Computerized tomographic brain findings in HIV/AIDS patients on highly active antiretroviral therapy treatment presenting with central nervous system manifestations in Gombe, North-East, Nigeria

Philip Oluleke Ibinaiye; Sefiya Adebanke Olarinoye-Akorede; Suleiman T Sa'ad; Nasiru M Tahir; Sahkir Muhammad Balogun; Aminu U Usman; Abubakar Ali-Gombe; Sani Garko; Dahiru M Yunsa; Timothy Y Umoru; Bello O Usman; Umar Abdulaziz

doi:10.4103/JRMT.JRMT_3_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 1 | Issue : 1 | Page : 20-24

Computerized tomographic brain findings in HIV/AIDS patients on highly active antiretroviral therapy treatment presenting with central nervous system manifestations in Gombe, North-East, Nigeria

Philip Oluleke Ibinaiye¹, Sefiya Adebanke Olarinoye-Akorede¹, Suleiman T Sa'ad², Nasiru M Tahir², Sahkir Muhammad Balogun³, Aminu U Usman², Abubakar Ali-Gombe⁴, Sani Garko², Dahiru M Yunsa², Timothy Y Umoru², Bello O Usman⁵, Umar Abdulaziz⁴
¹ Department of Radiology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
² Department of Radiology, Federal Teaching Hospital, Gombe, Nigeria
³ Epidemiology and Strategic Information, Center for Disease Control, Abuja, Nigeria
⁴ Department of Medicine, Federal Teaching Hospital, Gombe, Nigeria
⁵ Department of Medicine, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Date of Submission	17-May-2020
Date of Decision	28-May-2020
Date of Acceptance	05-Jun-2020
Date of Web Publication	25-Sep-2020

Correspondence Address:
Dr. Sefiya Adebanke Olarinoye-Akorede
Department of Radiology, Ahmadu Bello University and Teaching Hospital Shika, Zaria
Nigeria

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JRMT.JRMT_3_20

Abstract

Background: Despite the current availability of highly active antiretroviral therapy (HAART) in our hospital, neurologic complications of HIV still occur. Aim: The aim of this study was to document brain computed tomography (CT) findings in HIV patients receiving HAART who developed neurological complications and to examine the relationship of these findings with CD4 cell counts. Materials and Methods: Twenty patients with central nervous system symptoms out of 200 HIV/AIDS patients receiving HAART at the HIV Clinic of Federal Teaching Hospital, Gombe, were retrospectively studied. The findings were reviewed alongside their clinical features, CD4+ count, and HAART history. Results: CT findings were positive in 12 (60%) of the patients, while no abnormality was seen in 8 (40%) of the patients. The most common brain abnormality was atrophy (35%). Two out of 5 patients (40%) with CD4 counts >200 had abnormal CT findings compared with 9 out of 14 patients (64%) with CD4 counts <200 cells who had CT abnormalities. This finding was statistically significant (R = 0.864, P = 0.00). Conclusion: There is a high incidence of neurological complications and positive brain CT scans among the patients who defaulted from HAART treatment and with CD4 cell counts of <200 cells/μL.

Keywords: Computed tomography, highly active antiretroviral therapy, HIV/AIDS

How to cite this article:
Ibinaiye PO, Olarinoye-Akorede SA, Sa'ad ST, Tahir NM, Balogun SM, Usman AU, Ali-Gombe A, Garko S, Yunsa DM, Umoru TY, Usman BO, Abdulaziz U. Computerized tomographic brain findings in HIV/AIDS patients on highly active antiretroviral therapy treatment presenting with central nervous system manifestations in Gombe, North-East, Nigeria. J Radiat Med Trop 2020;1:20-4

