Book Review

The Neurology of AIDS

N Engl J Med 1999; 340:324-325January 28, 1999

Article

The Neurology of AIDS
Edited by Howard E. Gendelman, Stuart A. Lipton, Leon Epstein, and Susan Swindells. 615 pp., illustrated. New York, Chapman & Hall, 1998. $169.95. ISBN: 0-412-08631-X

Worldwide, 33 million adults and 2 million children are infected with human immunodeficiency virus type 1 (HIV-1). Despite preventive efforts, the epidemic of the acquired immunodeficiency syndrome (AIDS) continues to spread rapidly. Every day 16,000 persons become infected with the virus. Most of them live in developing countries, where costly antiretroviral medications are not available. It is estimated that in 30 to 50 percent of HIV-1–infected people, neurologic complications will develop. This virus can affect virtually every aspect of the central and peripheral nervous systems, directly or indirectly. The socioeconomic consequences of the neurologic dysfunction caused by HIV-1 infection are therefore of enormous proportions.

It has long been known that HIV-1 penetrates the central nervous system soon after infection, and it becomes resident predominantly in microglial cells. However, the determinants of viral latency and activation within the central nervous system are poorly understood. The nervous system diseases resulting from AIDS are further complicated by the frequent occurrence of opportunistic infections and tumors. Although much progress has been made in the clinical care of HIV-1–infected persons, many antiretroviral medications are neurotoxic. Finally, the potent protease inhibitors do not readily cross the blood–brain barrier. This fact makes clearance of the virus from the central nervous system unlikely in the near future.

The Neurology of AIDS comprehensively discusses all these important issues. Numerous clinicians and researchers who have made important contributions to the study of the neurology of AIDS have participated in writing this textbook. The book has four sections. The first discusses the determinants of HIV-1 entry into the nervous system and the pathogenesis of infection. It describes the laboratory and animal models used for studies of these phenomena, including transgenic mice and nonhuman primates. The next two sections deal with clinical aspects of HIV-1 infection of the nervous system in adults and children and discuss current indications for the diagnosis and treatment of such patients. The last section reviews the behavioral and psychiatric manifestations of HIV-1 infection.

Each section is divided into multiauthored chapters, which provide a comprehensive review of the literature as well as original research by the authors. Numerous figures and diagrams help present concepts that are often complicated in a clear and easy-to-understand fashion. Well-chosen reproductions of brain-imaging studies and color pictures of histologic specimens illustrate the multiple facets of HIV-1–associated damage to the nervous system. Unresolved issues and directions for future research are clearly outlined, and key concepts are summarized at the end of each chapter.

The book has a number of novel components. A panel discussion involving the editors and other authorities in the field has been placed at the beginning of the book. This sets the stage for the scholarly work described in the chapters that follow. Moreover, the book begins and ends with patients' perspectives on their own experiences with the neurologic complications of HIV-1 infection and their responses to treatment. Drawings by HIV-1–infected children representing how they see the AIDS virus in their bodies remind us of the personal burden of HIV-1.

Despite the rapid pace of clinical and basic research on HIV-1, this book is remarkably up to date. Future editions would, however, benefit from a chapter on central nervous system lymphoma, the principal tumor of the nervous system associated with HIV-1 infection. This topic is now covered in the chapter on neuroimaging. In addition to its neuropathological description, a separate discussion of the poorly understood HIV-1–associated vacuolar myelopathy would also be welcome.

This outstanding book provides a balanced account of current knowledge in the clinical and basic-science aspects of the neurology of AIDS. It reminds us how important it is to maintain a connection between the bench and the bedside if we want to keep pace with the evolving spectrum of neurologic complications of HIV-1 infection in the era of new antiretroviral treatments. The Neurology of AIDS will certainly appeal to clinicians, students, and researchers alike.

Igor J. Koralnik, M.D.
Harvard Medical School, Boston, MA 02215