1658. HIV Central Nervous System Escape (CNSE): Finding the needle in the haystack using cerebrospinal fluid (CSF) HIV viral load
Session: Poster Abstract Session: HIV: Neurological Complications and HAND
Saturday, October 10, 2015
Room: Poster Hall
  • CSF HIV poster 2015 pdf.pdf (120.3 kB)
  • Background: Without highly active antiretroviral therapy (HAART), cerebrospinal fluid (CSF) HIV viral load (VL) is typically 1-2 logs lower than plasma (pl) VL except with opportunistic meningitis (cryptococcus, TB), aseptic meningitis and white matter HIV encephalopathy.  In the context of HAART, central nervous system escape (CNSE) is the association of neurologic symptoms with elevated CSF HIV and suppressed pl HIV that resolve with CSF HIV suppression.  Since we recognized a case of CNSE in 2002, we request CSF HIV when lumbar puncture (LP) is done for clinical indications. CSFE is important to recognize since optimizing HAART can ameliorate symptoms.

    Methods: Retrospective review of patients (pts) from our HIV inpt medical service and outpt clinic who had LP for clinical indications and who had simultaneous pl and CSF HIV VL from 2002 to 2015.  The lower limit of detection (LLQ) varied according to the prevailing technology.

    Results: 42 patients on HAART had 45 paired CSF-pl specimens.  CSF HIV was < LLQ in 32 patients who had controlled pl HIV (median 56/ml,  <LLQ- 6169/ml).  3 had detectable (det) CSF HIV early on HAART before complete pl HIV suppression. 1 had dementia and CSF HIV (7609)> pl HIV (257/ml) after 3 months boosted protease (PI/r) HAART. 1 had CSF HIV(274/ml)  > pl HIV<47/ml during cryptococcal meningitis; 1 had CSF HIV (343/ml) during pl rebound (2781/ml).  1 had CSF HIV > pl HIV on 2 occasions: in 2003 following HAART resumption (CSF 1769/ml, pl 1064/ml) after a treatment interruption resulting in HIV aseptic meningitis and again in 2011 during recurrent toxoplasmic retinitis (pl <47/ml, CSF 71/ml) while on PI/r HAART.  2 patients had overt CNSE: both pts had cognitive decline and disabling involuntary movements; both were effectively on PI/r monotherapy due to resistance of companion HIV drugs.  The 2002 patient had CSF HIV 266,667/ml, pl HIV 7,392/ml.  Following addition of ZDV/TDF, she had CSF HIV 231/ml, pl HIV<50/ml with complete symptom resolution.  The 2009 patient had CSF HIV 57,996/ml, plasma HIV 789/ml.  With raltegravir,maraviroc, tenofovir, emtricitabine treatment, he had CSF HIV <48/ml, pl HIV 311/ml and full symptom resolution.

    Conclusion: Undet CSF HIV is the norm with controlled pl HIV.  Clinical CNSE occurred with regimens that were effectively PI/r monotherapy and was ameliorated by adjusting HAART.  CSF > pl HIV occurred with PI/r HAART .

    Elizabeth Jenny-Avital, MD1, Julie Hoffman, M.D.2, Mindy Katz, MD3, Jason Leider, MD4 and Stephen Apfelroth, MD3, (1)Medicine, Jacobi Medical Center--Albert Einstein College of Medicine, Bronx, NY, (2)Albert Einstein College of Mediicine, Bronx, NY, (3)Jacobi Medical Center, Bronx, NY, (4)Medicine, Jacobi Medical Center, Bronx, NY


    E. Jenny-Avital, None

    J. Hoffman, None

    M. Katz, None

    J. Leider, None

    S. Apfelroth, None

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