Clinical neuropathy in HIV/AIDS: an eight-year review of hospitalized patients in Sokoto,northwestern Nigeria

Abstract

HIV/AIDS is a multi-systemic disease that targets mainly the immune and nervous systems. Although about 4.4% of Nigerians are infected with HIV, data on the spectrum of HIV-related nervous disease in this population is rare. This study describes the neurological manifestations of HIV/AIDS in northern Nigeria. We undertook retrospective and descriptive analyses of the demographic, clinical, neurologic and laboratory data of all hospitalized HIV/AIDS adults in a referral hospital in northwestern Nigeria. The study period covered 2000 to 2007. We studied 322 HIV/AIDS patients (218 men, 104 women) aged 33.4 ± 11.4 years (range: 18–65 years) who constituted 3.5% of the total medical admissions. HIV transmission was exclusively by heterosexual intercourse involving multiple partners. The majority (70.2%) was married and 78.9% were in stage III/IV HIV/AIDS disease. Fifty-two (16.2%) had CD4+ T-cell count determination, the mean value being 220 ± 147.2 cells/m³, and 58 (18.0%) were on highly active antiretroviral therapy. Fifty-one (15.8%) had neurological complications dominated by central nervous diseases including encephalitis (17.6%), dementia (16.2%) and stroke (14.9%). Peripheral nerve involvements were relatively infrequent. Compared with HIV/AIDS patients without neurological complications, a significantly higher proportion of those with HIV-associated neuropathy had a stage IV disease (30% versus 9.4%, χ² = 19.5, P < 0.001). Neurological complications, particularly central nervous diseases, are an important cause of morbidity in the HIV/AIDS population.

Introduction

An estimated 40 million people world wide are living with HIV/AIDS.¹ The global AIDS epidemic continues to disproportionately affect Sub-Saharan Africa, where about 70% of the total global adult AIDS population lives.² In Nigeria, it is estimated that 4.4% of the population are infected with HIV,³ making the country the third highest (after India and South Africa) HIV/AIDS patient population. HIV/AIDS, although a multi-systemic disorder, targets mainly the immune and nervous systems in its early stage. Neurological complications have therefore been found to present as early manifestation of HIV/AIDS in 7–20% of patients, and account for 30% of AIDS-related mortality.^4,5 There are limited data characterizing the neurological morbidity of HIV/AIDS in Nigeria. In this report, we describe the neurological manifestations of adults with HIV/AIDS seen over an eight-year period in a referral hospital in northwestern Nigeria.

Methods

This is a retrospective study carried out from 1 January 2000 to 31 December 2007 at the Usmanu Danfodiyo University Teaching Hospital in Sokoto, northwestern Nigeria, a referral centre with a catchment population of 12.3 million. The study population included all adults (322) aged 18 years and above admitted into the medical wards suffering from HIV/AIDS during the period under review. Their records were retrieved. Patients were considered to have HIV/AIDS if they tested positive to enzyme-linked immunosorbent assay (ELISA) carried out using two different kits and satisfied the Nigerian Guidelines⁶ and World Health Organisation (WHO)⁷ clinical diagnostic criteria of AIDS. Demographic, laboratory and clinical data including neurological examination findings were recorded. AIDS dementia complex was diagnosed if patients had cognitive, motor and behavioural impairment. Data entry and analysis were done using Statistical Package for Social Sciences (SPSS) version 12. Independent t-test (two-tailed) and chi-square tests were used to determine the differences in means and proportions, respectively, between two groups. A P value of <0.05 was considered statistically significant.

Results

A total of 9117 patients (5152 men; 3965 women) were admitted to the medical ward during the study period. Of these patients, 322 (3.5%), consisting of 218 men and 104 women aged 33.4 ± 11.4 years (range 18–65 years), had HIV/AIDS. HIV transmission was exclusively via heterosexual intercourse involving multiple partners. The general characteristics and neurological manifestations of the patients are shown in Tables 1 and 2. The majority were married urban dwellers in WHO stage III/IV disease. Of the 322 HIV/AIDS patients, 51 (15.8%) had neurological complications. Fifty-eight (18.0%) were on highly active antiretroviral therapy (HAART) including nevirapine, lamivudine and stavudine. Encephalitis, AIDS dementia complex and stroke were the leading neurological diseases (Table 2). The stroke patients had none of the traditional risk factors of stroke. Compared with HIV/AIDS patients without neurological complications, those with HIV-associated neuropathy contained a significantly higher proportion of subjects with stage IV disease (30% versus 9.4%, χ² = 19.5, P < 0.001). The groups did not differ significantly in age, gender or the use of HAART or anti-TB drugs. Although patients with neurological complications were older (35.8 ± 9.8 versus 33.0 ± 11.6 years) and had lower CD4+ T-cell counts (216.8 ± 94.4 versus 220.9 ± 155.7 cells/mm³) these differences were statistically insignificant.

