Andre Mochan

Stroke in Black South African HIV-Positive Patients: A Prospective Analysis

Background and Purpose— Stroke associated with HIV infection is poorly characterized. In this study we analyze the association in a black African population. Methods— The clinical, laboratory, and radiological characteristics of 35 hospital-based black South African, heterosexual, HIV-infected patients who did not abuse intravenous drugs and presented with strokes were prospectively studied. The patients were antiretroviral therapy naive. Patients with other intracranial space-occupying lesions were excluded from the study. Results— The age range was 20 to 61 years (mean, 32.1 years). There were 21 female and 14 male patients, with a female to male ratio of 1.5:1. Cerebral infarction occurred in 33 patients (94%) and intracerebral hemorrhage in 2 patients (6%). Underlying causes were identified in 30 of the 35 patients (86%) and included coagulopathies, meningitis, cardioembolism, and hypertension. The most common coagulopathy was protein S deficiency. No cause was found in 5 patients (14%). Conclusions— The results are similar to data from studies on young black African stroke patients who are HIV negative.

The frequency and profile of neurology in black South African HIV infected (clade C) patients - a hospital-based prospective audit.

AIM To determine the frequency and spectrum of neurological illnesses in Black South African hospital-based HIV infected (clade C) patients. METHOD A prospective audit of 506 consecutive HIV infected medical inpatients at the Helen Joseph Hospital, Johannesburg, South Africa. RESULTS The patients had a mean age of 37 years; a male:female ratio of 1.2:1; a mean CD4 count of 107 cells/ml. Eighty four percent of patients had AIDS defining CD4 counts (less than 200 cells/ml). Seventy five percent of patients had a neurological illness. In 64% the neurological illness occurred in association with a non-neurological (systemic) illness. Eleven percent of patients had an isolated neurological illness. The predominant systemic illness was tuberculosis (TB), occurring with a frequency of 46%. The neurological spectrum in our patients was similar to that described in the literature, (clade B virus data) other than for a greater frequency of infectious illnesses. CONCLUSION The neurological profile of HIV infection is a function of the environment and the immunological state of the patient (CD4 count) rather than an influence of the clade.

Reduced risk of toxoplasma encephalitis in HIV-infected patients -- A prospective study from Gauteng South Africa.

Toxoplasma seroprevalence was determined in 307 consecutive HIV-infected medical inpatients at the Helen Joseph Hospital, Johannesburg, South Africa, using an enzyme linked immunosorbent assay to detect immunoglobulin G (IgG) and IgM antibodies. The mean age of patients was 36 years, with a female to male ratio of 1.3 to 1. The mean CD4 count was 109 cells/mL. Toxoplasma antibodies were detected in 25 patients (8%). Twenty-two of these patients were IgG positive and IgM negative, i.e. reactivation toxoplasmosis. Only two patients (0.65%) had clinical manifestations of toxoplasmosis (one toxoplasma encephalitis and one retinitis). The risk for toxoplasma encephalitis (TE) was 0.33%. These results indicate that the toxoplasma seroprevalence and the TE risk in this population is low. The implication from this study is that in HIV-infected populations where the toxoplasma seroprevalence is low, the TE risk will be low and empiric treatment of focal brain lesions with anti-toxoplasma therapy may be inappropriate.

New onset seizures in HIV―Seizure semiology, CD4 counts, and viral loads

Thirty‐seven HIV‐positive patients with new‐onset seizures (NOS) were prospectively identified during a 1‐year study period. The patients were categorized according to the different mechanisms causing NOS in HIV, namely focal brain lesion (FBL) in 21 patients (57%), meningitis in 6 patients (16%), metabolic derangement (no patient), and no identified cause (NIC) other than HIV itself (10 patients, 27%). Seizure semiology, CD4 counts, and blood and cerebral spinal fluid (CSF) viral loads were studied to identify any special characteristics of the different categories. With respect to seizure semiology, all NIC patients had generalized seizures. Two‐thirds of the meningitis patients had generalized seizures with one‐third having focal seizures. Half of the patients with FBL had generalized seizures and one‐third had focal seizures. Status epilepticus was strongly associated with FBL. No significant difference could be detected between the subgroups with respect to CD4 counts and serum and CSF viral loads. The median CD4 count in all patients was 108 cells/ml, indicating advanced immunosuppression. In the FBL group this was 104 cells/ml. In the meningitis group the median CD4 count was 298 cells/ml, and in the NIC group this was 213 cells/ml. Similarly, no differences were noted in the NOS categories with respect to serum and CSF viral loads. Seizures in HIV are a nonspecific manifestation of the seizure mechanism.

