TUGAS 20 September 2017

1. Komplikasi HIV? Yang terkait dengan syaraf?

Neurologic complications occur in more than 40% of patients with HIV infection.
They are the presenting feature of AIDS in 10-20% of cases. At autopsy, the
prevalence of neuropathologic abnormalities is 80%. [1, 2, 3, 4] Although an ongoing
decline in HIV-associated CNS disease has been observed in very recent years, the
mortality from these diseases remains high. [5]

Types of CNS complications

Several different types of CNS complications accompany HIV infection. Conditions
that may be caused, directly or indirectly, by HIV itself include the following:

HIV-associated neurocognitive disorder (HAND syndrome) [6]

Vacuolar myelopathy
Certain peripheral neuropathies

Conditions caused by infectious, autoimmune, or neoplastic processes secondary to

immunodeficiency include the following:

CNS lymphoma
Kaposi sarcoma
Progressive multifocal leukoencephalopathy (PML)
Fungal infections (eg, cryptococcal meningitis, Penicillium
marneffeiencephalitis [7]

Tuberculous meningitis
Cerebrovascular diseases [8, 9]

Certain neuropathies and myopathies

Toxoplasmosis
Neurocysticercosis
Cytomegalovirus (CMV) encephalitis

Some neurologic conditions are caused by antiretroviral drugs. In addition, AIDS

patients are susceptible to the same neurologic diseases as patients who do not have
HIV infection.
In AIDS, a clinical presentation often cannot be explained with a single diagnosis.
New-onset neurologic complications often are superimposed on an ongoing process
with a different etiology. Clinical features reflect the sum of deficits at several
anatomic sites.
Neurologic immune reconstitution inflammatory syndrome
Neurologic immune reconstitution inflammatory syndrome (NeuroIRIS) is a newly
recognized complication of combination antiretroviral therapy. [10] In a recent
retrospective study of 461 patients started on combination antiretroviral therapy, 7
patients (0.7%) developed NeuroIRIS. [11] In general, the risk of IRIS appears to be
high in patients whose CD4+ lymphocyte count is below 50 cells/mL at the start of
antiretroviral therapy. [12]
Associated cerebrovascular diseases
Specific types of cerebrovascular disease are associated with HIV infection. In
addition, with improved treatment and prolonged survival, more HIV-infected
patients reach an older age and are at risk for cerebrovascular diseases unrelated to
HIV infection. HIV-positive patients may suffer transient ischemic attacks (TIAs) or
hemorrhagic, thrombotic, or embolic strokes.
A Danish population study showed that HIV-infected individuals have an increased
risk of stroke with and without proven risk factors. Low CD4 cell count at the start of
antiretroviral therapy and exposure to abacavir, but not with HAART, were
important risk factors seen in this population. [13]
HIV-positive patients are at risk for strokes at much younger ages than typically are
associated with stroke. As in the HIV-seronegative population, age itself is a risk
factor for stroke in HIV-infected individuals.

Pathophysiology
When immune defenses are impaired, opportunistic infections and neoplasms arise,
often from reactivation of previously acquired organisms. This mechanism applies to
agents such as Toxoplasma gondii and Epstein-Barr virus (EBV); the latter is strongly
associated with CNS lymphoma. Other organisms, such as the JC or SV40 viruses
that cause progressive multifocal leukoencephalopathy, may be activated directly
by HIV gene products.
The likelihood of a particular neurologic syndrome correlates with the clinical stage
of HIV infection as reflected by viral load, immune response, and CD4+ lymphocyte
counts. This, in turn, is related to the severity of immunodeficiency and
autoimmunity and to serum and tissue cytokine levels.

Manifestations of acute HIV infection are often subclinical but may include

meningitis,
acute encephalopathy with seizures,
confusion, and delirium.
HIV enters the CNS soon after initial infection. Early peripheral nerve manifestations
include isolated
acute cranial nerve palsies and
Guillain-Barr syndrome.
Neurologic complications seen in AIDS include AIDS dementia complex,
vacuolar myelopathy, opportunistic infections and neoplasms, and chronic
neuropathies (usually several years after HIV infection).
Neurologic immune reconstitution inflammatory syndrome (TERKAIT HIV)
NeuroIRIS manifests several weeks after the start of highly active antiretroviral
therapy. There is a paradoxical clinical deterioration despite improving CD4 cell
counts and viral load. Antiretroviral-naive patients are at particular risk independent
of baseline CD4+ counts. NeuroIRIS is an uncommon complication of combination
antiretroviral therapy but has a very poor outcome.

Cerebrovascular disease
AIDS seems to confer additional risk for ischemic and hemorrhagic stroke
independent of other stroke-related risk factors. Some mechanisms responsible for
strokes, both nonspecific and specific to HIV, include hypertension, hypotension,
cardiac disease, illicit drug use, coagulopathy, vasculitis (infectious, autoimmune),
and hemorrhage (including hemorrhage into neoplasms and abscesses), but other
mechanisms may be operative that are less well understood.

A. Premature atherosclerotic cerebral arteriopathy associated with highly active

antiretroviral therapy (HAART)induced metabolic disorders has become an
additional risk factor in patients with AIDS.
Several studies have documented subclinicZal cervical artery atherosclerosis, as
assessed by intima-media thickness, ultrasound detection of carotid artery plaques,
and intracerebral small-vessel disease, all being associated with the induced
metabolic changes. [9]

2. Epilepsi
3. Epilepsi absence khas diberikan obat apa? Dan obat anti epilepsi yang lain?