Неврозы – Neuroses

Neurological presentations

Many patients develop neuropsychiatry manifestations including cognitive and memory impairment, personality change and mental slowness progressing to mutism, incontinence and paraplagia. The virus is neurotropic causing dementia of presenile type (AIDS-dementia complex).

Myelopathy may present as ataxia.

Peripheral neuropathy is characterised by symmetrical glove and stocking sensory loss associated with muscle pain and weakness.

Choroidoretinitis due to CMV or HIV infection may result in progressive visual loss.

In some cases, central nervous system disease is related to opportunistic infection such as toxoplasmosis, cryptococcosis or HSV or to primary lymphoma of the brain.

Neoplastic presentations

Kaposi’s sarcoma (KS) is characterised by painless red-purple lesions on any part of the body including palms, soles, gastrointestinal tract and lymph nodes. KS is more common in homosexual men (up to 25%) than in other patients.

Extranodal B-cell lymphoma including brain lymphoma is reported with increased frequency in patients with HIV infection

Pyrexia of unknown origin

MAI infection becomes disseminated in ADDS patients and may present with fever, pancytopacnia and hepatitis. Kaposi’s sarcoma and lymphoma may present as pyrexia of unknown origin.

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Cardiovascular syphilis and neurosyphilis

Prednisolone 20 mg twice daily for two days prior to commencement of penicillin is recommended for patients with cardiovascular or neurosyphilis.

Aqueous procaine penicillin G 1.5 g daily intramuscularly with probenecid 500 mg four times daily by mouth for 21 days may be used for patients with cardiovascular syphilis and for patients with neurosyphilis managed as outpatients.

For patients with neurosyphilis treated as inpatients, intravenous benzylpenicillin G 4 g at four hourly intervals with probenecid 500 mg four times daily by mouth for 10 days may be used.

Asymptomatic patients with positive CSF findings should be treated as having neurosyphilis.

Patients with neurosyphilis should be referred for specialist advice. Benzathine penicillin should not be used for the treatment of neurosyphilis because an adequate level of penicillin in the CSF is not achieved. However, if the CSF examination is negative, benzathine penicillin G 1.8 g intramuscularly at 7 day intervals for 3 doses may be used for the treatment of cardiovascular or gummatous disease in patients unable to comply with daily injections.

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Infection may ascend from endocervix to the upper genital tract causing endometritis, salpingitis and pelvic inflammatory disease. Late sequelae include tubo-ovarian abscess and peri-hepatitis (Fitz-Hugh-Curtis syndrome).

Urethritis in females may cause dysuria and frequency without much discharge and be misdiagnosed as cystitis.

Infection of one or both Bartholin’s glands just inside the vulva may result in local pain, swelling and tenderness.

Anorectal infection secondary to genital infection is common in females. Anal sex may result in anorectal infection in both males and females. Anorectal infection may be asymptomatic or may present as a mucopurulent anal discharge and anal discomfort, including discomfort on defaecation.

Oral sex may result in oropharyngeal infection which may be asymptomatic or present as sore throat or pain on swallowing.

Conjunctivitis may occur in neonates as a result of transmission from an infected mother during parturition. Gonococcal conjunctivitis may occur as a local outbreak in older children or adults due to close contact or autoinoculation in communities with high carrier rates of gonorrhoea and poor hygiene standards.

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The physical examination should include oral, genital and anal examination. In female patients, a vaginal speculum should always be used to visualise the cervix and bimanual pelvic examination should be done. In patients with anorectal symptoms and in homosexual men, proctoscopy should be done to exclude anal canal pathology.

Patients must be treated with the same consideration as other patients. The examination should be carried out in privacy without interruption. Appropriate instruments should be used with gentleness and skill.

Laboratory investigations are directed at:

confirmation of the existence of disease; and

identification of the causative organism or organisms.

Patients should be told what investigations are being done and why they are considered necessary.

The investigations to be undertaken will be determined by the presentation and clinical findings, test results and the differential diagnosis

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