Acquired immunodeficiency syndrome (AIDS)

A condition in humans in which progressive failure of the immune system allows life-threatening opportunistic infections and cancers to thrive.

The most common conditions producing focal CNS lesions in AIDS: 1)

1. CNS Toxoplasmosis in AIDS

2. Primary central nervous system lymphoma in AIDS

3. Progressive multifocal leukoencephalopathy (PML)

4. Cryptococcal abscess

5. TB (Tuberculoma).

Neurologic complications are common in patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Although both the central nervous system (CNS) and the peripheral nervous system can be affected, 80% of patients with HIV/AIDS have CNS involvement during the course of their illness. The brain is the primary site of HIV/AIDS-associated CNS complications. Spinal cord involvement is rare, particularly focal intramedullary spinal cord lesions without any associated cerebral lesions. Among various opportunistic infections and malignancies, toxoplasmosis and CNS lymphoma are the most common causes of focal neurologic disease in patients with HIV/AIDS. Distinguishing between toxoplasmosis and CNS lymphoma is challenging, as the diseases have similar clinical presentations.

40–60% of all patients with acquired immunodeficiency syndrome (AIDS) will develop neurologic symptoms, with one–third of these presenting initially with their neurologic complaint 2) 3) Only ≈ 5% of patients that die with AIDS have a normal brain on autopsy.


Aside from opportunistic infection and tumors caused by the immunodeficient state, infection with the Human Immunodeficiency Virus (HIV) itself can cause direct neurologic involvement including:

1. AIDS encephalopathy: the most common neurologic involvement, occurs in ≈ 66% of patients with AIDS involving the CNS

2. AIDS dementia AKA HIV dementia complex

3. aseptic meningitis

4. cranial neuropathies: including “Bell’s palsy” (occasionally bilateral)

5. AIDS-related myelopathy: vacuolization of spinal cord; see Myelopathy

6. peripheral neuropathies

Although the number of patients with AIDS who require brain biopsy has decreased, the procedure still has merits. The paradigm we developed was useful for selecting patients for early biopsy. Patients with AIDS who also have intracerebral lesions should have toxoplasmosis titers performed, and those whose titers are negative for toxoplasmosis should undergo early brain biopsy 5).

Cryptococcosis is a fungal infection caused by Cryptococcus spp. that enters the body via inhalation, which mainly invades the lungs and central nervous system.

Patients with CNS toxoplasmosis have a median survival of 446 days, which is similar to that with PML but longer than AIDS-related PCNSL 6).

Patients with CNS lymphoma in AIDS survive on average a shorter time than similarly treated CNS lymphoma in nonimmunosuppressed patients (3 months vs. 13.5 mos). Median survival is < 1 month with no treatment. CNS lymphoma in AIDS tends to occur late in the disease, and patients often die of unrelated causes (e.g. Pneumocystis carinii pneumonia) 7).

In a woman with newly diagnosed HIV infection, myelopathy manifested as an isolated, single intramedullary spinal cord lesion.

Common methods to distinguish the diagnoses of toxoplasmosis and CNS lymphoma are addressed. There should be a high index of suspicion for toxoplasmosis in patients with HIV/AIDS presenting with a focal intramedullary spinal cord lesion 8).

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Levy RM, Bredesen DE, Rosenblum ML. Neurological manifestations of the acquired immunodeficiency syndrome (AIDS): Experience at UCSF and review of the literature. J Neurosurg. 1985; 62: 475–495
Simpson DM, Tagliati M. Neurologic Manifestations of HIV Infection. Ann Intern Med. 1994; 121: 769–785
Levy RM, Bredesen DE, Rosenblum ML. Neurological manifestations of the acquired immunodeficiency syndrome (AIDS): Experience at UCSF and review of the literature. J Neurosurg. 1985; 62: 475–495
Rosenow JM, Hirschfeld A. Utility of brain biopsy in patients with acquired immunodeficiency syndrome before and after introduction of highly active antiretroviral therapy. Neurosurgery. 2007 Jul;61(1):130-40; discussion 140-1. PubMed PMID: 17621028.
Sadler M, Brink NS, Gazzard BG. Management of Intracerebral Lesions in Patients with HIV: A Retrospective Study with Discussion of Diagnostic Problems. Q J Med. 1998; 91:205–217
Chappell ET, Guthrie BL, Orenstein J. The Role of Stereotactic Biopsy in the Management of HIVRelated Focal Brain Lesions. Neurosurgery. 1992; 30:825–829
Mohole J, Ho AL, Sussman ES, Pendharkar AV, Lee M. Focal Intramedullary Spinal Cord Lesion in Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome: Toxoplasmosis Versus Lymphoma. World Neurosurg. 2019 Jul;127:227-231. doi: 10.1016/j.wneu.2019.04.057. Epub 2019 Apr 11. PubMed PMID: 30981796.
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