PRESENTATION AND COURSE OF AIDS DEMENTIA COMPLEX - 10 YEARS OF FOLLOW-UP IN AMSTERDAM, THE NETHERLANDS

Objective: To assess the clinical presentation and course of the AIDS dementia complex (ADC). Design: Retrospective study of a consecutive s eries of symptomatic HIV-1-infected patients [Centers for Disease Cont rol and Prevention (CDC) stages IVA, B, C and D] evaluated for neurolo gical symptoms between 1982 and 1992. Setting. An academic referral ce ntre for AIDS. Patients. A total of 536 symptomatic HIV-1-infected pat ients evaluated for neurological symptoms between 1982 and 1992. Inter ventions: Zidovudine treatment, which was introduced in The Netherland s on 1 May 1987 for patients with severe symptoms of HIV infection (CD C stages IVA, B, C and D). Main outcome measures: Diagnosis of ADC and CD4 cell count, clinical features, neuropsychological abnormalities, computed tomography (CT) and magnetic resonance imaging (MRI) abnormal ities, cerebrospinal fluid (CSF) findings and course in patients with ADC. Results: ADC was diagnosed in 40 out of 536 (7.5%) immunosuppress ed, neurologically symptomatic HIV-1-infected patients in CDC stage IV , and was the AIDS-defining illness in six. The mean CD4 cell count of the 40 patients with ADC was 109 x 10(6)/l. Neuropsychological abnorm alities in 15 out of 17 patients tested were in accordance with subcor tical dementia. On CT scan of the brain, 70% showed no or only mild co rtical atrophy. MR] was more sensitive than CT scan for detecting whit e matter abnormalities (73 versus 35%; P = 0.02). CSF examination show ed mononuclear pleocytosis in 25%, protein level increase in 55%, and HIV-1 p24 core protein in 38% (13 out of 34). The mean survival was 6. 7 months in the 40 ADC patients, but 4 months in 20 patients who had n ever used zidovudine, compared with 14.8 months in 10 patients who sta rted zidovudine after they were classified as having ADC (P< 0.001). T hree of these 10 patients improved remarkably, and two slightly, after starting zidovudine. ADC developed after discontinuation of zidovudin e in nine patients. Only one patient developed ADC while receiving 600 mg zidovudine. Conclusions: MRI is more sensitive than CT for detecti ng white matter abnormalities. To date, there is no specific or sensit ive CSF marker for ADC. Zidovudine may improve symptoms and prolong su rvival in patients with ADC, which rarely developed with continued zid ovudine use in our study.