How to cite this URL:
Ibinaiye PO, Olarinoye-Akorede SA, Sa'ad ST, Tahir NM, Balogun SM, Usman AU, Ali-Gombe A, Garko S, Yunsa DM, Umoru TY, Usman BO, Abdulaziz U. Computerized tomographic brain findings in HIV/AIDS patients on highly active antiretroviral therapy treatment presenting with central nervous system manifestations in Gombe, North-East, Nigeria. J Radiat Med Trop [serial online] 2020 [cited 2023 Mar 26];1:20-4. Available from: http://www.jrmt.org/text.asp?2020/1/1/20/296113

Introduction

The pathologic basis of the central nervous system (CNS) manifestations seen in HIV/AIDS patients has been attributable directly to the virus as well as indirectly from reduction in immune status, allowing for opportunistic infections (OIs) and neoplasms to become manifest. No body system is exempted from the infection; however, the brain is said to be involved in about a quarter of patients infected with HIV as an initial manifestation.^[1] While more than half will have a neurologic disease in the course of the disease, findings at autopsy show neurologic abnormality in almost 90%.^[2] The syndrome complex of neuro-HIV includes acute fulminant encephalopathy, neurologic immune reconstruction inflammatory syndrome, HIV-associated neurocognitive disorders (HANDs), CNS-OIs, CNS lymphoma, stroke, vascular myelopathy, and distal sensory polyneuropathy.^{[3],[4],[5],[6],[7],[8],[9],[10]}

The introduction of antiretroviral agents has changed the face of HIV infection and its complications worldwide. Despite a general decline in CNS complication environments where treatment is optimal, there is still an increased incidence of some CNS manifestations like HAND, distal polyneuropathy, and cerebrovascular accidents due to improved survival of patients.^[11],[12] In most parts of sub-Saharan Africa, however, the overall burden still persists due to factors like availability and affordability of highly active antiretroviral therapy (HAART)^[13] or poor compliance and comorbidities where the drugs are available.

Most treatment algorithms begin with brain imaging (computed tomography/magnetic resonance imaging [CT/MRI]) even before cerebrospinal fluid analysis (to rule out raised intracranial pressure). Due to its protean manifestation, there is no characteristic imaging feature that is pathognomonic for HIV.^[14] However, imaging findings could be characteristic in the appropriate clinical setting and absence of co-founders. Imaging could help to make a confident diagnosis, rule out important differentials, and detect complications. Brain imaging is also an invaluable noninvasive tool for planning treatment, some of which could simply be medical. Only a few studies in Nigeria have corroborated brain CT findings with CD4 counts in HIV-positive patients with neurologic complications. Our study aimed at filling this gap and to compare our current findings with previous ones available in the literature.

Materials and Methods

Following ethical approval from the institution ethics committee, we conducted a 2-year retrospective review of 20 patients with CNS symptoms out of 200 HIV-positive patients. These patients had received treatment at the HIV Clinic of Federal Teaching Hospital, Gombe, and later developed neurological symptoms. The patients were referred to the radiology department for brain CT examination. The examination was carried out using a multi-slice CT machine (Phillips Brilliance 16-slice CT scanner, manufactured by Royal Phillips Amstelplein 2, 1070 MX Amsterdam, Netherlands.), at 5 mm slice thickness, employing our standard brain protocol for pre- and postcontrast studies. Postcontrast studies were carried only after the initial noncontrast study scan had been reviewed to rule out acute hemorrhage. The images were reviewed by two consultant radiologists with 10 and 12 years of experience in neuroradiology.

The patients' biodata and clinical, immunological, and drug history were extracted from their hospital case notes. Data were analyzed using SPSS (version 20, Chicago, IL, USA); relevant correlations using Fisher's test were carried out such as CD4 cell counts versus CT findings and CD4 cell counts versus duration of HIV to test for the statistical level of significance. The level of significance was set at P < 0.05.

No autopsy or histology was performed.

Results

The patients' age ranged from 12 to 57 years; the mean age was 34.4 ± 10.3 years. The mean age for males was 34.3 ± 10.3 years, while that of females was 33.4 ± 8.3 years. The duration of HIV infection in males and females patients was 2.1 ± 1.6 years and 4.0 ± 3.4 years, respectively, while the mean onset of CNS complaints from diagnosis of HIV infection was 2.4 ± 1.2 years [Table 1].

