Focal Brain Lesions in People with HIV

Patients presenting with neurologic symptoms and evidence of focal brain disorders should be evaluated immediately. The clinical presentation of focal brain lesions reflects the function in the area of brain involved. Typical symptoms or signs can include motor or sensory deficits, visual complaints, headache, seizures, or changing level of arousal. Initial studies of key importance include magnetic resonance brain imaging with and without a contrast agent such as gadolinium. When clinically safe, lumbar puncture for detailed cerebrospinal fluid (CSF) analysis is very helpful in the differential diagnosis. Combined clinical, radiologic, and diagnostic evaluation of the CSF can often provide solid evidence of the cause of the lesion(s) and may obviate the need for brain biopsy. The status of systemic human immunodeficiency virus (HIV) infection is important in the differential diagnosis, choice of therapy, and prognosis. Thus, concurrent evaluation of the history and status of the HIV infection is vital. Determination of a specific cause of symptomatic focal lesions is important; this should be pursued aggressively unless the global status of the subject suggests that therapy would be futile. With current therapy, many patients presenting with aggressive focal brain lesions can be successfully treated and can return to productive lives.