What is the best course of treatment for an HIV-positive patient experiencing seizures, with symptoms of confusion and decreased concentration, but no other neurological deficits?

Management of Seizures in HIV-Positive Patients

For HIV-positive patients experiencing seizures with confusion and decreased concentration, levetiracetam is the first-line antiepileptic drug due to its minimal drug interactions with antiretroviral therapy, broad spectrum activity, and favorable side effect profile. 1

Etiology of Seizures in HIV Patients

• Seizures occur in approximately 6-11% of HIV-positive patients, significantly higher than the general population 2, 3
• Common causes include:
  • Opportunistic infections (particularly toxoplasmosis, cryptococcal meningitis) 2, 4
  • HIV encephalopathy or direct viral effects 5, 4
  • Metabolic derangements 5, 6
  • Neoplasms (including primary CNS lymphoma) 6, 4
  • Medication side effects (particularly efavirenz) 1, 2

Diagnostic Approach

• MRI should be performed as soon as possible in all immunocompromised patients with suspected encephalitis or seizures 4
• Lumbar puncture is essential, with CSF analysis for:
  • PCR for HSV 1 & 2, VZV, enteroviruses, EBV, and CMV 4
  • Cryptococcal antigen testing 4
  • Toxoplasma antibody testing 4
  • CSF culture for bacterial pathogens including Listeria monocytogenes 4
• EEG should be considered, especially if there's concern for nonconvulsive status epilepticus in patients with persistent altered consciousness 4, 7

Treatment Approach

Acute Seizure Management

1. First-line treatment: Benzodiazepines for acute seizure control 7, 8

   • Lorazepam 0.1 mg/kg IV at 2 mg/min
   • Diazepam 0.15-0.2 mg/kg IV at 5 mg/min

2. Second-line treatment (if seizures persist after benzodiazepines):

   • Levetiracetam 30 mg/kg IV at 5 mg/kg/min 7, 1
   • Valproate 30 mg/kg IV at 6 mg/kg/hour (if levetiracetam unavailable) 7, 9
   • Avoid phenytoin/fosphenytoin if possible due to drug interactions with antiretrovirals 1

3. Refractory status epilepticus:

   • Consider propofol (1-2 mg/kg IV bolus, followed by 2-10 mg/kg/hour infusion) 7
   • Barbiturates may be used but carry higher risk of hypotension 7

Long-term Seizure Management

• First choice: Levetiracetam due to:

  • Minimal drug interactions with antiretroviral therapy 1
  • Broad spectrum activity 1
  • Favorable side effect profile 1

• Alternative options (if levetiracetam unavailable/ineffective):

  • Lacosamide, gabapentin, or pregabalin for partial-onset seizures 1
  • Valproate (has shown safety and efficacy in small studies) 9
  • Avoid enzyme-inducing antiepileptic drugs (phenytoin, carbamazepine, phenobarbital) as they can cause virological failure of antiretroviral therapy 1, 2

Management of Underlying Causes

• Treat opportunistic infections if identified 4
  • For cryptococcal meningitis: amphotericin B plus flucytosine 4
  • For toxoplasmosis: appropriate antimicrobial therapy 4
• For HIV-associated CNS lymphoma: rituximab-HD-MTX (3 g/m²) with fully active ART 4
• Ensure optimal antiretroviral therapy - patients with HIV suffering from neurological disease should be treated in an HIV center 4

Prognosis and Follow-up

• Among patients with new-onset seizures, approximately 63% will have seizure recurrence 2
• Patients with only provoked seizures due to acute illness have better prognosis than those who develop epilepsy 3
• Regular monitoring of:
  • Antiretroviral efficacy (CD4 count and viral load) 9
  • Antiepileptic drug levels (if applicable) 1
  • Cognitive function and neurological status 4

Special Considerations

• Confusion and decreased concentration may represent HIV-associated neurocognitive disorder or an opportunistic infection 4
• Early initiation of HAART and prophylactic use of cotrimoxazole may reduce seizure incidence in HIV patients 2
• In resource-limited settings where newer antiepileptic drugs are unavailable, valproate may be preferred over enzyme-inducing AEDs 9, 1