Table 1: The patients' age, duration of HIV, CD4 count with test of statistics

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Only five patients were compliant on treatment, while 15 were either noncompliant or defaulted [Table 2].

Table 2: Level of compliant among male and female patients

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[Table 3] shows the nature and frequency of clinical presentation among the patients. The most common presentation was hemiparesis in 10 (50% of the patients), followed by headache in 9 (45% of patients) patients.

Table 3: Nature and frequency of clinical presentation among patients

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Eight (40%) of the patients had normal CT findings, while 12 (60%) had abnormal findings on CT scans. The distribution of lesions in the brain was as follows: cerebellum 1, cerebral cortex 4, lentiform nucleus 2, thalamus 2, peri-ventricular white matter 3, and external capsule 1.

The most common CT findings were cerebral atrophy in 7 patients (35%) and ex-vacuo ventricular dilatation in 5 patients (25%) and periventricular white matter changes in 5 patients (25%). Cerebral infarcts occurred in 4 patients (20%), of which one was hypertensive. Intracranial mass was demonstrated in 2 (10%) of the patients, the two cases were male and later defaulted from treatment (CD4 counts <100 cells). One of the masses was in the basal ganglia and showed ring enhancement, while the other was solitary and in the frontal lobe. Three cases (15%) also demonstrated extensive fingerlike nonenhancing hypodense lesions in the temporal and parietal lobes [Figure 1], [Figure 2], [Figure 3], [Figure 4].

Figure 1: Dilatation of lateral ventricles, sulci and basal cisterns in cerebral atrophy

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Figure 2: Left cortical and subcortical acute infarcts involving lentiform nucleus, thalamus and parietal lobe

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Figure 3: Enhanced masses in the frontal lobes and both thalami with focal calcification in the right thalamus in a case of toxoplasmosis who responded well to treatment

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Figure 4: Enhanced mass in the left frontal lobe in a case treated for cerebral lymphoma

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In [Table 4], only 19 patients analysed because CD 4 count result was absent in one patient. Two out of 5 patients (40%) with CD4 counts >200 had abnormal CT findings compared with 9 out of 14 patients (64%) with CD4 counts <200 cells who had CT abnormalities. This finding was statistically significant (R = 0.864, P = 0.00).

Table 4: Relationship of computed tomography findings and CD4 counts

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Patients with CD4 count <200 were 2.7 times more likely to have positive CT findings compared to those with a CD4 count of >200, but the finding was not statistically significant (P = 0.67).

The CD4 count versus duration of HIV showed a negative and nonsignificant correlation (R = 0.048, P = 0.84).

The overall prevalence of neurologic disease in HIV-positive patients in our study was 10%, while the prevalence was 3.2% among those who are actively compliant with HAART.

Discussion

CNS can be involved at any stage of the disease and not necessarily at the late stage; hence early diagnosis is key, especially as neuroimaging techniques such as CT and MRI are becoming increasingly available in our environment. From our study, the average onset of neurologic symptoms from the duration of HIV infection was about 2 years.

The overall prevalence of neurologic disease in HIV-positive patients in our study was 10%, while the prevalence was only 3.2% among those who are actively compliant with their treatment (HAART). This is significantly lower than previous reports. Oshinaike et al.^[15] reported that a third of their patients on HAART had clinically evident neurologic disease, while another African study^[16] showed that 44.6% also had neurologic complications of HIV disease. Both the authors agreed that neurologic involvement was associated with patients who had a more advanced disease, i.e., lower CD4 counts than patients without neurologic manifestation. The finding that the frequency of neurologic complications increases with the severity of immune depression (low CD4count) was confirmed in our study.

