Vacuolar Myelopathy

Spinal cord disease is common in HIV-infected individuals. Myelopathy presents with spastic paraparesis and the pseudoataxia that results from proprioceptive loss. The clinical features indicating impaired function of the lateral corticospinal tract and the posterior columns of white matter (gracile and cuneate fasiculi) are similar to those seen in vitamin B12-deficient individuals. Vacuolar myelo-pathy usually occurs late in AIDS and is typically progressive. The estimated prevalence at autopsy is 46.5%, compared to 26.8% clinically.102

As the neurological signs predict, pathological changes are found mostly in the thoracic spinal cord, predominantly in the posterolateral columns of white matter. Disease typically progresses from the mid-thoracic to the lumbar spine. Microscopic examination reveals myelin loss with relative axonal preservation.103 HIV is not always found in diseased tissues. MRI changes in the spinal cord include atrophy with diffuse, intramedullary, non-enhancing lesions on T2-weighted imaging. One study of nine patients showed that L-methionine, 3 g twice a day for 6 months, may result in improved strength and bladder and sexual function, and in improved somatosensory evoked potential changes.104

Clinical syndromes—unclear or multiple etiologies STROKE

Two retrospective studies indicated an increased stroke risk in HIV-infected subjects. One study demonstrated an odds ratio of 2.3 for HIV-infected patients even after controlling for risk factors such as cocaine use.105 After controlling for intravenous drug abuse, the second study defined a stroke rate among AIDS patients of 0.56% compared to 0.025% in the general population.106 The same study also noted that half of the HIV-infected stroke patients had CNS infections that might predispose to stroke: toxoplasmosis, Cryptococcus, tuberculosis and zoster; thus, the exact etiology of HIV-related stroke is unclear. Finally, stroke has been the presenting sign of HIV infection in children as young as 2 months.107

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