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HIV-associated vasculopathy, opportunistic infections often cause stroke
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Opportunistic infections and HIV-associated vasculopathy are both common causes of stroke among patients with HIV in Malawi, study data showed.
Researchers also reported that HIV-associated vasculopathy may be a result of “an immune reconstitution-like syndrome” that occurs after patients begin ART.
“We recently showed that HIV infection makes a major contribution to the overall stroke burden in Malawi. It was the second leading risk factor overall, and the most important among young stroke patients,” Laura A. Benjamin, MRCP, PhD, and colleagues wrote. “Starting [ART] appeared to contribute to stroke risk in the very immunosuppressed, but the mechanism of this is unknown.”
The researchers recruited 64 patients with HIV and 107 patients without HIV for a prospective analysis of adults who were treated for ischemic stroke at Queen Elizabeth Central Hospital in Blantyre, Malawi in 2011. Benjamin and colleagues reported the clinical, histologic and radiologic features of stroke in patients with HIV compared those without HIV.
Patients who had HIV tended to have strokes at significantly younger ages (median, 40 years vs. 66 years; P < .001), the researchers reported. They were also less likely to have hypertension (42% vs. 89%; P < .001), as well as a variety of other vascular risk factors including hypercholesterolemia, diabetes and smoking. However, Benjamin and colleagues wrote, those with HIV were more likely to have large artery disease (21% vs. 10%; P < .001).
The most common etiologies were HIV-associated vasculopathy (n = 24; 38%) and opportunistic infections (n = 16; 25%), the researchers reported. fourth of patients (n = 16; 25%) experienced a stroke shortly after beginning ART, which the researchers wrote suggested an immune reconstitution-like syndrome. Patients who had a stroke after starting ART showed a low CD4 count, even though they demonstrated a lower viral load (P < .001), Benjamin and colleagues wrote.
“This study describes too few cases of ischemic stroke occurring in patients with HIV on long-term ART with high CD4 cell counts and virus less than the limit of detection to know whether HIV infection, despite successful antiretroviral treatment, poses an increased risk of ischemic stroke,” Bryan Smith, MD, of the section of infections of the nervous system at NIH, wrote in an accompanying editorial. “However, the study provides a thorough description of accurately diagnosed strokes in those with HIV and, in doing so, highlights areas in need of further research. Additional research support should be given to understanding whether the [immune reconstitution of inflammatory syndrome]-associated strokes seen amongst this cohort are related to [central nervous system] virus or inflammation that could be managed with more directed therapy.” – by Andy Polhamus
Disclosure: Smith reports no relevant financial disclosures. The researchers report funding from a fellowship and an award provided from the Wellcome Trust.
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