A careful history and physical examination is of particular importance as the management of acute episodes differs from that of progressive and static encephalopathy. The acute episode may be indicative of meningitis or encephalitis. A condition with gradual onset with slow progression may suggest a degenerative disorder. Appropriate investigations will need to be carried out to establish the diagnosis. Neurologic abnormalities in HIV infected children may include:
Acute episodes: Sudden development of fits, neck stiffness or irritation may occur and this may indicate opportunistic infection. Physical deficits such as hemiplegia, monoplegia or paraplegia may occur as a result of opportunistic infection of the brain and/or spinal cord.
Progressive encephalopathy: This is a slow but progressive reduction in motor and intellectual function beginning in the first year of life. There may be a delay or regression of developmental milestones, hypotonia, or microcephaly. Often children with neurologic problems may simply lose interest in their surroundings and have no interest in playing. Some children may lose learned language or social skills while others may show increased clumsiness. There may be a progressive decline in intellectual and behavioural function.
Static encephalopathy: A non-progressive mental impairment may occur. Neurologic deficits such as loss of milestones simply persist and the child is considered to be simply "slow" in everything.
Managing encephalopathy should include evaluating the child with the help of a neurologist, where possible. If nothing other than HIV is found, the treatment goal is to reduce viral load. Depending on the severity, the patient will need a support system, which includes physical therapy, a social worker, and surgery to minimize contractures
Peripheral neuropathy: Several types of peripheral neuropathy affecting single or multiple nerves have been documented (e.g. axonal neuropathy, demyelinated neuropathy, polyradiculopathy and radiculopathy). HIV related neuropathy occurs in as many as one third of patients with %CD4 <15; it presents with dysaesthesias and numbness in a "glove and stocking distribution".
Neuropathy in children is more difficult to diagnose and less well described than in adults. In fact some ARV’s can cause neropathy (eg stavudine, didanosine, and zalcitabine) which may necessitate changing the drug regimen
Pain associated with neuropathy may respond to analgesics combined with antidepressants (eg amitryptyliine) or anticonvulsants (eg carbamazepine)
Seizures are common non specific manifestations of neurological illnesses associated with HIV. Seizures may be due to:
Space-occupying lesions (most often cerebral toxoplamosis or tuberculoma)
No identified cause other than HIV infection
Treatment is aimed at underlying disorder and seizure control through standard anti-epileptic medication. NB drug interactions may be a problem for patients on HAART; for those on HAART the drug of choice if sodium valproate
In patients presenting with focal seizures, treatment for toxoplasmosis should be considered if no other cause is apparent.