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Table of Content - Volume 20 Issue 3 - December 2021


 

Clinical profile of neurological manifestations and CD4 counts in patient living with HIV cases and its outcome with treatment with ART at a tertiary hospital

 

Sanjay B Jagtap1*, Pooja M Patil2

 

1Professor, Department of Medicine, M.I.M.S.R. Medical College, Latur, Maharashtra, INDIA.

2Junior Resident, Department of Medicine, Vilasrao Deshmukh Government Medical College, Latur, Maharashtra, INDIA.

Email: drsb_jagtap@yahoo.com  

 

Abstract              Background: HIV/AIDS causes a wide spectrum of disease manifestations. Approximately 40% to 70% of all persons infected with HIV develop symptomatic neurological disorders. The present study was carried out to assess the prevalence of various neurological manifestations in HIV positive patients, its correlation with CD4 counts and whether there are any changes in these manifestations with ART. Material and Methods: Present study was single-Centre, prospective, descriptive cross-sectional study, conducted in patients with HIV/AIDS infection, Age between 15– 65 years, with neurological sign/symptoms. Results: By using Convenience sampling the minimum sample size of 50 was determined. Maximum cases belonged to the age group of 31-40 years (28.0%), followed by age categories of 21-30 years and 41-50 years (22.0%). There were 34 (68.0%) males and 16 (32.0%) females in the study. It was observed that maximum number of cases 26 (52.0%) had a CD4 count of ≤ 150 cells/mm3. About 17 (34.0%) cases had a CD4 count of 151-300 cells/mm3. Only 7 (14.0%) had a CD4 count above 300 cells/mm3. The mean CD4 counts were 169.8 ± 109.0 cells/mm3. The commonest symptom was altered sensorium (90.0%), followed by headache (70.0%), fever (68.0%), vomiting (66.0%) cases, generalized tonic clonic seizures (46.0%), memory loss (26.0%) and sensory deficit (8.0%) of the cases. There were multiple symptoms per case and the commonest combination of symptoms was vomiting and headache in 32 (64.0%) cases. Conclusion: The neurological manifestations particularly the sensory deficits, memory loss, higher motor functions and cerebellar signs are observed predominantly in cases with CD4 cell counts < 150 cells/mm3, showed a significant improvement with ART and increase in the CD4 cell counts.

Keywords: Neurological involvement, HIV/AIDS, tubercular Meningitis, tuberculoma ART, CD4 cell counts

 

INTRODUCTION

With the onset of the fourth decade of the AIDS epidemic since its introduction, HIV (Human Immunodeficiency Virus) still remains one of the leading infectious killer claiming more than 690 000 lives during 2019.1 In 2019, out of the 38.0 million people living with HIV globally, 1.7 million were newly infected with the virus1. 26.0 million people were receiving HIV antiretroviral therapy (ART) globally, of which two million are from countries in the WHO South-East Asia Region.2 HIV/AIDS causes a wide spectrum of disease manifestations. The nervous system is among the most frequent and serious targets of HIV infection.3 Approximately 40% to 70% of all persons infected with HIV develop symptomatic neurological disorders.4 Although, the nervous system involvement typically occurs with profound immunosuppression and in the presence of acquired immunodeficiency syndrome (AIDS) defining illnesses, yet in 10% to 20% of HIV seropositive persons it heralds AIDS.2 CNS infections are the third commonest cause of morbidity and second commonest cause of mortality in HIV patients.5 Neurological illness may occur throughout the course of infection from seroconversion to full-blown AIDS.6 Neurological problems may occur as the initial manifestations of symptomatic HIV infection in 10 - 20% of patients.7 Neurological manifestations can be either primary to pathological process of HIV infection or secondary to opportunistic infections or neoplasms. It may be inflammatory, demyelinating or degenerative in nature. The present study was carried out to assess the prevalence of various neurological manifestations in HIV positive patients, its correlation with CD4 counts and whether there are any changes in these manifestations with ART.

 

MATERIAL AND METHODS

Present study was single-center, prospective, descriptive cross-sectional study, conducted in Department of Medicine, Vilasrao Deshmukh Government Medical College, Latur, India. Study duration was of 18 months. After approval from the Ethics Committee and with written informed consent, the study was conducted.