Table 1

The demographic characteristics of the study population

Characteristics	Frequency (N = 322) N (%)
Sex
Male	218 (67.7)
Female	104 (32.3)
Tribe
Hausa	232 (72.1)
Others	90 (27.9)
Residence
Urban	225 (69.9)
Rural	97 (30.1)
Marital status
Married	219 (68.0)
Single	60 (18.7)
Divorced	40 (12.4)
Others	3 (0.9)
Occupation
Civil Service	89 (27.6)
Housewife	78 (24.2)
Trading	69 (21.4)
Farming	24 (7.5)
Students	21 (6.5)
Driving	14 (4.4)
Professionals	6 (1.9)
Others	21 (6.5)
Staging
I/II	56 (17.4)
III/IV	266 (82.6)
Highly active anti-retroviral therapy	58 (18.0)
Anti-TB therapy	47 (14.6)
	Mean ± standard deviation
Age (years)	33.4 ± 11.4
CD4 lymphocyte count (cells/mm³)	220 ± 147.2

Table 2

Neurological diseases in HIV/AIDS patients (some patients had multiple neurological complications)

Disease	Frequency (N = 322) N (%)
Encephalitis	13 (4.0)
AIDS dementia complex	12 (3.7)
Stroke	11 (3.4)
Delirium	11 (3.4)
Seizure	8 (2.5)
Distal sensory peripheral neuropathy	7 (2.2)
Herpes zoster	6 (1.9)
Myelitis (spinal cord compression syndrome)	4 (1.2)
Myopathy	2 (0.6)
Facial nerve palsy	2 (0.6)

Discussion

This report shows that HIV/AIDS constituted 3.5% of the total medical admissions and affected mainly married urban dwelling men in their economically productive years. This hospital-based disease burden is lower than the 20.1% seen in Burkina Faso, West Africa⁷ and, perhaps, reflects the comparatively lower prevalence rate of HIV/AIDS in Nigeria.^3,6 The prevalence of neurological diseases among HIV/AIDS patients in our study is similar to the 14.7% reported in Burkina Fasso,⁸ but lower than in Kenya (21.2%),⁹ India (22.3%),¹⁰ Brazil (46.5%),¹¹ Poland (57.5%),¹² and Tanzania (67%).¹³

There are conflicting reports on the spectrum of neurological diseases in patients with HIV/AIDS. In our study, central nervous system diseases, including encephalitis, dementia and stroke, were the leading neurological manifestations of HIV/AIDS. This agrees with the reports from other West and East African countries,^8,9,13,14 and India.⁹ Herpes zoster was the most common opportunistic infection of the nervous system seen in this study which is consistent with the findings of Di Constanzo et al. ¹⁵ Acquired immune deficiency syndrome is an emerging cause of stroke in young native Africans (15–49 years) who have no traditional risk factors of stroke.¹⁶ Vasculitidis, cardio-embolism and hypercoaguability state are the mechanisms underlying stroke in HIV/AIDS.^17,18

AIDS–related central nervous system disorders are typically seen in patients with advanced disease and have been attributed to neuronal and astrocyte apoptosis which is, in turn, secondary to the neuropathological effects of HIV viral proteins, inflammatory mediators, opportunistic illnesses and treatment-related complication.^4,5,19 The spectrum of HIV-associated nervous disorders may be influenced by differences in the epidemiology of opportunistic infections of the nervous system, and the use of HAART. These factors, as well as differences in study design, may explain the different patterns of HIV-associated neuropathy seen in different populations. HAART reduces the prevalence of opportunistic nervous system infections and neoplasm but increases that of peripheral neuropathy.^20,21 It has also been shown to shift the clinical neurological manifestation of HIV/AIDS from acute severe dementia to a chronic variety with subtle minor cognitive impairment.²² The proportion of patients who received HAART in our study is too small to make any meaningful statistical impact on HIV-associated neuropathy.

A major limitation of this study is its retrospective design which might be contributory to the recorded relatively low prevalence of neurological complications of HIV/AIDS. We concentrated on the clinical aspects of HIV-associated neuropathy because neuro-imaging facilities such as computed tomography scans and magnetic resonance imaging are rarely available or affordable in this setting. The number of autopsies performed is also extremely low for socio-cultural reasons. A prospective study is required to confirm our findings.

In conclusion, central nervous system diseases including stroke, encephalitis and dementia impose a huge burden on the HIV/AIDS population. We recommend HIV counselling and testing for young adults with unexplained stroke.

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