Clinical manifestation

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HIVE is considered to be a subcortical dementia, typically emerging over the course of weeks and months. Acutely developing symptoms point to another etiology. Fever, exhaustion, the effects of tranquilizers and reduced physical condition, e.g. with opportunistic infection, may all mimic dementia. In these cases, diagnosis of HIVE can only be made after repeated examinations when the condition mimicking dementia has improved.

Symptoms are occasionally noted by relatives earlier than by the patient himself. This is why a history given by these persons is of utmost importance. Typical complaints are slowing of reasoning, forgetfulness, difficulties concentrating, lack of energy drive, mild depressive symptoms and emotional blunting. For symptoms and signs see Tables 1 and 2.

Table 1: Symptoms of HIV encephalopathy including history given by close relatives or companions

Cognition Forgetfulness, difficulties concentrating, mental slowing (apprehension, processing).

Emotional Loss of drive and initiative, withdrawal from social activities, failure to manage the financial and administrative aspects of one's life, depressive mood, emotional blunting.

Motor Slowing and impairment of fine movements (e.g. typing, buttoning up), and disturbance of gait.

Autonomous Impaired micturition (urgency), loss of sexual libido, erectile dysfunction.

Table 2: Signs of HIV Encephalopathy

Neurological Early stages: impaired gait, slowing of rapidly alternating movements, findings hypomimia, occasionally tremor and short stepped gait.

Later: brisk tendon reflexes, positive Babinski sign, slowing of gaze saccades, sphincter impairment including incontinence. Palmomental, grasp and glabella reflexes. Occasionally accompanying polyneuropathy. In the terminal stages spastic tetraplegia and dual incontinence.

Neuropsycho- Slowing of psychomotor speed (e.g. naming the months in reverse), im-logical findings pairment of short term memory (recall of verbally presented items, digit span), and mental flexibility (spelling simple words backwards).

Psychological Early stages: emotional blunting, disappearance of strong personality findings traits, distractability, loss of initiative.

Later: problems with recalling events in the correct time order, disorientation in time, space and situation. Finally mutism.

Impairment of alertness, neck stiffness and focal or lateralizing neurological signs (e.g. hemiparesis, aphasia) are not typical of HIVE. Psychotic symptoms without cognitive or motor disturbance do not warrant a diagnosis of HIVE. The coincidence of psychosis with HIVE is rare. Focal and generalized epileptic seizures are rare manifestations of HIVE.

The severity of HIVE may functionally be categorized according to the Memorial Sloan Kettering scale (Price 1988).

Severity of HIVE

(equivocal/subclinical) no impairment of work or capacity to perform activities of daily living (ADL); normal gait; slowing of ocular movements and movements of extremities may be present.

(mild) able to perform all but the more demanding aspects of work or ADL, but with unequivocal signs or symptoms of functional, intellectual or motor impairment; can walk without assistance.

(normal) normal mental and motor function.

Stage 1:

Stage 2:

(moderate) able to perform basic activities of self-care, but cannot work or maintain the more demanding aspects of daily life; able to walk, but may require a single prop.

Stage 3:

(severe) major intellectual incapacity (cannot follow news or personal events, cannot sustain complex conversation, considerable psycho-motor slowing); motor disability (cannot walk without assistance, usually manual slowing and clumsiness.

Stage 4:

(end stage) almost mutistic. Intellectual and social comprehension and output are at a rudimentary level; almost or completely mute; paraparetic or paraplegic with urinary and fecal incontinence.

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