Inclusion criteria: Patients with HIV/AIDS infection, Age between 15– 65 years, with neurological sign/symptoms.

Exclusion criteria: Patients with peripheral neuropathies (difficult to distinguish whether the neuropathy was AIDS related or due to the side effects of ART).

Known case of Diabetes Mellites, Collagen vascular diseases, Hypertension, vasculitis

Patients with paraneoplastic syndromes, malignancies, neuropathies

Cases were studied with reference to detailed history and clinical and neurological examination, case proforma sheet was completed with prescribed blood investigations, CSF, MRI and others where indicated were conducted. ART was provided according to the NACO guidelines8. Appropriate treatment was given according to the disease. The outcome measures would be change in neurological symptoms, signs, CD4 counts and death or survival after 6 months of follow up of ART.

Data was collected and compiled using Microsoft Excel 2013 and then analyzed using SPSS 23.0 version and Open Epi Software Version 2.3 by calculating frequency, percentage and for cross-tabulations between various parameters. The means and standard deviations (SD) were calculated for the continuous variables, while ratios and proportions were calculated for the categorical variables The chi-square test was used for statistical analysis. P value less than 0.5 was considered as statistically significant.

 

 

 

RESULTS

By using Convenience sampling the minimum sample size of 50 was determined. Maximum cases belonged to the age group of 31-40 years (28.0%), followed by age categories of 21-30 years and 41-50 years (22.0%). There were 34 (68.0%) males and 16 (32.0%) females in the study. It was observed that maximum number of cases 26 (52.0%) had a CD4 count of ≤ 150 cells/mm3. About 17 (34.0%) cases had a CD4 count of 151-300 cells/mm3. Only 7 (14.0%) had a CD4 count above 300 cells/mm3. The mean CD4 counts were 169.8 ± 109.0 cells/mm3.

 

Table 1: Age wise distribution of cases

General characteristics

Frequency(n)

Percentage (%)

Age group (Years)

 

 

≤ 20

5

10.0

21-30

11

22.0

31-40

14

28.0

41-50

11

22.0

>50

9

18.0

Gender - Male/ Female

34/ 16

68.0/ 32.0

CD4 count

 

 

≤ 150cells/mm3

26

52.0

151-300cells/mm3

17

34.0

>300cells/mm3

7

14.0

The commonest symptom was altered sensorium (90.0%), followed by headache (70.0%), fever (68.0%), vomiting (66.0%) cases, generalized tonic clonic seizures (46.0%), memory loss (26.0%) and sensory deficit (8.0%) of the cases. There were multiple symptoms per case and the commonest combination of symptoms was vomiting and headache in 32 (64.0%) cases.

Table 2: Distribution of the cases according to Neurological symptoms

Symptoms*

Number

Percentage

Altered Sensorium

45

90.0

Headache

35

70.0

Fever

34

68.0

Vomiting

33

66.0

Generalized tonic clonic Seizures

23

46.0

Memory loss

13

26.0

Sensory Deficit

4

8.0

*Multiple symptoms were observed per case

 

Combination

of symptoms

Frequency

Vomiting

Headache

 

 

32

Vomiting

Headache

 

Altered

Sensorium

31

 

Headache

Fever

 

31

 

Headache

Fever

Altered

Sensorium

30

Vomiting

Headache

Fever

 

28

The most common neurological sign was altered higher mental function (94.0%), followed by motor signs (52.0%), cranial nerve (44.0%), meningeal irritation (38.0%), cerebellar signs (26.0%) and sensory losses (24.0%) of the cases. The commonest combination observed was higher mental function involvement and motor signs in 23 (46.0%) of the cases.

