Kugathasan Ruthiran, Collier Dami A, Haddow Lewis J, El Bouzidi Kate, Edwards Simon G, Cartledge Jonathan D, Miller Robert F, Gupta Ravindra K
University College London Hospital NHS Foundation Trust, United Kingdom.
Division of Infection and Immunity, University College London, United Kingdom.
Clin Infect Dis. 2017 Apr 15;64(8):1059-1065. doi: 10.1093/cid/cix035.
Human immunodeficiency virus type 1 (HIV-1) can replicate independently in extravascular compartments such as the central nervous system, resulting in either cerebrospinal fluid (CSF) discordance (viral load [VL] in CSF 0.5 log10 copies HIV-1 RNA greater than plasma VL) or escape (detection of HIV VL >50 copies/mL in CSF in patients with suppressed plasma VL <50 copies/mL). Both discordance and escape may be associated with neurological symptoms. We explored risk factors for CSF discordance and escape in patients presenting with diverse neurological problems.
HIV-infected adult patients undergoing diagnostic lumbar puncture (LP) at a single center between 2011 and 2015 were included in the analysis. Clinical and neuroimaging variables associated with CSF discordance/escape were identified using multivariate logistic regression.
One hundred forty-six patients with a median age of 45.3 (interquartile range [IQR], 39.6-51.5) years underwent 163 LPs. Median CD4 count was 430 (IQR, 190-620) cells/µL. Twenty-four (14.7%) LPs in 22 patients showed CSF discordance, of which 10 (6.1%) LPs in 9 patients represented CSF escape. In multivariate analysis, both CSF discordance and escape were associated with diffuse white matter signal abnormalities (DWMSAs) on cranial magnetic resonance imaging (adjusted odds ratio, 10.3 [95% confidence interval {CI}, 2.3-45.0], P = .007 and 56.9 [95% CI, 4.0-882.8], P = .01, respectively). All 7 patients with CSF escape (10 LPs) had been diagnosed with HIV >7 years prior to LP, and 6 of 6 patients with resistance data had documented evidence of drug-resistant virus in plasma.
Among patients presenting with diverse neurological problems, CSF discordance or escape was observed in 15%, with treatment-experienced patients dominating the escape group. DWMSAs in HIV-infected individuals presenting with neurological problems should raise suspicion of possible CSF discordance/escape.
1型人类免疫缺陷病毒（HIV-1）可在血管外腔室（如中枢神经系统）中独立复制，导致脑脊液（CSF）不一致（CSF中的病毒载量[VL]比血浆VL高0.5 log10拷贝HIV-1 RNA）或逃逸（血浆VL<50拷贝/mL的患者CSF中检测到HIV VL>50拷贝/mL）。不一致和逃逸都可能与神经症状相关。我们探讨了出现各种神经问题的患者发生CSF不一致和逃逸的危险因素。
分析2011年至2015年在单一中心接受诊断性腰椎穿刺（LP）的HIV感染成年患者。使用多因素逻辑回归确定与CSF不一致/逃逸相关的临床和神经影像学变量。
146例患者接受了163次LP，中位年龄为45.3（四分位间距[IQR]，39.6 - 51.5）岁。CD4细胞计数中位数为430（IQR，190 - 620）个/μL。22例患者中的24次（14.7%）LP显示CSF不一致，其中9例患者的10次（6.1%）LP表现为CSF逃逸。在多因素分析中，CSF不一致和逃逸均与头颅磁共振成像上的弥漫性白质信号异常（DWMSA）相关（校正比值比分别为10.3[95%置信区间{CI}，2.3 - 45.0]，P = 0.007和56.9[95% CI，4.0 - 882.8]，P = 0.01）。所有7例发生CSF逃逸的患者（10次LP）在LP前>7年被诊断为HIV感染，6例有耐药数据的患者中有6例血浆中有耐药病毒的记录证据。
在出现各种神经问题的患者中，15%观察到CSF不一致或逃逸，逃逸组中以有治疗经验的患者为主。出现神经问题的HIV感染者中的DWMSA应引起对可能的CSF不一致/逃逸的怀疑。
