Neurologic infections in people with HIV: shifting epidemiological and clinical patterns.

OBJECTIVES: The aim of this study was to define the frequency, risk factors, and clinical outcomes of both AIDS-defining and non-AIDS-defining neurologic infections among people with HIV (PWH). DESIGN: We conducted a retrospective observational cohort study by linking the clinical database at the Southern Alberta HIV Clinic (SAC) with the regional hospital and microbiology databases to identify cases and the associated morbidity and mortality for these neurologic infections from 1995 to 2018. METHODS: Neurologic infections were categorized into AIDS-defining and non-AIDS defining. Annual incidence rates per 1000 person-years were calculated. Cox proportional hazards models estimated adjusted hazard ratios (aHR) and 95% confidence intervals of risk factors for neurologic infections in PWH and mortality outcomes. RESULTS: Among 2910 PWH contributing 24 237 years of follow-up, 133 (4.6%) neurologic infections were identified; 107 (80%) were AIDS-defining and 26 (20%) non-AIDS defining. While the incidence of AIDS-defining neurologic infections declined over time, no change was seen in incidence of non-AIDS defining infections. The risk of having any neurologic infection was greater among black PWH (aHR = 2.5 [1.6-4.0]) (vs. white PWH) and those with a CD4 + T-cell nadir of less than 200 cells/µl (aHR = 6.6 [4.0-11.1]) (vs. ≥200 cells/µl). More AIDS-defining neurologic infections occurred in PWH with lower CD4 + T-cell counts and higher HIV viral loads. PWH with any neurologic infections experienced more seizures, strokes, all-cause mortality (aHR = 2.2 [1.5-3.2] and HIV-related mortality (aHR = 6.4 [3.9-10.7] (vs. no neurologic infection). CONCLUSION: Both AIDS and non-AIDS defining neurologic infections continue to occur in PWH resulting in significant morbidity and mortality. Early diagnosis and initiation of ART remain crucial in preventing neurological infections in PWH.

Sex Differences of Hospital and Emergency Department Presentations of Stroke in Canada.

We provide an updated estimate of adult stroke event rates by age group, sex, and stroke type using Canadian administrative data. In the 2017-2018 fiscal year, there were an estimated 81,781 hospital or emergency department visits for stroke events in Canada, excluding Quebec. Our findings show that overall, the event rate of stroke is similar between women and men. There were slight differences in stroke event rate at various ages by sex and stroke type and emerging patterns warrant attention in future studies. Our findings emphasize the importance of continuous surveillance to monitor the epidemiology of stroke in Canada.

Patient-reported outcomes of neurologic and neuropsychiatric symptoms in mild COVID-19: a prospective cohort study.

BACKGROUND: Various neurologic manifestations have been reported in patients with COVID-19, mostly in retrospective studies of patients admitted to hospital, but there are few data on patients with mild COVID-19. We examined the frequency and persistence of neurologic/neuropsychiatric symptoms in patients with mild COVID-19 in a 1-year prospective cohort study, as well as assessment of use of health care services and patient-reported outcomes. METHODS: Participants in the Alberta HOPE COVID-19 trial (hydroxychloroquine v. placebo for 5 d), managed as outpatients, were prospectively assessed 3 months and 1 year after their positive test result. They completed detailed neurologic/neuropsychiatric symptom questionnaires, the telephone version of the Montreal Cognitive Assessment (T-MoCA), the Kessler Psychological Distress Scale (K10) and the EuroQol EQ-5D-3L (measure of quality of life). Close informants completed the Mild Behavioural Impairment Checklist (MBI-C) and the Informant Questionnaire on Cognitive Decline in the Elderly. We also tracked use of health care services and neurologic investigations. RESULTS: The cohort consisted of 198 participants (87 female [43.9%] median age 45 yr, interquartile range 37-54 yr). Of the 179 participants with symptom assessments, 139 (77.6%) reported at least 1 neurologic symptom, the most common being anosmia/dysgeusia (99 [55.3%]), myalgia (76 [42.5%]) and headache (75 [41.9%]). Forty patients (22.3%) reported persistent symptoms at 1 year, including confusion (20 [50.0%]), headache (21 [52.5%]), insomnia (16 [40.0%]) and depression (14 [35.0%]); 27/179 (15.1%) reported no improvement. Body mass index (BMI), a history of asthma and lack of full-time employment were associated with the presence and persistence of neurologic/neuropsychiatric symptoms; female sex was independently associated with both (presence: odds ratio [OR] adjusted for age, race, BMI, history of asthma and neuropsychiatric history 5.04, 95% confidence interval [CI] 1.58 to 16.10). Compared to participants without persistent symptoms, those with persistent symptoms had more hospital admissions and family physician visits, and worse MBI-C scores and less frequent independence for instrumental activities at 1 year (83.8% v. 97.8%, p = 0.005). Patients with any or persistent neurologic symptoms had worse psychologic distress (K10 score ≥ 20: adjusted OR 12.1, 95% CI 1.4 to 97.2) and quality of life (median EQ-5D-3L visual analogue scale rating 75 v. 90, p < 0.001); 42/84 (50.0%) had a T-MoCA score less than 18 at 3 months, as did 36 (42.9%) at 1 year. Participants who reported memory loss were more likely than those who did not report such symptoms to have informant-reported cognitive-behavioural decline (1-yr MBI-C score ≥ 6.5: adjusted OR 15.0, 95% CI 2.42 to 92.60). INTERPRETATION: Neurologic/neuropsychiatric symptoms were commonly reported in survivors of mild COVID-19, and they persisted in 1 in 5 patients 1 year later. Symptoms were associated with worse participant- and informant-reported outcomes. Trial registration: ClinicalTrials.gov, no. NCT04329611.