This study shows a 60% prevalence of abnormal CT findings in HIV-positive patients with neurologic symptoms. Males were twice as likely to have positive CT findings (80%) when compared with females (40%). A similar observation was made in the study by Eze and Eze^[17] where 24 males (66.67%) and 12 females (33.33%) had positive CT findings. Among our patients, we suggest that the likely reason could be because female patients attended their clinic appointment regularly and they were more compliant with drug regimen than their male counterparts. Graham et al.^[18] also stated a high prevalence of CT abnormalities in HIV patients presenting with uncomplicated headache and low CD4 counts. For patients with CD4 counts >200, MRI was suggested. We also advocate MRI scans for the early detection of subtle brain changes. In our series, we noted five patients with advanced disease (CD4 <200) and focal neurologic signs with negative CT findings; perhaps, further MRI studies would have revealed subtle abnormalities that were missed on CT. Furthermore, early MRI findings cannot be ruled out in patients with CD4 counts >200 cells even if CT finding is normal.

The predominant CT findings in our study were cerebral atrophy (35%) and ex-vacuo ventricular dilatation (25%), periventricular white matter changes (25%), cerebral infarcts (20%), and cerebral masses with mass effects (10%). In HIV infection, CNS disease has diverse and overlapping features. Atrophy plus ex-vacuo ventricular dilatation is the most common finding in HIV encephalitis.^[18] CT is similar to MRI in depicting cortical atrophy, but CT is superior to MRI in showing meningeal disease.^[18] Ozoh et al.^[19] also reported that the most common CT finding was cerebral atrophy found in 168 out of 364 patients (46.2%). This value, which is higher than ours (35%) could be accounted for by their larger sample size.

The differential diagnoses of the intracranial masses associated with this study were toxoplasmosis, cerebral abscess, and lymphoma. Neurotoxoplasmosis and primary central nervous system lymphoma (PCNSL) have similar imaging features; however, multiple ring-enhancing lesions located in the basal ganglia and thalamus in the presence of cerebral atrophy would be highly suggestive of toxoplasmosis, while solitary lesions would suggest lymphoma. Tuberculous abscess can be differentiated from bacterial abscess as the former is associated with the enhancement of basal meninges.

We also made an imaging diagnosis of progressive multifocal leukoencephalitis in 3 (15%) patients who had extensive, finger-like nonenhancing lesions involving the white matter of the temporal and parietal lobes. This can be differentiated from PCNSL which is enhancing and also demonstrates the mass effect. These imaging features can inform the early institution of medical therapy.

The use of effective HAART reduces the incidence of HIV infection and its complications. In Nigeria, there has been an overall reduction in incidence by 21% since its peak in 1997 and this has been attributed to effective therapy. This big picture is not reflected in every center. Apart from cost and availability being leading factors where the burden still lingers, a major contributor in our center was noncompliance. Only 6 (30%) of the patients with CNS complications in our study were compliant with therapy. The statistics from our study shows a strong and significant correlation between CD4 count and HAART status. All defaulters showed CD4 counts <200 out of which 64% had abnormal CT scans.

Hemiparesis was the most common presentation in this study and it occurred majorly in patients <40 years of age who did not have previous comorbidities like hypertension. CT brain in this group of patients revealed atrophy and infarcts. Stroke is not an unusual finding in HIV patients and it occurs as part of the syndrome complex or as a complication of treatment.^[16]

Headache was next frequent in our study, occurring in 45% of the patients. It was the most common presentation (60%–90%) in previous studies.^{[16],[20],[21]} Headache in HIV-positive patients should be considered exhaustively as it could be the sole presentation of a sinister CNS disease. It is reported to be the only complaint in 97.3% of patients with Cryptococcus meningitis by Luma et al.^[16]

Conclusion

There is a high incidence of neurological complications and positive brain CT scan findings among the patients who defaulted from HAART treatment and with CD4 cell counts of <200 cells/μL. We recommended that further MRI studies should be carried out on HIV patients with neurological symptoms but normal CT finding as this may reveal subtle abnormalities that are missed on CT.

Limitations

Our sample size is small; therefore, a future study with a larger population size may be required to corroborate our findings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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