Book Review

HIV Neurology

N Engl J Med 2001; 345:1713December 6, 2001

Article

HIV Neurology
(Contemporary Neurology Series. Vol. 61.) By Bruce James Brew. 276 pp., illustrated. New York, Oxford University Press, 2001. $89.50. ISBN: 0-19-513363-3

Neurologic disease complicating human immunodeficiency virus (HIV) infection is common. Clinically significant neurologic disease ultimately affects up to 60 percent of HIV-infected persons, and pathological evidence of nervous system involvement at autopsy is even more frequent. These disorders have a substantial effect on the quality of life of the HIV-infected person and commonly affect survival as well. No part of the neuraxis is immune from the ravages of these complications. These disorders may affect the brain, the spinal cord, peripheral nerves, or muscles. Not infrequently, they present in stereotypical fashion, permitting a strong suspicion of the correct diagnosis, but perhaps as often, their clinical presentation is confusing. Furthermore, the presence of multiple, coexisting neurologic diseases may prove confusing to the clinician. The body of knowledge regarding these disorders has evolved considerably since the recognition of the AIDS pandemic, and the development of new information regarding pathogenesis, diagnosis, and management continues apace. For these reasons, a working, up-to-date knowledge of these disorders is essential for physicians and other health care workers who treat patients with AIDS.

HIV Neurology is part of the popular Contemporary Neurology Series from Oxford University Press. Its author, Bruce Brew, is one of the leading authorities on the neurologic complications of HIV and AIDS. Brew is a clinician-scientist who writes from firsthand experience when describing the diagnosis and treatment of AIDS-related neurologic diseases. He has also made substantial contributions to our understanding of many aspects of these disorders, and his depth of knowledge is apparent throughout the book. Brew states in the preface, “Although there are several other books similar to the present one, none has taken a predominantly clinical approach to . . . the diagnosis and therapy of HIV-related neurologic complications.” It is the emphasis on the clinical approach to these disorders that is the book's strength.

Three chapters (1, 2, and 4) in the first part of the book (the overview section) address many of the important clinical issues involved in dealing with the neurologic problems of patients with AIDS. The introductory chapter tackles the importance to the physician of neurologic complications of HIV by highlighting the frequency of these disorders, the confusion they often engender in clinicians who attempt to diagnose them, and their treatable nature. Separate, equally brief chapters in the overview section address other principles of HIV-related neurology, such as the ways in which the nature of neurologic disease varies according to the duration and severity of HIV-related immunosuppression; the relative frequency of various neurologic complications, which may coexist; the masking of subclinical disease by the superimposition of other conditions; the need to modify the “classic approach to neurologic diagnosis”; and the usefulness of recognizing patterns of disease when diagnosing these disorders. Although one may take issue with the recommendation that the “classic approach” be modified, as well as with the wisdom of separating these valuable points into three chapters, these chapters certainly offer useful tips for physicians who deal with HIV-infected patients and their neurologic problems.

Included among these introductory chapters is a chapter entitled “Introduction to HIV Disease,” which is a scholarly treatise on retrovirus biology and the general features of HIV. Brew's familiarity with these topics and the clarity of his writing shine through in this chapter, as well as in later chapters on the neurologic complications of primary HIV infection and on AIDS dementia complex, which are particularly lucid and comprehensive.

Because the book has a single author, I had hoped that it would be free of the problem that has plagued other books dealing with this topic — namely, repetition. However, in large part, the design of HIV Neurology quite appropriately parallels the approach that Brew advocates for clinicians who encounter HIV-infected persons with neurologic disease — that of stratifying such patients according to the severity of their immunosuppression and then determining the specific nature of the neurologic disorder or disorders. For example, do the disorders reflect diffuse or focal brain disease, or do they affect the spinal cord, peripheral nerves, or muscles? The book is logically divided into sections and chapters that reflect this approach. As a consequence, repetition becomes unavoidable.

The discussions of the opportunistic infections of the central nervous system that occur in patients with AIDS suffer somewhat from their brevity, with little space allocated to discussions of the pathogens, epidemiology, unusual clinical presentations, diagnostic methods, and controversies regarding treatment. Other problems with the book are few and minor. These include an occasional misstatement, such as the comment that oral hairy leukoplakia is seen only on the lateral borders of the tongue; the use of terms that are not widely used, such as “HIV multinucleate giant cell myelitis”; inaccurate labeling of some of the figures, such as that of Figure 6-7, indicating that it demonstrates the “topographic distribution of neuropathologic changes in AIDS dementia complex,” whereas the figure in reality displays the distribution of HIV p24 antigen in various regions of the brain; the inclusion of some tables that add little to either the understanding or the classification of these disorders; and occasional citation errors. The inclusion of a few more images relevant to the opportunistic infections of the central nervous system and improvements in some of the images that are included would be welcome. Finally, the color plates would probably best be located in the front or back of the book rather than being inserted in the middle of the chapter on less common spinal cord diseases.

This book provides a very good presentation of the clinical approach to the neurologic complications of HIV infection. It should appeal particularly to physicians who treat patients with AIDS and who seek a thoughtful, well-reasoned, and concise treatise.

Joseph R. Berger, M.D.
University of Kentucky School of Medicine, Lexington, KY 40536-0284
jrbneuro@uky.edu