Multiple sclerosis in South Africa

Since there are no well-documented epidemiological studies on multiple sclerosis (MS) in South Africa, we devised a questionnaire to determine qualitative data. Responses were obtained from 430 patients: 91% had magnetic resonance imaging (MRI) scans, 64% had lumbar punctures and 49% had evoked potentials to establish the diagnosis of MS. A total of 71% of the respondents were aged 30 - 59 years, 73% were female, and 89% were white. In terms of MS type, 46% had relapsing-remitting MS, 13% secondary progressive MS, 12% primary progressive MS, 12% benign MS, and 17% not known. Disease-modifying treatment was not used by 32% of respondents, and 30% were treated with methotrexate and 22% with interferon beta. These findings are similar to those in the literature, except for the under-utilisation of interferons as disease-modifying treatment.

Is stroke a HIV-related neurologic manifestation?

Neurologic illnesses occur commonly in association with HIV infection, are frequently debilitating and often life-threatening. The commonly recognized HIV-related neurologic illnesses include encephalopathy (dementia), myelopathy, neuropathy and myopathy. Stroke as a HIV-related manifestation is an increasingly recognized and evolving issue. This article reviews the literature on the association of stroke and HIV, stroke risk and stroke mechanisms in HIV-infected patients, and the role of antiretroviral drugs in HIV-related stroke.

Stroke and HIV - causal or coincidental co-occurrence? : editorial

Stroke is responsible for a large part of the global burden of disease. Worldwide in 1990 it was the second commonest cause of mortality causing approximately 4.4 million deaths. Two-thirds of these deaths occurred in less developed countries. In South Africa in 2001 it was the fourth leading reported natural cause of mortality. HIV infection has in the wake of our pandemic become a leading cause of death and dread disease with an estimated 15% of the population being infected. A co-occurrence of these two illnesses is therefore expected. The debate rests with regard to whether or not there is a causal relationship. The first suggestion that there is an association between HIV and stroke came from autopsy and case series from the USA. These were followed by population studies to determine the risk of this association. The first of these was a study from KwaZulu-Natal (KZN) that found an HIV prevalence of 16% in a young stroke population. The prevalence of HIV in that region at that time was also 16% suggesting that there was no significant increase in the risk of stroke associated with HIV infection. In another population-based study from Baltimore USA the incidence of stroke in persons with AIDS was 0.2% per year. In this study AIDS was found to confer an adjusted relative risk of 13.7 for ischaemic stroke (IS) and 25.5 for intracerebral haemorrhage (ICH) indicating that AIDS is strongly associated with both IS and ICH. A criticism directed at this study has been that only patients meeting the Centers for Disease Control (CDC) definition of AIDS were included. In a study from Germany on 772 HIV-infected patients a prevalence of 1.2% for stroke and an annual incidence rate for IS of 216/100 000 population was reported. The prevalence was highest in young adult patients with advanced HIV infection. This latter finding has been consistently observed in studies reporting on the association between HIV and stroke. The results in this regard thus appear to be inconclusive but favour an increased stroke risk at least with advanced HIV/AIDS. (excerpt)

CIDP in a HIV endemic population: A prospective case series from Johannesburg, South Africa.

OBJECTIVE To describe patients with Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP) in Johannesburg, South Africa, a setting of high HIV prevalence, and to determine the influence, if any, of HIV on CIDP. METHODS Patients were recruited prospectively. The study design was a hospital based case series of unselected consecutive CIDP patients. CIDP was diagnosed according to the European Federation of Neurological Societies/Peripheral Nerve Society criteria for the diagnosis of CIDP (First Revision). Demographic, clinical, laboratory and electrophysiological data were documented. RESULTS Twenty three patients with CIDP were recruited over a two year period. Mean age was 38 years. The female to male ratio was 3.6:1. Less than half (43%) had a raised cerebrospinal fluid (CSF) protein. All patients had idiopathic CIDP, three had associated diabetes mellitus. Ten patients (43%) were HIV positive. Thirteen patients were HIV negative. Clinical and electrophysiological characteristics were identical in the two groups. In the HIV positive group all the patients were black females. The CD4 counts ranged from 87 to 747 cells/mm(3). HIV positive status was associated with a progressive disease course and significantly with a CSF lymphocytic pleocytosis (p=0.007). Albuminocytological dissociation was associated with HIV negative status. CONCLUSIONS Testing for HIV in patients with CIDP in a region of high HIV prevalence is recommended. CSF lymphocytic pleocytosis occurs in HIV associated CIDP.