Case: A 55-Year-Old HIV-Infected Woman With Cognitive Difficulties

A 55-year-old woman with well-controlled HIV infection is brought to the clinic by her family members because she has been having trouble with repeat and recall. Her family has observed that she was forgetting such things as where she put her keys, was leaving the stove on, and was having difficulty managing her medications, preparing meals, and paying bills. She had lost a small amount of weight.

She was initially diagnosed with AIDS in 1997, with a CD4+ cell count of 18/µL. Her risk factor was unprotected sex with her husband, who did not know his status at the time. Her nadir CD4+ cell count was 0/µL in 2000 when she finally began treatment, but she quickly achieved virologic suppression. Her other medical history includes squamous cell anal cancer in the same year as her diagnosis treated with resection and radiation, and mild hypertension. The patient had no personal or inherited dementia history. She was married, with 2 grown children, and had worked in retail for nearly 10 years but stopped working around 2000 when she developed symptomatic HIV infection. She never smoked, uses no drugs, and does not drink alcohol.

She had been functioning well and living independently, with well-controlled HIV infection and normal CD4+ cell counts on tenofovir, emtricitabine, and efavirenz, until approximately 2008 when she began struggling with acyclovir-resistant recurrent vaginal herpes simplex virus (HSV) infection. She was prescribed topical cidofovir but her children and family noticed that she seemed to need repeated reminders on how to use the medication. Family members had not noted any other memory problems at that time. Later in 2008, she moved away briefly to warmer climates to live with other family members. While there, she stopped taking antiretroviral drugs to pursue herbal remedies. She felt well until approximately 3 months prior to the visit, when family members noticed the trouble with repeat and recall and brought her back for follow-up.

On presentation, she is a pleasant woman with a normal physical examination except for cognitive issues, 10-lb weight loss, and recurrence of genital herpes. She scores 19 of 30 points on an initial Mini-Mental State Examination.[12] Her CD4+ cell count is 777/µL and her plasma HIV RNA level is 442 copies/mL. Her folic acid level, rapid plasma reagin test result, vitamin B12 level, thyroid-stimulating hormone (TSH) level, complete blood cell count, hepatic panel, and basic metabolic profile are within normal limits. She undergoes a lumbar puncture. The cerebrospinal fluid (CSF) has 1 white blood cell, 0 red blood cells, normal protein and glucose, and results for toxoplasmosis, cryptococcal antigen, Venereal Disease Research Laboratory (VDRL), JC virus, HSV, cytomegalovirus, Epstein-Barr virus, and varicella zoster virus tests are negative. Given the functional decline in instrumental activities of daily living (IADL), she is also referred to a neurologist and undergoes a battery of neurologic and neuropsychologic tests, an electroencephalogram, and brain magnetic resonance imaging (MRI). The brain MRI reveals subtle ischemic change. Her electroencephalogram is unremarkable.