Issue 1-2012 Ingo Husstedt and Stefan Evers, Münster Epileptic seizures in HIV and AIDS Basically idiopathic epilepsies are (that inherited epilepsies) to be distinguished from symptomatic (for example, cerebral toxoplasmosis). Cause of symptomatic epilepsies can be opportunistic infections, strokes and even drug use with HIV infection in patients. Fig. 1 Partial complex seizure; left before the attack, the right rhythmic movements of the right arm and psychological absence with rigid, expressionless glance Fig. 2 Generalized epileptic seizure; left before the attack, right in attack In principle, partial and generalized seizures can be distinguished. The conspicuous changes and manifestations in an epileptic seizure depend on the function of the brain area in which the attack occurs. There occur involuntary rhythmic contractions of the body, wherein the arbitrary motion is canceled. Even pain or changes in sense perception can represent partial seizures.
Other typical symptoms are blurred vision, changes in smell, taste, hearing and balance. If in addition to these symptoms impaired responsiveness to stimuli or the memory is changed, it is called partial complex seizures (Fig. 1) Generalized seizures Frequency in Germany Seizures are one of the most common chronic diseases in neurology. For Germany, the number of patients is estimated with epilepsy 400000-800000 at 30,000 new cases per year. In addition to the persons concerned with a secured epilepsy, it is estimated that approximately 5% of the population is a latent epilepsy, which also corresponds to the proportion of the population at least once developed an epileptic seizure in life, but without suffering from epilepsy. Acute assistance in epilepsy Try to catch or lie down, the best place in recovery position the falling Move out of danger zone to bring out, thereby transporting the upper body and not on the extremities, as it can easily lead to dislocation Defensive movements give way, because it can very easily lead to physical confrontations otherwise Slide no object between the teeth, usually more damage depends on when it brings benefits
Useless around standing are asked to leave, since regaining consciousness “Gaffer” are very uncomfortable Duration of the attack register, especially in the first epileptic seizure briefing organize hospitalized Table 1 Best known are generalized seizures (Fig. 2). This caused complete loss of consciousness on, often an initial scream with tension of the muscles, it comes to the fall and generalized rhythmic twitching of muscles with Zungenbiss, breath holding with turning blue in the face and salivation. Often these attacks are accompanied by stool or urine loss and the person is disoriented for some time after the attack. causes Depending on the stage of HIV infection have up to 90% of patients to a form of Neuro-AIDS. Trigger of seizures may be the HIV-associated neuro-cognitive disorder, has been previously reported (HIV \x26amp; more 2/2007, www. hivandmore. de/archiv), as well as opportunistic infections, alcohol and drug use. Each newly occurring epileptic seizure in a patient with HIV infection represents an acute emergency, which must be sent immediately to a neurological department.
It is estimated that epileptic seizures in up to 20% of all HIV-infected persons may occur. In a group of 500 patients who were admitted to the emergency in a neurological clinic, led, inter alia, at 20% of epileptic seizures for emergency Aufnahme. 1 In most studies are primary generalized seizures with 30% as the most common form beschrieben. 2 by a retrospectively examined collective of Neuro-AIDS clinic at the University Hospital Münster reported 6% epileptic seizures or epilepsy. Who is in such an epileptic seizure, one should not panic, but be calm and collected verhalten. 3 So threatening such seizure may look, it is not dangerous for those involved in the rule. It is virtually impossible to stop an attack that has been started. All relief efforts are aimed at potential complications and particular injuries to verhindern. 3 Stationary clarification Fig. 3 Generalized spikes / waves during a generalized epileptic seizure Fig.