 

Table 3: Distribution of cases according to Neurological signs

Neurological signs

Number

Percentage

Higher mental function (HMF)

47

94.0

Motor

26

52.0

Cranial Nerves

22

44.0

Meningeal irritation

19

38.0

Cerebellar signs

13

26.0

Sensory

12

24.0

**Multiple signs were observed per case

 

 

 

 

 

 

Combinations of Neurological signs

Frequency

HMF

Motor

 

23

HMF

 

Cranial Nerve

22

HMF

 

Meninges

21

HMF

Motor

Cranial Nerve

11

 

Motor

Cranial Nerve

11

Most common diagnosis among males was tubercular meningitis (32.4%) cases, followed by tuberculoma (20.6%), cerebrovascular accident (11.8%) and cryptococcal meningitis (2.9%). Among females, there were 3 out of 16 cases each of tubercular meningitis, toxoplasma and HIV related neurocognitive disease respectively and Potts spine (6.3%). PML showed lowest mean CD4 counts at 78.5 cells/mm3. HIV associated neurocognitive disease was present at mean CD4 counts of 81.8 cells/mm3. Highest mean CD4 counts were observed among Cerebrovascular Accident at 328.5 cells/mm3 and Potts spine with 253.67 cells/mm3.


 

Table 4: Neurological Patterns according to Gender

Neurological Patterns

Gender

 

Mean CD4 count

Male (%)

Female (%)

Total

 

Tubercular meningitis

11 (32.4%)

3 (18.8%)

14 (28%)

167.64 ± 104.42

Tuberculoma

7 (20.6%)

2 (12.5%)

9 (18%)

155.11 ± 73.02

Cerebrovascular Accident

4 (11.8%)

2 (12.5%)

6 (12%)

328.5 ± 76.42

Toxoplasma

2 (5.9%)

3 (18.8%)

5 (10%)

104 ± 68.15

HIV associated Neurocognitive Disease

2 (5.9%)

3 (18.8%)

5 (10%)

81.8 ± 23.41

Bacterial Meningitis

2 (5.9%)

2 (12.5%)

4 (8%)

195.5 ± 125.5

Potts Spine

2 (5.9%)

1 (6.3%)

3 (6%)

253.67 ± 117.36

Progressive Multifocal Leuco-encephalopathy

2 (5.9%)

0

2 (4%)

78.5 ± 13.44

Cryptococcal Meningitis

1 (2.9%)

0

1 (2%)

90

Others

1 (2.9%)

0

1 (2%)

58

Total

34 (100%)

16 (100%)

50 (100%)

 

*SD cannot be calculated as there is only one case in these categories

Maximum cases 28 (56.0%) had moderate dementia, 16 (32.0%) had severe dementia and only 3 (6.0%) cases had mild dementia and normal cognition respectively according to the mini mental status examination at baseline. While maximum cases 27(54.0%) had moderate involvement, 6(12.0%) had severe involvement and 17(34.0%) cases had mild involvement respectively according to the GCS scores at baseline.

 Table 5: Baseline Mini Mental Status Examination (MMSE) and GCS categorization

MMSE categorization

Number

Percentage

Severe Dementia(< 9 points)

16

32

Moderate Dementia (10-20 points)

28

56

Mild Dementia (21-24 points)

3

6

Normal Cognition (25-30 points)

3

6

GCS categorization

Number

Percentage

Mild involvement (13-15 points)

17

34.0

Moderate involvement (9-12 points)

27

54.0

Severe involvement (3-8 points)

6

12.0

Mean values for CSF cellularity were 8.02± 4.88 cells/mm3 and mean proteins were 44.86 ± 8.76 gm/dl.

 

 

 

 

Table 6: Distribution of cases according to CSF finding

CSF Findings

Mean ± SD

CSF Cells/mm3

8.02 ± 4.88

Proteins gm/l

44.86 ± 8.76

Glucose mg/dl

41.36 ± 12.24

Lymphocytes cells/µl

2.88 ± 14.02

Polymorphonuclear cells/µl

0.1 ± 0.25

The commonest MRI finding was presence of exudates with meningeal enhancement (38.0%) followed by Tuberculoma (18.0%), infarct (12.0%), toxoplasmosis (10.0%), HIV Encephalitis (10.0%), Pott’s spine (6.0%) and PML (4.0%).

