HIV: human immunodeficiency virus; CT: computed tomography; MRI: magnetic resonance imaging; ART: antiretroviral therapy; IgG: immunoglobulin G; RPR: rapid plasma reagin; LP: lumbar puncture; CNS: central nervous system; CSF: cerebrospinal fluid; PCR: polymerase chain reaction; AFB: acid-fast bacilli; TB: tuberculosis; NAAT: nucleic acid amplification testing; EBV: Epstein-Barr virus; CMV: cytomegalovirus; AIDS: acquired immunodeficiency syndrome.
* CNS lesions in patients with HIV and CD4 counts >500 cells/microL or who are on stable ART regimens are unlikely to present with opportunistic infections or AIDS-associated malignancies and should be evaluated the same as an immunocompetent patient. Refer to UpToDate content for further information.
¶ Signs of impending herniation include impaired consciousness, papilledema, and Cushing triad (hypertension, bradycardia, and irregular breathing). Refer to UpToDate content on evaluation and management of elevated intracranial pressure for additional information.
Δ Contraindications to LP include impending herniation, presence of focal neurologic signs or evidence of mass effect on imaging (eg, midline shift), and increased risk of bleeding (eg, severe thrombocytopenia, coagulopathy with predisposition to bleeding). Refer to UpToDate content on LP technique, indications, and contraindications for additional information.
◊ LP should ideally be performed within 48 hours of patient presentation to a health care facility.
§ Depending on the clinical context and varying degree of suspicion for certain etiology, additional tests include: CMV PCR and HIV viral load and genotype. Refer to UpToDate text on evaluation of CNS lesions in patients with HIV for additional information.
¥ Tuberculoma should be suspected in any patient with history of prior TB infection or disease, known or possible TB exposure, and/or past or present residence in or travel to an area where TB is endemic. If tuberculoma is suspected, obtain mycobacterial blood culture and CSF AFB stain, culture, and TB NAAT. Evaluate for extraneural TB.
‡ Prophylaxis against toxoplasmosis includes trimethoprim-sulfamethoxazole, atovaquone, and combination therapy with dapsone, pyrimethamine, and leucovorin. Refer to UpToDate text on toxoplasmosis in patients with HIV for additional information.
† Preferred therapy for toxoplasmic encephalitis is sulfadiazine plus pyrimethamine. Refer to UpToDate text on toxoplasmosis in patients with HIV for additional information.
** The most common etiologies of CNS lesions are listed. The differential diagnosis should be altered based on the clinical context of each specific patient. Refer to UpToDate text on evaluation of CNS lesions in patients with HIV for additional information.