4 Generalized spikes / waves under photic stimulation as a provocation method Each first epileptic seizure in an HIV-infected persons and an overall evaluation in a Department of Neurology, generally under steady state conditions. The derivation of an electroencephalogram ( “brain power curve”) returns with spikes / waves the crucial points, as they are typical for epileptic seizures (Fig. 3). In some cases, methods are used that provoke these changes as the photic stimulation with a flickering light (Fig. 4). Magnetic resonance imaging is used for the detection of lesions of the brain such as e. g. cerebral toxoplasmosis in AIDS stage (Fig. 5). The HIV-associated neurocognitive disorder leads to changes in the brain, may be the cause of epileptic seizures, the HIV virus is already a few weeks after the acquisition of HIV infection in the brain detectable. In 30% of all people infected with HIV, the HIV virus can be detected by PCR in the cerebrospinal fluid, although the virus is suppressed to undetectable levels in the plasma. Indications for treatment
As a rule, there is an indication for treatment with anticonvulsants, if at least two attacks without provocation factors (sleep deprivation, alcohol consumption, drug use) have occurred. In epileptic seizures because of focal lesions of the brain, treatment with antiepileptic drugs is indicated in many cases. In a prospective study of 500 patients, which included five years, (35%), metabolic disorders or unknown causes were the main causes of epileptic seizures toxic drugs (47%), intracranial lesions (18%) were found. It was in 70% of cases to generalized seizures, in 12% of simple motor seizures in 18% resulted to partial-complex Anfälle. 5 investigations on its own collective, that in 40% of cases in erstaufgetretenen seizures an opportunistic infection as a trigger vorlag. 2 drug prevention Fig. 5 33 year old patient from Cameroon. HAART with boosted atazanavir plus tenofovir / emtricitabine. For cerebral toxoplasmosis sulfadiazine 4x 2 g, Daraprim 2x 50 mg, atovaquone 2x 1. 5g © Prof.
Heindel, Department of Clinical Radiology UK Münster Possible causes of HIV-associated epilepsy acute meningitis / encephalitis HIV-associated neurocognitive disorder opportunistic infections CMV Toxoplasmosis cryptococcosis PML HSV encephalitis cerebral tuberculosis primary cerebral lymphoma strokes drugs
antiretroviral medication Tab. 2 HAART usually includes drugs that have a high potential for interaction with anticonvulsants. Older substances for the treatment of epileptic seizures as Although such phenylhydantoin or valproic acid are cheap and in principle also effective, but have a high rate of side effects such as Fatigue, neuropathy and hair loss. Moreover, they have a wide range of interactions with HAART. Good are the substances gabapentin, pregabalin and levetiracetam, the two first and coexisting distalsymmetrischer, HIV-associated neuropathic pain have a significant therapeutic effect. The up-dosing follows the general guidelines, it has to be done einschleichend. Own investigations received by the patients, who were set to anticonvulsant therapy, 50% of people infected with HIV drugs such as unsuitable Valproic acid, carbamazepine, lamotrigine, clonazepam or Phenylhydantoin. 2 Antiepileptic drugs must be taken regularly, skipping increases the risk of an epileptic seizure, especially when sleep deprivation, alcohol or drugs are added. Depending on the cause and the course can possibly be done to three years of seizure freedom a slow tapering off after two. Here regular checks by a neurologist is necessary.
In one attack, which is classified by the treating neurologist as an opportunity attack, the driving ability is back after an observation period of 3 to 6 months, if the triggering conditions of the occasion seizure no longer apply. In other epileptic seizures – as due to an opportunistic infection – is driving ability at the earliest after one year seizure freedom. Prof. Ingo W. Husstedt Neuro-AIDS Outpatient Clinic of Neurology, University Hospital Münster Albert-Schweitzer-Straße 33 48129 Münster Email: husstedt@uni-muenster. de 1 Satishchandra P, Sinha S: Seizures in HIV-seropositive indivuduals: NIMHANS experience and review. Epilepsia 2008; 49: 33-41 2 Kellinghaus C, C Engbring, Husstedt IW et al .
: Frequency of seizures and epilepsy in neurological HIV-infected patients. Seizure 2008; 17: 27-33 3 Landesärztekammer Baden-Württemberg, Patient information: First aid for an epileptic seizure. http://www. aerztekammer-bw. de 4 Goldstein MA, Harden CL: Human immunodeficiency virus (HIV). http://professionals. epilepsy. com 5 Pascual-Sedano B, Iranzo A, Marti-Fabregas J et al . : Prospective study of new-onset seizures in patients with human immunodeficiency virus infection: etiologic and clinical aspects. Arch Neurol 1999; 56: 609-612