 

 

 

 

 

Table 7: Distribution of cases according to MRI findings (n = 50)

MRI Findings

Number

Percentage

Basal exudates/ Meningeal Enhancement

19

38

Tuberculoma

9

18

Infarct

6

12

Toxoplasma

5

10

HIV Encephalitis

5

10

Potts Spine

3

6

PML

2

4

There were 12(24.0%) deaths among the study population. It was observed that among those with severe dementia at baseline 9 out of 16 died during the course of the study. The deaths among those with moderate dementia were 3 out of 28 and no deaths were reported among those who had normal cognition and mild dementia at baseline respectively (3 cases each).

 

Table 8: Distribution of cases according to MMSE scores at the end of 6 months of ART

MMSE scores at 6 months after ART

Death

Survived

Total

Severe Dementia

9 (56.3%)

7 (43.7%)

16

Mild Dementia

0

3 (100%)

3

Moderate Dementia

3 (10.7%)

25 (89.3%)

28

Normal Cognition

0

3 (100 %)

3

Total

12

38

50

26 patients at baseline had CD4 counts of < 150 cells/mm3. Out of these, 9 (34.6%) showed CD4 counts of 151-300 and 17 (65.4%) still remained in the same CD4 count category. Out of the 17 cases that had 151-300 CD4 cells/mm3, 8 (47.1%) remained in the same category, whereas, the counts improved for 7 (41.2%) cases to > 300 cells/mm3and declined to ≤ 150 cells/mm3 among 2 (11.8%) cases. Those who had CD4 counts > 300 cells/mm3 maintained their counts at the end of 6 months of ART. This change in the CD4 counts at 6 months of treatment was statistically significant (X2 = 35.399; df=4; p<0.0001) when compared to the baseline CD4 counts.

 

Table 8: CD4 counts after 6 months of ART

CD4+ count Baseline

CD4+ count after 6 months n (%)

 

<=150

151-300

>300

Total

≤150

17 (65.4%)

9 (34.6%)

0

26 (100%)

151-300

2 (11.8%)

8 (47.1%)

7 (41.2%)

17 (100%)

>300

0

0

7 (100%)

7 (100%)

Grand Total

19 (38%)

17 (34%)

14 (28%)

50 (100%)

The mean CD4 counts at the end of 6 months of treatment were 261.47 cells/mm3 with a SD of 119.82 cells/mm3 as compared to mean baseline CD4 counts of197.76 cells/mm3 with a SD of 108.84 cells/mm3 which was statistically significant (p <0.0001)

 

Table 9: Mean differences in the CD4 counts at the end of 6 months of ART (n=38)

CD4 counts

Mean ± SD

CD4+ count after 6 months

261.47 ± 119.82

CD4+ count Baseline

197.76 ± 108.84

Difference Before and after

63.71 ± 64.55

Out of those who had severe dementia at baseline only 1 out of 7 (14.3%) remained as severe dementia after 6 months of ART. Among those who had moderate dementia at baseline 1 out of 25 (4.0%) deteriorated to severe dementia, while improvement was observed in 20 out of 25 (80.0%). All cases with mild dementia reverted to normal cognition after 6 months of treatment. These changes in the MMSE post ART were statistically significant (Pearson chi X2 = 19.1936; df=12; P = 0.024; Fisher's exact p = 0.012)


 

Table 10: MMSE findings after 6 months of ART (n = 38)

MMSE count Baseline

MMSE after 6 months n (%)

 

Severe Dementia

Mild Dementia

Moderate Dementia

Normal Cognition

 

Total

Severe Dementia

1 (14.3%)

2 (28.6%)

1 (14.3%)

3 (42.9%)

7 (100%)

Mild Dementia

0

0

0

3 (100%)

3 (100%)

Moderate Dementia

1 (4%)

2 (8%)

4 (16%)

18 (72%)

25 (100%)

Normal Cognition

0

0

0

3 (100%)

3 (100%)

Total

2 (5.3%)

4 (10.5%)

5 (13.2%)

27 (71.1%)

38 (100%)

Patients with severe involvement classification on the GCS scores 2 out of 3 (66.7%) reverted to the mild category and only 1 (33.3%) was retained in the severe category. Of those who were in the moderate category 18 out of 22 (81.8%) were converted to mild category and 4/22 (18.2%) were in moderate category. In the mild category, 12/13 (92.3%) were retained in the same category and 1 (2.6%) deteriorated to severe category. This difference was not found to be statistically significant.

Table 11: GCS findings after 6 months of ART

GCS count Baseline

GCS after 6 months n(%)

Mild

Moderate

Severe

Total

Mild

12 (92.3%)

1 (7.7%)

0

13 (100%)

Moderate

18 (81.8%)

4 (18.2%)

0

22 (100%)

Severe

2 (66.7%)

0

1 (33.3%)

3 (100%)

Total

32 (84.2%)

5 (13.2%)

1 (2.6%)

38 (100%)

This table shows that there was a statistically significant improvement in the mean CD4 counts of cases with altered sensorium, sensory deficit and memory loss as compared to the mean baseline CD4 counts after 6 months of receiving ART.

 

Table 12: Mean CD4 count levels WITH specific Neurological Symptoms at 6 months

Neurological

Symptoms

Present

Absent

 

p value

Mean ± SD (n) (cells/mm3)

 

Vomiting

0

261.47 ± 119.82 (38)

--

Headache

134 ± 94.46 (3)

272.4 ± 116.37 (35)

0.0535

Fever

0

261.47 ± 119.82 (38)

--

Generalized tonic clonic

Seizures

 

134 ± 94.46 (3)

 

272.4 ± 116.37 (35)

 

0.0535

Altered Sensorium

69.6 ± 26.31 (5)

290.55 ± 99.44 (33)

<0.0001

Sensory Deficit

152

264.06 ± 121.74 (36)

0.0207

Memory loss

79.25 ± 49.62 (4)

282.91 ± 106.65 (34)

0.0006

It was observed that there was a significant improvement in the mean CD4 counts among those with altered higher mental function, those with motor signs and cerebellar signs.

 

Table 13: Mean CD4 count levels with Neurological Signs after 6 months of ART

Neurological

Signs

Present

Absent

 

p value

Mean ± SD (n) (cells/mm3)

 

Cranial Nerves

189.5±150.61 (2)

266.97± 120.63 (35)

0.3868

Meningeal irritation

0

261.47 ± 119.82 (38)

--

Higher mental function

139.4 ± 113.7 (10)

305.07 ± 88.73 (28)

<0.0001

Motor

152.5 ± 124.13 (8)

290.53 ± 102.22 (30)

0.0025

Sensory

181 ± 53.73 (3)

268.37 ± 121.79 (35)

0.2304

Cerebellar signs

119.67 ± 108.32 (3)

273.63 ± 114.05 (35)

0.0306

This study shows that the overall CD4 counts improved for all the conditions as compared to the baseline (refer to table no 11). After 6 months of treatment, the CD4 counts were the highest for cases with CVA, followed by Potts Spine, TBM, tuberculoma, toxoplasma, HIV associated neuro-cognitive disease and least for PML.

 

Table 14: Mean CD4 count levels with Neurological patterns after 6 months of ART

Disease Pattern

Number (%)

CD4 counts Mean ± SD

Tubercular meningitis

9 (18.0)

280.44 ± 110.07

Tuberculoma

6 (12.0)

274.67 ± 38.36

Cerebrovascular Accident

6 (12.0)

363.83 ± 112

Toxoplasma

4 (8.0)

223.5 ± 135.98

HIV associated Neurocognitive Disease

5 (10.0)

139.2 ± 75.41

Bacterial Meningitis

3 (6.0)

330.33 ± 61.45

Potts Spine

3 (6.0)

283.67 ± 147.46

Progressive Multifocal Leuco-encephalopathy

2 (4.0)

74.5 ± 40.31

 

DISCUSSION

The neurological manifestations, natural course and outcome of HIV disease is likely to be different in India from other countries because of prevailing endemic infections, poverty, illiteracy, inability to take anti-retroviral therapy (ART) and malnutrition. The neurological manifestations that occur in HIV patients are either due to the primary pathological process of HIV infection or are secondary to opportunistic infection or neoplasms.9 In the present study, the neurological involvement was found to be maximum 72.0% in the age group of 20–50 years, which correlates with other studies by Sharma et al.,10 which reported a prevalence of neurological manifestations among 90.0% of the cases in the age group of 18-67 years. The predilection of the virus to the nervous tissues in the earlier phases of the disease and insidious onset of the neurological manifestations makes the younger populations susceptible.11,12 Therefore, it is essential to conduct clinical and neurological examinations of the diagnosed cases for early identification and treatment of the neurological manifestations of HIV particularly in the younger age groups. The current study reveals that about 68.0% of the affected population was male. This was similarly reported by other studies by Devulapally N et al.,13 that reported the prevalence of HIV related opportunistic infections in 63.63% of the males and in the study by Mir et al.,14 which revealed a male: female ratio of 4.2:1. The male preponderance observed in our study can be explained by the fact that the prevalence rates of HIV also follow a similar pattern of male to female affliction ratio of 2:1, thus explaining the male preponderance in the neurological manifestations as well.15 The commonest symptom observed in the present study was altered sensorium in 45 (90.0%), followed by headache in 35 (70.0%), fever in 34 (68.0%), vomiting was observed in 33 (66.0%) cases, generalized tonic clonic seizures among 23 (56.0%), memory loss among 13 (26.0%) of the cases and the least common symptom was sensory deficit observed only in 4 (8.0%) of the cases. These were similarly reported by several other studies conducted in India.16,17,18 In a study conducted by Lakshmi et al.,19 most common signs and symptoms were a headache (92.31%), fever (79.49%). Kumar et al.20 reported headache among 90.0% of the cases and altered sensorium among 45.0% of the cases. Prasad et al.,21 noted a headache in 89.5% and fever in 78.9%. Fever was found in 59.0% of the cases in a study conducted by Perello et al.22 Among the common neurological signs observed in the present study, altered higher mental function was present in 47 (94.0%) of the cases, followed by motor signs in 26 (52.0%) of the cases and cranial nerve involvement in 22 (44.0%). These signs were reported by other studies too.23 The most common neurological manifestation of HIV infection in this study was tuberculous involvement of the CNS. It was seen in 14 (28.0%) patients in the form of TBM. About 9 (18.0%) patients had Tuberculoma. This is similar to the findings of other studies.9,10

Among the less common findings were Pott’s Spine, Progressive multi-focal Leuco-encephalopathy (PML) and cryptococcal meningitis. However, some studies reported higher burden of cryptococcal meningitis as opposed to the present study.21,25 The present study reported a mortality rate of 24%, which was similar to that reported by the study conducted by other authors. In a study by Perello et al.22 reported 18.0% patients died during the study76. The mortality due to HIV was reported to be 8.1% in a study by Jha et al.26 A very low mortality rate of 3.8% was reported from a large dataset in a study by Javalkar et al.27 from Karnataka as opposed to the present study. It was observed that more than half the cases 26 (52.0%) had a CD4 count of ≤ 150 cells/mm3. A study by Ghate M et al.reported that CD4 counts less than 200 cells/mm3, posed a higher risk for developing opportunistic infections in HIV positive patients.28 Similarly, in our study the neurological diagnoses with infective pathologies like TBM (167.64 ± 104.42 cells/mm3), Tuberculoma (155.11 ± 73.02 cells/mm3), Toxoplasmosis (104 ± 68.15 cells/mm3) and Cryptococcal Meningitis (90 cells/mm3) had lower CD4 counts as compared to other non-infective conditions with the exception of Pott`s Spine. Low CD4 counts with neurological manifestations was observed in present study as well as other studies also.29,30 There was an improvement in the neurological signs and symptoms particularly the sensory manifestations along with the improvement in CD4 counts after the initiation of the ART, over a duration of 6 months. This increase in the CD4 cell counts as also the improvement in the neurological manifestations correlates with the ART induces suppression of viral load.9 Staszewski et al. also reported strong association between the extent of viral suppression induced by therapy and the rise in CD4 cell count.30 Furthermore, it was observed that the CD4 levels continued to rise even at 72 weeks of initiation of ART. Other studies also reported an increase in CD4 cell count even after two years of ART especially in the subject whose CD4 count baseline was <200 cells/mm3.31,32It is necessary to improve the availability of diagnostic facilities like neuro- imaging (CT and MRI) along with blood, CSF studies and biochemical assays for diagnosing and treating the neurological manifestations at earlier stages through provision of HAART, CD4 counts and viral load facilities in order to monitor and improve the outcomes of patients with neuro-AIDS.

