GL, Bennett JE, Dolin R.
  8. Watkins CC, Treisman GJ. Cognitive impairment in patients with AIDS – prevalence and severity. HIV AIDS (Auckl). 2015;7:35-47.
  9. Mandel, Douglas and Bennett's Principles and Practice of Infectious Diseases. 8th ed. Philadelphia, Pennsylvania: Churchill Livingstone; 2015.

  • AIDS dementia complex and HIV‐1 brain infection: clinical‐virological correlations - BJ Brew, M Rosenblum, K Cronin - Annals of , 1995 - Wiley Online Library
  • Cerebral blood flow SPECT with Tc-99m exametazine correlates in AIDS dementia complex stages: a preliminary report - A Ajmani, E Habte-Gabr, M Zarr, V Jayabalan - Clin Nucl Med, 1991 - ukpmc.ac.uk
  • AIDS Dementia Complex and HIV‐1 Infection: A View From the Clinic - RW Price, JJ Sidtis, BJ Brew - Brain Pathology, 1991 - Wiley Online Library
  • A detailed phenomenological comparison of complex visual hallucinations in dementia with Lewy bodies and Alzheimer's disease - C Ballard, I McKeith, R Harrison - International , 1997 - Cambridge Univ Press
  • AIDS dementia complex and HIV‐1 brain infection: clinical‐virological correlations - BJ Brew, M Rosenblum, K Cronin - Annals of , 1995 - Wiley Online Library
  • HIV-associated neurologic disease incidence changes: Multicenter AIDS Cohort Study, 1990–1998 - N Sacktor, RH Lyles, R Skolasky, C Kleeberger - Neurology, 2001 - AAN Enterprises
  • Brief battery: relationship to standardized tests and sensitivity to cognitive impairment in mild traumatic brain injury, schizophrenia, and AIDS dementia complex - P Maruff, E Thomas, L Cysique - Archives of clinical , 2009 - acn.oxfordjournals.org