Pearls & Oy-sters: Trigeminal Cystic Schwannoma Presenting With Foster Kennedy Syndrome, Sixth Nerve Palsy, and Focal Seizures.

Foster Kennedy syndrome refers to a finding of optic atrophy in one eye from direct compression of the optic nerve by a mass lesion and contralateral papilledema in the nonatrophic optic nerve caused by an increased intracranial pressure. When the fundoscopy finding is not due to a direct compressive mass, the term pseudo-Foster Kennedy syndrome is used; this can be caused by any process or processes that result in optic atrophy in one eye and optic disc edema in the other. Identifying Foster Kennedy syndrome in a patient calls for expedient neuroimaging looking for an intracranial mass lesion. In this article, we present the case of a patient presenting with vision loss and Foster Kennedy syndrome who was found to have a large trigeminal cystic schwannoma. While several other accompanying symptoms were not evident from the patient complaint, a careful history and physical examination revealed additional localizing clues: unilateral sensory changes in the face and pterygoid and masseter atrophy, unilateral cranial nerve VI palsy, and episodes of intense déjà vu sensation, which were presumed to represent temporal lobe-onset focal aware seizures. Trigeminal schwannomas are a rare entity, and they are even more rarely cystic. This case highlights an unusual scenario where a slow expansion of the tumor ultimately resulted in vision loss and presentation of the patient to medical attention.

Quality of life, respiratory symptoms, and health care utilization 1 year following outpatient management of COVID-19: a prospective cohort study.

The long-term impact of COVID-19 among those with mild infections is not well characterized. Among 81 adults who completed online assessments at 3- and 12-months following infection, quality of life scores did not significantly improve over time. Among 62 subjects who also completed telephone interviews, respiratory symptoms or exercise limitation were reported by 42% at a median follow-up of 387 days (IQR 251-402 days). Those with persistent respiratory symptoms scored lower on the EQ-5D visual analog score compared to those without. Persistent respiratory symptoms were associated with a lower likelihood of full-time employment at 1 year (aOR 0.09, 95%CI 0.01-0.91; P = 0.041). In an adjusted linear regression, persistent respiratory symptoms (P = 0.037) and female sex (P = 0.016) were both independent risks for increased visits to a primary care provider. This cohort study demonstrates that respiratory symptoms are frequent at 1 year following COVID-19 and more importantly, are associated with negative impacts on employment, quality of life, and health care utilization. Further research is needed to determine the pathophysiology and risk factors for persistent symptoms as well as optimal management strategies to improve the level of functioning and quality of life.

Case Series of Guillain-Barré Syndrome After the ChAdOx1 nCoV-19 (Oxford-AstraZeneca) Vaccine.

Purpose of Review: Vaccination has been associated with Guillain-Barre syndrome (GBS). Amid a global vaccination campaign to stop the spread of COVID-19, fears of GBS can contribute to vaccine hesitancy. We describe 3 cases of GBS in Calgary, Canada, presenting within 2 weeks of receiving the ChAdOx1 nCoV-19 (COVISHIELD) Oxford-AstraZeneca vaccination and review the available literature. Recent Findings: All 3 patients presented to the hospital in Calgary, Alberta, Canada, within a one-month time frame with GBS. Their clinical courses ranged from mild to severe impairment, all requiring immunomodulatory treatment. Summary: There is currently little evidence to support a causal relationship between vaccination and GBS. Furthermore, there is limited evidence to support recurrent GBS in patients with GBS temporally associated with vaccination. Neurologists should approach discussions with patients regarding GBS after vaccination carefully so as not to misrepresent this relationship and to educate patients that the risk of COVID-19 infection outweighs the small individual risk of a vaccine-associated adverse event.

Two heterozygous Cav3.2 channel mutations in a pediatric chronic pain patient: recording condition-dependent biophysical effects.

We report expression system-dependent effects of heterozygous mutations (P769L and A1059S) in the Cav3.2 CACNA1H gene identified in a pediatric patient with chronic pain and absence seizures. The mutations were introduced individually into recombinant channels and then analyzed by means of electrophysiology. When both mutants were co-expressed in tsA-201 cells, we observed a loss of channel function, with significantly smaller current densities across a wide range of voltages (-40 to +20 mV). In addition, when both mutant channels were co-expressed, the channels opened at a more depolarizing potential with a ~5-mV right shift in the half-activation potential, with no changes in half-inactivation potential and the rate of recovery from inactivation. Interestingly, when both mutants were co-expressed in the neuronal-derived CAD cells in a different extracellular milieu, the effect was remarkably different. Although not statistically significant (p < 0.07), current densities appeared augmented compared to wild-type channels and the difference in the half-activation potential was lost. This could be attributed to the replacement of extracellular sodium and potassium with tetraethylammonium chloride. Our results show that experimental conditions can be a confounding factor in the biophysical effects of T-type calcium channel mutations found in certain neurological disorders.