Neues bei HIV und Neuro-Aids

Zusammenfassung

Trotz sehr effektiver Behandlungsoptionen für die systemische HIV-Infektion sind Neuro-Aids und die HIV-assoziierte neurokognitive Störung ein klinisches und alltagsrelevantes Problem. Man unterscheidet 3 Stufen, das HIV-assoziierte, neuropsychologische Defizit (ANPD), das milde, HIV-assoziierte neurokognitive Defizit (MNCD) und die HIV-assoziierte Demenz (HAD). Die Behandlungsmöglichkeiten HIV-assoziierter neuro-kognitiver Störungen umfasst die antiretrovirale Therapie (cART), die den CPE-Score zur Penetration der Medikamente ins ZNS berücksichtigen sollte. Es ist sinnvoll, bei Auftreten multiresistenter Virusvarianten im Blut auch im Liquor entsprechende Untersuchungen durchzuführen. Im peripheren Nervensystems treten neben der klassischen, distal-symmetrischen, HIV-assoziierten Polyneuropathie immunogen vermittelte Neuropathien oder Myopathien auf (CIDP, AIDP). Durch die antiretrovirale Therapie (cART) verursachte Polyneuropathien sind differenzialdiagnostisch zu berücksichtigen. Erworbene mitochondrial toxische Myopathien treten häufiger auf, da nun eine cART durchaus über 10 – 20 Jahre durchgeführt wird. Bei Patienten mit schweren depressiven Episoden zeigte sich eine 6-mal höhere Wahrscheinlichkeit, die Einnahme der cART mindestens einmal zu vergessen. Depressive Episoden sind oft ein Grund für mangelhafte Adhärenz, korrelieren mit einer höheren Viruslast und sind dringend zu behandeln. In den letzten Jahren kam es infolge der verbesserten cART zu einem Rückgang der opportunistischen Infektionen (OI) des ZNS.

Die häufigsten OI stellen die progressive multifokale Leukoenzephalopathie (PML), die Toxoplasma-Enzephalitis und die Kryptokokken-Meningitis dar. Bei rasch progredientem Verlauf einer OI muss an ein Immunrekonstitutionssyndrom (IRIS) gedacht werden. Es gibt momentan keine sichere Methode, z. B. die Verschlechterung einer PML durch den natürlichen Krankheitsverlauf von der Verschlechterung durch ein IRIS zu unterscheiden. Infolge der deutlich zunehmenden Lebenserwartung treten Komorbiditäten mehr in den Vordergrund. Zu den viralen Biomarkern für die Krankheitsaktivität im ZNS zählen Neopterin als Marker der Makrophagenaktivierung, das Neurofilament-Leichtprotein und das Gesamt-Tau-Protein.

Abstract

Despite very effective treatment options for HIV-infection, Neuro-Aids and neuro-cognitive disorders remain a problem. There are three stages: HIV-associated, neurocognitive impairment (ANI), mild, HIV-associated neurocognitive deficit (MNCD) and HIV-associated dementia (HAD). Antiretroviral combination therapy (cART) should take into account the CNS penetration effectiveness (CPE)-score of the antiretroviral drugs. CSF-viral load and genetic virus variants should be analysed. There are also virus-associated complications of the peripheral nervous system. Besides the classic distal symmetrical, HIV-associated polyneuropathy, immunogenic neuropathies (CIDP, AIDP) and myopathies also occur. Polyneuropathies caused by cART represent a differential diagnosis. Acquired mitochondrial toxic myopathies occur more frequently, because nowadays cART is administered over 10 – 20 years. Depression, a frequent psychiatric complication, is associated with poor adherence and higher viral loads, and must be treated promptly. In recent years, the prevalence of opportunistic CNS-infections has declined due to the modern antiretroviral therapy. Progressive multifocal leucoencephalopathy (PML), Toxoplasma gondii encephalitis and Cryptococcus neoformans meningitis are the most common OIs. In case of rapidly progressive disease, an immune reconstitution syndrome (IRIS) should be considered. There is currently no reliable method to differentiate PML-deterioration from IRIS-PML. Because of a significantly increased life expectancy, comorbidities become more relevant. Neopterine as a marker of macrophage activation, neurofilament light protein and total tau protein represent biomarkers for disease activity in the CNS.

Schlüsselwörter

HIV-Infektion - Neuro-Aids - HIV-assoziierte neurokognitive Störung - Komorbiditäten - opportunistische Infektionen

Keywords

HIV-infection - neuro-aids - HIV-associated neurocognitive disorder - comorbidities - opportunistic infecctions

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