New onset seizures in HIV-infected patients without intracranial mass lesions or meningitis—a clinical, radiological and SPECT scan study

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Abstract

Fifteen HIV-infected patients who presented with new onset seizures (NOS) as the sole neurological manifestation, in whom no cause for the seizure was identifiable, were studied. The patients were mainly female with an average age of 31.3 years. They had generalised new onset seizures with a latency of 1.6 months between the discovery of the HIV positivity and the onset of the seizure. The neurological examinations were normal with no dementia. The electroencephalographic examinations were either normal or there was a generalised epileptic disturbance (GED). The patients have AIDS defining CD4+ T lymphocyte cell counts. There was a high prevalence of pulmonary tuberculosis (PTB) or multiple non-neurological illnesses in our study group. They have normal cerebrospinal fluid (CSF) analysis except for the presence of the HIV virus. All the patients have normal computerised tomogram (CT)/magnetic resonance imaging (MRI) scans of the brain. All the patients studied have abnormal right or left temporal lobe perfusion defects on the SPECT scan studies of the brain.

The findings suggest that the new onset seizures in the HIV-infected patients are associated with direct HIV infection. The SPECT scan findings suggest that the HIV virus induce a focal metabolic abnormality or encephalopathy. The new onset seizure is then the manifestation of this abnormality.

Introduction

New onset seizures (NOS) have been described in the HIV-infected patients. Three percent of the HIV patients in a prospective study, and between 11% and 17% in retrospective studies were found to have suffered NOS at some time during their illness [1], [2], [3], [4], [5], [6], [7]. In the majority of the patients (two-thirds) reported in these studies, the NOS were associated with an intracranial mass lesion, infection or metabolic disturbance [1], [2], [3], [4], [5], [6], [7].

In 5.9–46% of the reported patients, however, no cause for the seizures was identifiable [1], [2], [3], [4], [5], [6], [7]. This latter group of the patients are of interest because they imply that the HIV infection itself may be the cause of the seizure. The nature and mechanisms by which this occurs have, however, not been defined [1], [2], [3], [4], [5], [6], [7]. Investigation by this group of the patients with no identifiable cause for the seizures is therefore important.

We describe here the clinical, biochemical and radiological features (including SPECT scan studies) of the 15 HIV-infected patients in whom no cause for the NOS were identified.

Section snippets

Patients and methods

HIV-infected patients, older than 18 years, who presented with new onset seizures (NOS) to the Chris Hani Baragwanath Hospital (CHBH) in Soweto, South Africa during the period of July 1998 to July 1999 were studied. The CHBH is a 3300-bed public university hospital that serves a predominantly black urban population of approximately 3 million people. The patients recruited into the study were in-patients, admitted to the medical wards of the CHBH. All the patients in the study were black,

Results

Fifteen HIV-infected patients with NOS and no intracranial lesion (mass lesion or meningitis) were studied (Table 1). The patients had the following characteristics.

Discussion

The cardinal feature of our HIV-positive patients was that there was no evidence of the HIV-associated opportunistic infection or space occupying lesion. The NOS were the sole neurological manifestation in these patients. None of the patients had a clinical dementia or focal neurological deficits. There was also no atrophy on the CT/MRI scans of the brain and no white matter lesions on the MRI scan of the brain (a feature of HIV encephalopathy, seen in AIDS dementia). The only imaging

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