AIDS-related cytomegalovirus neurologic disease
- Mark A Jacobson, MD
Mark A Jacobson, MD
- Clinical Health Sciences Professor of Medicine
- University of California San Francisco
Cytomegalovirus (CMV) neurologic disease is an uncommon serious complication of AIDS, which can cause paralysis or rapidly fatal encephalitis. Prior to the availability of potent antiretroviral therapy (ART), CMV neurologic disease occurred in up to 2 percent of patients with AIDS , primarily in those with a CD4 count <50 cells/microL. However, the incidence of CMV neurologic disease has decreased since ART became available [2,3].
This topic will discuss AIDS-related CMV neurologic disease. Discussions of other CMV-related diseases in HIV-infected patients are found elsewhere. (See "Pathogenesis, clinical manifestations, and diagnosis of AIDS-related cytomegalovirus retinitis" and "Treatment of AIDS-related cytomegalovirus retinitis" and "AIDS-related cytomegalovirus gastrointestinal disease" and "Cytomegalovirus infection as a cause of pulmonary disease in HIV-infected patients".)
It is hypothesized that cytomegalovirus (CMV) end-organ disease results from the hematogenous spread of CMV. The presence of CMV in blood (as measured by culture, CMV DNA amplification, or antigen detection) is a risk factor for the development of CMV disease in patients with AIDS . However, patients with viremia (eg, those with a positive blood CMV DNA test result) do not necessarily have invasive disease. (See 'Evaluation' below.)
Impaired CD4 cell function or number is the key immune deficit that permits uncontrolled CMV replication. Studies in transplant recipients and patients with AIDS indicate that CD4-dependent CMV-specific cytotoxic T lymphocyte activity is critical for preventing CMV replication and end-organ disease [5-7]. Although most cases of CMV disease occur in patients with a CD4 cell count <50 cells/microL, patients may be predisposed before such severe CD4 cell depletion occurs. As an example, in a longitudinal study, patients with AIDS who subsequently developed CMV disease had lower T-cell proliferative responses to CMV, both early and late, compared to patients who did not develop disease . Genetic factors may also contribute to this predisposition, since low responses to CMV were more common in those with HLA-B44 and HLA-DR7.
Viral factors may also impact disease. CMV strains in the cerebrospinal fluid of HIV-infected patients with encephalitis may differ significantly from those strains present in the general population. A phylogenetic analysis suggests possible viral recombination events that may have an effect on neurovirulence .
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- NATURAL HISTORY
- CLINICAL MANIFESTATIONS
- Peripheral neuropathy
- Peripheral neuropathy
- Ganciclovir and foscarnet
- - Severe disease
- - Mild disease
- - Adverse reactions
- - Dosing of cidofovir
- - Toxicity related to cidofovir
- Duration of treatment
- When to initiate antiretroviral therapy
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS