|Year : 2007 | Volume
| Issue : 4 | Page : 266-269
Reversal of acquired immunodeficiency syndrome-dementia complex with antiretroviral therapy
Iyer Kamalam, SR Daga, Naresh Tayade
Department of Pediatrics and Psychiatry, B. J. Medical College and Sassoon General Hospital, Pune, India
S R Daga
Department of Pediatrics, B. J. Medical College and Sassoon General Hospital, Pune - 411 001
Source of Support: None, Conflict of Interest: None
| Abstract|| |
A 10-year-old child presented with neuroregression. Human immunodeficiency virus infection was confirmed. computed tomographic scan and psychological evaluation confirmed dementia. There was remarkable improvement on anti-retroviral therapy.
Keywords: Anti-retroviral therapy, dementia, human immunodeficiency virus infection
|How to cite this article:|
Kamalam I, Daga S R, Tayade N. Reversal of acquired immunodeficiency syndrome-dementia complex with antiretroviral therapy. Ann Indian Acad Neurol 2007;10:266-9
|How to cite this URL:|
Kamalam I, Daga S R, Tayade N. Reversal of acquired immunodeficiency syndrome-dementia complex with antiretroviral therapy. Ann Indian Acad Neurol [serial online] 2007 [cited 2020 Sep 28];10:266-9. Available from: http://www.annalsofian.org/text.asp?2007/10/4/266/37822
| Introduction|| |
HIV-infected children have significantly more cognitive and neurodevelopmental impairments than normal children. , Human immunodeficiency virus may directly damage the functioning of the central nervous system or more likely through the neuroimmunological host response to neurotoxic viral products, it may lead to chronic static encephalopathy. Coexisting social factors often compound the problem. Recent studies show a lower prevalence of severe impairment in cognition and poor neurodevelopmental outcomes among preschool children,  coinciding with the widespread use of antiretroviral therapy (ART). ART is known to reduce the number of events that require hospital care and ambulatory care.  Only small proportions of HIV-infected children receive ART and die due to opportunistic infections in a country such as India. Hence, dementia is rarely seen. Underdiagnosis might also be contribute to this. On the other hand, this entity has become rare in developed countries due to the early introduction of ART among HIV-infected children. To the best of our knowledge, dementia has not been reported among HIV-infected children in Indian literature. We report a case where dementia regressed after ART.
| Case Report|| |
A 10-year-old male child was brought by his paternal grandmother from interior Maharashtra with a complaint of fever of 1-month duration. The fever was of high grade and without chills. On enquiring directly the grandmother also complained that the child is socially withdrawn and does not communicate as well as he used to do 6 months before. Family history revealed that the father of the child died 10 years before, and his mother expired 2 years back. The exact cause of death was unknown to the grandmother. Clinical examination was unremarkable except mild pallor and hepatomegaly. Investigations revealed the following observations: Hb - 8.3 g/dL, total leucocyte count - 16,700/cmm, with N - 82% and L - 18%. Platelet count was 4,40,000/cmm and the Elisa0 test for HIV infection was positive. Chest X-ray did not reveal any abnormality. Mantoux test was negative. MRI brain revealed mild generalized cerebral atrophy. A diagnosis of HIV infection with occult bacteremia and probable dementia was made. His fever responded to treatment with cotrimoxazole and chloroquine. The opinion of the neuropsychologist was sought.
On clinical interview by the neuropsychologist, the most salient aspect in the child appeared to be his decline in the cognitive and motor functions. He had acquired abnormality in attention, concentration, speed in information processing, slowed movements and speech and language as assessed on the basis of mental status examination. This cognitive dysfunction was causing the impairment of daily activities with poor motivation. The child was subjected to detailed neuropsychological investigation in order to verify the cognitive deficits. NIMHANS Neuropsychological Battery for Children (2004) was administered. The clinical observation showed the child to be conscious and having normal sensory functions of vision/hearing/touch, although his motor functions appeared to be retarded. He was oriented to time, place and person. His appearance was appropriate for the situation. During the entire testing session, he was apathetic, socially withdrawn and unresponsive pervasively. When probed, his expressive speech was retarded and the speech output was reduced. Problem with comprehension was apparent with the test instructions being grasped slowly and many repetitions were required. His attention had to be aroused.
On administration of the procedures, the following findings emerged:
Intellectual/selective attention verbal fluency: The child could not be subjected to the tests that assess the intellectual ability, selective attention or verbal fluency.
Expressive speech: From the assessment of expressive speech tests, the child could repeat only 1/4 of the sounds and 2/10 of the words given. He scored 4/5 in the test for object naming, 3/5 in the test for naming by description and 1/10 in the test for categorical naming. The child could not construct sentences as a measure of narrative speech. Thus, the child had poor expressive speech ability.
Design fluency, working memory, test of planning, set-shifting ability, verbal learning and memory and visuospatial construction, verbal comprehension, nonverbal learning and memory: The child could not be subjected to the tests assessing the same.
Visual recognition : On recognition of pictured objects, he could identify 3/10 correctly.
Focal signs : Signs of apraxia, body schema disturbances, route-finding difficulty, unilateral spatial neglect, somatosensory perception could not be assessed. The child, however, could read to the first standard level and copy a passage, although slowly with errors and missing punctuation marks. His calculative ability was poor with simple addition and subtraction sums being difficult for the child.
