title: HIV-associated opportunistic CNS infections: pathophysiology, diagnosis and treatment.
abstract: Nearly 30 years after the advent of antiretroviral therapy (ART), CNS opportunistic infections remain a major cause of morbidity and mortality in HIV-positive individuals. Unknown HIV-positive disease status, antiretroviral drug resistance, poor drug compliance, and recreational drug abuse are factors that continue to influence the morbidity and mortality of infections. The clinical and radiographic pattern of CNS opportunistic infections is unique in the setting of HIV infection: opportunistic infections in HIV-positive patients often have characteristic clinical and radiological presentations that can differ from the presentation of opportunistic infections in immunocompetent patients and are often sufficient to establish the diagnosis. ART in the setting of these opportunistic infections can lead to a paradoxical worsening caused by an immune reconstitution inflammatory syndrome (IRIS). In this Review, we discuss several of the most common CNS opportunistic infections: cerebral toxoplasmosis, progressive multifocal leukoencephalopathy (PML), tuberculous meningitis, cryptococcal meningitis and cytomegalovirus infection, with an emphasis on clinical pearls, pathological findings, MRI findings and treatment. Moreover, we discuss the risk factors, pathophysiology and management of IRIS. We also summarize the challenges that remain in management of CNS opportunistic infections, which includes the lack of phase II and III clinical trials, absence of antimicrobials for infections such as PML, and controversy regarding the use of corticosteroids for treatment of IRIS.
authors: Section of Infections of the Nervous System, National Institute for Neurologic Disorders and Stroke, National Institutes of Health, 10 Center Drive, Building 10/7C103, Bethesda, Maryland 28092, USA.
authors: Lauren N
authors: LN
authors: Bowen
authors: Section of Infections of the Nervous System, National Institute for Neurologic Disorders and Stroke, National Institutes of Health, 10 Center Drive, Building 10/7C103, Bethesda, Maryland 28092, USA.
authors: Bryan
authors: B
authors: Smith
authors: Translational Neuroradiology Unit, National Institute for Neurologic Disorders and Stroke, National Institutes of Health, 10 Center Drive, Building 10/5C103, Bethesda, Maryland 20892, USA.
authors: Daniel
authors: D
authors: Reich
authors: Department of Pathology, National Cancer Institute, National Institutes of Health, 10 Center Drive, Building 10 Magnuson CC 2A10, Bethesda, Maryland 20892, USA.
authors: Martha
authors: M
authors: Quezado
authors: Section of Infections of the Nervous System, National Institute for Neurologic Disorders and Stroke, National Institutes of Health, 10 Center Drive, Building 10/7C103, Bethesda, Maryland 28092, USA.
authors: Avindra
authors: A
authors: Nath
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000175:diagnosis / Q000209:etiology; D003586:Cytomegalovirus Infections / Q000175:diagnosis / Q000209:etiology; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy; D006801:Humans; D054019:Immune Reconstitution Inflammatory Syndrome / Q000175:diagnosis / Q000209:etiology; D007968:Leukoencephalopathy, Progressive Multifocal / Q000175:diagnosis / Q000209:etiology; D016919:Meningitis, Cryptococcal / Q000175:diagnosis / Q000209:etiology; D016781:Toxoplasmosis, Cerebral / Q000175:diagnosis / Q000209:etiology; D014390:Tuberculosis, Meningeal / Q000175:diagnosis / Q000209:etiology