 

CONCLUSION

Neurological involvement can occur at any stage of HIV and can be considered as the starting point for the progression of HIV infection towards AIDS. Tubercular Meningitis and Tuberculoma are the commonest neurological manifestations observed in the present study The neurological manifestations particularly the sensory deficits, memory loss, higher motor functions and cerebellar signs are observed predominantly in cases with CD4 cell counts < 150 cells/mm3, showed a significant improvement with ART and increase in the CD4 cell counts

 

REFERENCES

  1. UNAIDS: GLOBAL HIV and AIDS FACTSHEET 2020. Available at: https://www.unaids.org/en/resources/fact-sheet Accessed on 3rd Nov 2020.
  2. WHO Factsheet 2019. HIV/AIDS in the South-East Asia Available at: https://www.who.int/southeastasia/health-topics/hiv-aids Accessed on 3rd Nov 2020
  3. Rosenblum ML, Levy RM, Bredesen DE. AIDS and The Nervous System. New York: Raven Press, 1988.Resnick L, Berger JR, Shapshak P, Tourtellotte WW. Early penetration of theblood-brain-barrier by HIV. Neurology. 1988 Jan;38(1):9-14.
  4. Levy RM, Bredesen DE, Rosenblum ML. Neurological manifestations of the acquired immunodeficiency syndrome (AIDS): Experience at UCSFand review of the literature. J Neurosurg. 1985;62:475-495.
  5. Fauci AS, Fellkers GK, Lane C. Ch.197: HIV Disease; AIDS and Related disorders. In: Harrisons principle of internal medicine, Braunward E; et al. NewYork, Mc-Graw Hill, 20th Edition. 2019; 1391-1397.
  6. Burdo T H, Soulasc, J Krishna A, Sugimoto et al. Increased monocyte turnover From bone marrow correlates with severity of HIV encephalitis.PLoS.patho, 2010;6(4):e 100842.
  7. HIV Sentinel Surveillance and HIV Estimation in India 2016. A Technical Brief. Available at: http://naco.gov.in/surveillance-epidemiology-0 Accessed on 3rd Nov 2020.
  8. National AIDS Control Organization. ART treatment. 2016. Available at: http://www.naco.gov.in/treatment Accessed on 19th Feb 2021
  9. Singer EJ, Valdes-Sueiras M, Commins D, Levine A. Neurologic presentations of AIDS. Neurol Clin. 2010;28(1):253-275. doi:10.1016/j.ncl.2009.09.018
  10. Sharma SR, Hussain M, Habung H. Neurological manifestations of HIV-AIDS Neurology India 2017; 65(1):357-61.
  11. Wiley CA, Schrier RD, Nelson JA, et al. Cellular localization of human immunodeficiency virus infection within the brains of acquired immune deficiency syndrome patients. Proceedings of the National Academy of Sciences of the United States of America. 1986;83:7089–7093.
  12. Bolokadze N, Gabunia P, Ezugbaia M, Gatserelia L, Khechiashvili G. Neurological complications in patients with HIV/AIDS. Georgian Med News 2008; 165:34-8.
  13. Devulapally N, Pandharpurkar D, B. Gouthami, Gudikandula K. A Clinical Study on Opportunistic Infections among HIV/AIDS Patients Admitted in the Department of General Medicine of a Tertiary Care Hospital. Int J contemporary Medical Research. 2019;6(4): D4-8
  14. Mir M A, Ahmad P M, Siddeque M A, Sofi F A, Ahmad S N, Da M R. Clinical and demographic profile of HIV/AIDS patients diagnosed at a tertiary care centre in Kashmir. J Pak Med Assoc 2010; 60(6):428- 31
  15. CDC. Diagnoses of HIV infection in the United States and dependent areas, 2018 (updated). HIV Surveillance Report 2020;31.
  16. Badave RR and Basavaraj A. Clinical Profile of Cryptococcal Meningitis in Patients Living with HIV Infection: An Experience from Western India. Medical Journal of Dr. D.Y. Patil Vidyapeeth January-February 2018;11:(1):30-32.
