ReviewMovement disorders and AIDS: a review
Introduction
Neurologic disorders are a well-known complication of human immunodeficiency virus (HIV) infection [1]. Movement disorders are increasingly recognized as a potential complication of acquired immune deficiency syndrome (AIDS) and may sometimes represent the initial manifestation of HIV infection [2]. A 2–3% incidence of movement disorders has been reported in various HIV-infected populations studied retrospectively at tertiary referral centers [3]. However, when carefully evaluated in prospective studies, the incidence of movement disorders, and particularly parkinsonism, in AIDS patients appears to be higher than previously appreciated. Prospective studies have shown evidence of basal ganglia dysfunction, particularly tremor and parkinsonism, in 5–44% of patients [4].
In this review, we will discuss the different hyperkinetic and hypokinetic movement disorders seen in the setting of HIV infection, including hemichorea–hemiballism [5], myoclonus [6], dystonia [7], parkinsonism [8], tremor [9], and paroxysmal dyskinesias [10]. We will also review movement disorders seen in association with HIV-associated dementia (HAD), AIDS-related opportunistic infections or due to medications.
Motor dysfunction in the form of generalized slowness of movements seen in the setting of global cognitive and behavioral abnormalities has been termed the AIDS dementia complex (ADC) [11]. In this syndrome, cognitive symptoms mimicking a subcortical dementia usually precede motor symptoms, which most often include a slowing of rapid movements of the eyes and limbs. Other terms have been used to refer to this constellation of motor and cognitive abnormalities, including HAD, HIV encephalopathy and in milder forms, HIV associated minor cognitive/motor disorder [11]. For the purposes of this review, we will heretofore refer to this complex of dementia and motor dysfunction in HIV patients as HAD. It should be noted that HAD is distinct from HIV encephalitis, which is a neuropathologic diagnosis rendered when there is histologic evidence of HIV-induced inflammatory lesions in the brain. Approximately 50% of those individuals dying from HAD will have HIV encephalitis [12].
Section snippets
Epidemiology of tremor
The reported incidence of tremor in AIDS patients has ranged from 5.5 to 44% of patients with HAD [9]. As HAD is a late-stage manifestation of HIV infection, this may suggest an increased incidence of tremor with increasing immunosuppression [13].
Clinical features and etiology of tremor
Tremor in AIDS patients may be seen as part of a parkinsonian (Table 1) syndrome or may occur as an isolated phenomena. The tremor is often symmetrical and may occur at rest, but more typically occurs as a mild bilateral postural tremor. Rarely
Epidemiology of parkinsonism
Mirsattari et al. found a 5% incidence of parkinsonism in 115 HIV-infected patients who fulfilled United Kingdom Parkinson's Disease Brain Bank (UKPDBB) criteria for the diagnosis of parkinsonism, as well as an additional 10 patients with parkinsonian features who did not meet the UKPDBB criteria [4]. One prospective study found that 50% of HIV inpatients with movement disorders had features of parkinsonism. The same study found a similar mean time of five months between HIV diagnosis and the
Epidemiology of chorea/ballism
Choreoathetosis in AIDS was first reported by Navia and coworkers in 1986 [58], the same year Martinez-Martin et al. described another HIV patient who presented with hemichorea–hemiballism [59]. One year later Nath and coworkers described three other cases [2]. Since then, a growing number of patients with HIV-related choreoathetosis and ballism have been reported.
The exact frequency of these disorders is not clearly established. While some studies have reported hemichorea–hemiballism as the
Epidemiology of myoclonus
Myoclonus is a rarely reported movement disorder in AIDS patients (Table 1). Both segmental and generalized myoclonus have been described in AIDS patients. In de Mattos et al.'s series of 2460 HIV positive inpatients, four patients had myoclonus, two with spinal myoclonus and two with generalized myoclonus [21].
Clinical features and etiology of myoclonus
Nath et al. described two patients with segmental myoclonus associated with a variety of other movement disorders and neurologic abnormalities [2]. No clear correlation was observed
Epidemiology of dystonia
Dystonia has rarely been reported in patients with AIDS. However, generalized, segmental, and focal dystonia have been described in AIDS patients (Table 1).
Clinical features and etiology of dystonia
De Mattos and coworkers in their review of 2460 HIV positive patients reported only one case of hemidystonia which was due to toxoplasmosis of the contralateral basal ganglia [21]. A case of postural tremor associated with dystonia and a case of paroxysmal dystonia were described among seven AIDS patients with movement disorders. The first
Conclusion
Patients with HIV infection, particularly patients with HAD, may manifest a variety of movement disorders. Recognition of the movement disorder in these patients is important since it may represent the initial presentation of HIV infection. Alternatively, the movement disorder may indicate the presence of an underlying mass lesion or CNS infection related to AIDS. It is also important to be cognizant of the heightened sensitivity of AIDS patients to the potential extrapyramidal side effects of
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