Personality changes : The exact duration of the same could not be elicited from the informant. This neuropsychological assessment profile is suggestive of deficits and inadequacies in all the assessed domains. Hence, this profile shows the involvement of diffuse brain damage.
Post-ART neuropsychological assessment was carried out in two sessions, each lasting for about 1½ h. He was alert and oriented to time, place and person. The child was friendly, co-operative for the sessions. His attention was easily distractible with other extraneous variables. He showed initiation spontaneously and his speech output was normal. His comprehension was poor and the instructions were given repeatedly. He attempted to answer all the questions openly and honestly. For the above mentioned reasons, it is believed that he performed to the best of his ability during the entire testing and that the test findings represent a valid estimate of his current level of functioning. On the administration of the procedures, the following findings emerged:
Intellectual: On Raven's children progressive matrices (CPM), he obtained scores that fall at the 10 th percentile. He is intellectually below average. No scatter was observed.
Test of motor coordination: From the test of hand tapping, the performance of the child was evaluated to be average.
Selective attention: On the color cancellation test, he completed the test after approximately 6 min and 23 s and by repeated instructions. His attention is below h percentile, which is indicative of attention impairment.
Fluency tests: The verbal fluency test by COWAT and nonverbal fluency test of design fluency could not be administered.
Expressive speech: The child on the assessment of repetitive speech tests could repeat 2/4 of the sounds and 9/10 of the words given. He scored 5/5 in the test of object naming, 3/5 in the naming by description test and 3/10 in categorical naming test - all indicative of nominative speech ability. The child could not construct sentences as a measure of the narrative speech. Thus, he presented with a fair nominative and repetitive speech ability with poor narrative speech.
Verbal working memory: In N-back test, he scored below the 5 th percentile.
Visuospatial working memory: In visuospatial working memory span test, he obtained below the 5 th percentile. On the N-back tests, he obtained 5 th percentiles.
Test of planning: On conducting Porteus-Maze test, he obtained a score below the 5 th percentile.
Set-shifting ability: On performing the Wisconsin Card Sorting Test (WCST), he showed set-shifting ability. The number of trials was 12. The total number of correct responses was 49. The total number of error was 71 with percentage errors as 59%. Perseverative errors were 39 and the percentage of preservative errors as 32%. Nonpreservative errors were 32 and percentage of preservative errors was 26%. The number of conceptual level responses was six in sets of three. No categories could be completed during the test.
Visuoperceptual ability: In the motor-free visual perception test, he obtained scores below the 5 th percentile.
Visuoconceptual ability: In the picture completion test, the score was below the 5 th percentile.
Visuospatial construction: In the block - design test, he obtained a score below 5 th percentile.
Verbal comprehension: In the token test, he was found obtain a score of 10 th percentile.
Visual recognition: In the recognition of pictured objects, he was found to identify 10/10 correctly.
Visual learning and memory: On the memory for designs tests, the child obtained a percentile rank of 50 on trial 1 and below 5 th percentile on trials 2, 3, 4 and 5. On the delayed recall test and the visual learning test, a percentile rank of below 5 th was scored.
Verbal learning and memory: In Rey's auditory verbal learning test, he obtained 25 th percentile on trial 1, 5 th percentile on trial 2, 10 th percentile on trial 3 and 4 and below 5 th percentile on trial 5. He again scored below the 5 th percentile in delayed recall test and learning test, respectively.
Focal signs: No signs of apraxia/body schema disturbances/route-finding difficulty/unilateral spatial neglect were elicited. He could read to the first standard level and copy a passage, although slowly with errors in spelling and missing punctuation marks. He could carry out simple addition and subtraction sums.
Somatosensory perception: In the test for tactile finger localization, he obtained 4/10 correct and in tactile form perception, he obtained 4/4 correct.
Personality changes: The informant of the child reported better sociability and cheerful mood in the child since the last 2 months.
Thus, after ART, either the tests could be carried out or improvement in performance was apparent [Table - 1].
| Discussion|| |
The clinical diagnosis of AIDS-dementia complex is based on the observation of significant cognitive decline and motor dysfunction in the setting of HIV infection and after exclusion of other reasonable etiologies. AIDS dementia may be progressive or relatively static and may improve dramatically with ART. While there are no pathognomonic laboratory features or radiographic features, the diagnosis is supported by the radiographic findings of HIV encephalitis. Patches or diffuse subcortical white matter changes and typically mild cerebral atrophy are observed. However, no association is observed between the behavioral problems and neuroimaging. 
The evolution of antiretroviral therapy has changed the epidemiology of AIDS dementia. It is possible that the higher rates of severe impairment found in earlier studies reflect the lack of treatment availability and thus higher rates of AIDS-defining illnesses. Findings reported by Tardieu suggest that other health markers such as circulating CD4 lymphocyte counts during the first year of life are predictive of cognitive functioning among vertically infected school-aged children.  Children who had experienced an AIDS-defining illness early in life scored significantly lower in verbal, perceptual performance, quantitative abilities and memory subtests than infected children with no AIDS-defining illness or noninfected children.  The results of this study suggest strongly that prevention of early AIDS-defining illness among young children with HIV infection is crucial for preventing poor neurodevelopmental outcomes. With early, appropriate, antiretroviral therapy, there is not only an increase in the odds for survival but also the children may avoid significant, developmental cognitive impairment. Improvement in our patient after ART supports this view.
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[Table - 1]