  17. Kumar D, Bishnoi S, Meena DS, Bohra GK, Midha N, Chhabra V, Bhambu SK. Evaluation of Clinical Profile, Diagnostic Tests, And Prognosis of Cryptococcal Meningitis in HIV Infected Patients in Western India. Infect Disord Drug Targets. 2020 May 16.
  18. Luma H N, Nguenkam Tchaleu B C, Temfack E, et al. "HIV-Associated Central Nervous System Disease in Patients Admitted at the Douala General Hospital between 2004 and 2009:A Retrospective Study", AIDS Research and Treatment, vol. 2013, ArticleID 709810, 6 pages, 2013.
  19. Lakshmi V, Sudha T, Teja VD, Umabala P. Prevalence of central nervous system cryptococcosis in human immunodeficiency virus reactive hospitalized patients. Indian J Med Microbiol 2007; 25:146-9.
  20. Kumar S, Wanchu A, Chakrabarti A, Sharma A, Bambery P, Singh S, et al. Cryptococcal meningitis in HIV infected: Experience from a North Indian tertiary center. Neurol India 2008;56: 444-49.
  21. Prasad KN, Agarwal J, Nag VL, Verma AK, Dixit AK, Ayyagari A, et al. Cryptococcal infection in patients with clinically diagnosed meningitis in a tertiary care center. Neurol India 2003; 51:364-6.
  22. Perello R, Vergara A, Monclus E, et al. Cytomegalovirus infection in HIV- infected patients in the era of combination antiretroviral therapy. BMC Infect Dis. 2019;19(1):1030. Published 2019 Dec 4. doi:10.1186/s12879-019-4643-6
  23. Price RW. Neurological complications of HIV infection. Lancet 1996; 348:445.
  24. Kapila K, Sharma YV, Kotwal J, Banerjee A, Kaur J. Cryptococcal meningitis: A Clinicopathological account of seven cases encountered in a military setting. Med J Armed Forces India 2003; 59:189-93.
  25. Abhilash KP, Mitra S, Arul JJ, Raj PM, Balaji V, Kannangai R, et al. Changing paradigm of cryptococcal meningitis: An eight-year experience from a tertiary hospital in South India. Indian J Med Microbiol 2015; 33:25-9.
  26. Jha P, Kumar R, Khera A, Bhattacharya M, Arora P, Gajalakshmi V. HIV mortality and infection in India: estimates from nationally representative mortality survey of 1.1 million homes. BMJ. 2010; 340: c621.
  27. Javalkar P, Prakash R, Issac S, Washington R and Halli SS. An Estimation of Mortality Risks among People Living with HIV in Karnataka State, India: Learnings from an Intensive HIV/AIDS Care and Support Programme Available at:https://journals.plos.org/plosone/article?id=10.1371/journal.pone.015661 1 Accessed on 12th Feb 2021.
  28. Ghate M, Deshpande S, Tripathy S, Nene M, Gedam P, Godbole S. Incidence of common opportunistic infections in HIV-infected individuals in Pune, India: analysis by stages of immunosuppression represented by CD4 counts. 2009; 13(1):e1-e8.
  29. Singh A, Bairy I, Shivananda PG. Spectrum of opportunistic infections in AIDS cases. Indian J Med Sci 2003;57:16—21.
  30. Staszewski S, Miller V, Sabin C, Schlecht C, Gute P, Stamm S, et al. Determinants of sustainable CD4 lymphocyte count increases in response to antiretroviral therapy. AIDS 1999;13:951-6.
  31. Hunt PW, Deeks SG, Rodriguez B, Valdez H, Shade SB, Abrams DI, et al. Continued CD4 cell count increases in HIV-infected adults experiencing 4 years of viral suppression on antiretroviral therapy. AIDS 2003; 17:1907-15.
  32. Kaufmann GR, Bloch M, Finlayson R, Zaunders J, Smith D, Cooper DA. The extent of HIV-1-related immunodeficiency and age predict the long-term CD4 T lymphocyte response to potent antiretroviral therapy. AIDS 2002; 16:359- 67.


 

























 








 




 








 

 









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