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cerebral cortex, with little recognizable neuronal loss In other patients, small or large perivascular foci of demyelination, like those of postinfectious encephalomyelitis, are observed; the nature of this diffuse lesion is not understood These forms of pathologic change may occur singly or together and all correlate poorly with the severity of the dementia AIDS Myelopathy, Peripheral Neuropathy, and Myopathy A myelopathy, taking the form of a vacuolar degeneration that bears a striking resemblance to subacute combined degeneration due to vitamin B12 de ciency, is sometimes associated with the AIDS dementia complex; or the myelopathy may occur in isolation, as the leading manifestation of the disease (Petito et al) This disorder of the spinal cord is discussed further on page 1059 AIDS may also be complicated by several forms of peripheral neuropathy Of 50 such patients reported by Snider and coworkers, 8 had a distal, symmetrical, axonal polyneuropathy, predominantly sensory and dysesthetic in type This has been the most common neuropathic pattern The HIV virus has been isolated from the peripheral nerves and ganglia In fact, this stands as the rst proven viral polyneuritis in man (Zoster being more a ganglionopathy) In other patients, a painful mononeuropathy multiplex occurs, seemingly related to a focal vasculitis, or there may be a subacute in ammatory cauda equina syndrome (a polyradiculitis) that is usually due to an accompanying CMV infection (Eidelberg et al) Cornblath and colleagues have documented the occurrence of an in ammatory demyelinating peripheral neuropathy, of both the acute (Guillain-Barre) and chronic types, in otherwise asympto matic patients with HIV infection Most of these patients had a mild pleocytosis in addition to an elevated CSF protein content Also, all of the patients with in ammatory demyelinating neuropathy recovered either spontaneously or in response to plasma exchange suggesting an immunopathogenesis similar to that of the Guillain-Barre syndrome Cornblath and associates have suggested that all patients with in ammatory demyelinating polyneuropathies should now be tested for the presence of HIV infection, but this is probably appropriate only in groups of patients or in geographic areas where the disease is prevalent Facial palsy is being reported with increasing frequency as a feature of AIDS; its relationship to the generalized polyneuritis of AIDS is uncertain In the rare complication of AIDS called diffuse in ltrative lymphocytosis syndrome (DILS), a variety of clinical syndromes has been described, including all of the usual AIDS polyneuropathies Some instances of polyneuropathy in AIDS patients are probably due to the nutritional depletion that characterizes advanced stages of the disease and to the effects of therapeutic agents These AIDS-related neuropathies are discussed in Chap 46 and are well summarized by Wulff and Simpson A primary myopathy, taking the form of an in ammatory polymyositis, has been described in AIDS patients, occurring at any stage of the disease (Simpson and Bender) In some of these cases, the myopathy has improved with corticosteroid therapy The original anti-AIDS drug, zidovudine (AZT), has been said to cause a myopathy, probably due to its effect on mitochondria, but some workers disagree and nd almost all such cases to be attributable to the AIDS virus itself (see page 1203) From listening to the discussions of our colleagues, it is apparent that this remains an area of controversy Opportunistic Infections and Neoplasms of the CNS in AIDS In addition to the direct neurologic effects of HIV infection, a va-.

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riety of opportunistic disorders, both focal and nonfocal, occur in such patients, as outlined in Table 33-2 Interestingly, there appears to be a predilection for certain ones CMV infection, primary Bcell lymphoma, cryptococcosis, toxoplasmosis, and progressive multifocal leukoencephalopathy (page 651), in this order of frequency (Johnson) The focal encephalitis and vasculitis of VZV infection, considered earlier in this chapter, and unusual types of tuberculosis and syphilis are other common opportunistic infections of AIDS Usually P carinii infection and Kaposi sarcoma do not spread to the nervous system Toxoplasmosis Of the focal complications, cerebral toxoplasmosis is the most frequent (and treatable; see page 623) In the autopsy series of AIDS reported by Navia and colleagues, areas of in ammatory necrosis due to Toxoplasma were found in approximately 13 percent (see Fig 32-7) Lumbar puncture, contrastenhanced CT scanning, and MRI are useful in diagnosis The spinal uid usually shows an elevation of protein in the range of 50 to 200 mg/dL, and one-third of patients have a lymphocytic pleocytosis Since the disease represents reactivation of a prior Toxoplasma infection, it is important to identify Toxoplasmaseropositive patients early in the course of AIDS and to treat them vigorously with oral pyrimethamine (100 mg initially and then 25 mg daily) and a sulfonamide (4 to 6 g daily in four divided doses) Curiously, the toxoplasmosis infection, so common in the brains of AIDS patients, is not a frequent cause of the typical infestation, namely, myositis The main clinical problem in reference to toxoplasmosis in AIDS is its differentiation from cerebral lymphoma as discussed below and in Chap 31 CNS Lymphoma In the Johns Hopkins study (see Johnson), about 11 percent of AIDS patients developed a primary CNS lymphoma, which may in some cases be dif cult to distinguish from toxoplasmosis clinically and radiologically If the cytologic study of the CSF is negative and there has been no response to antibiotics, stereotaxic brain biopsy may be necessary for diagnosis The prognosis in such patients is considerably less favorable than in nonAIDS patients; the response to radiation therapy, methotrexate, and corticosteroids is short-lived, and survival is usually measured in months In the face of enhancing focal brain lesions in AIDS, the current approach is to assume initially the presence of toxoplasmosis, which is treatable Antibody tests for toxoplasmosis should be obtained; the absence of IgG antibodies mandates that treatment be changed in order to address the problem of brain lymphoma Also, if antitoxoplasmal therapy with pyrimethamine and sulfadiazine fails to reduce the size of the lesions within several weeks, another cause should be sought, again mainly lymphoma In those patients who cannot tolerate the frequent side effects of pyrimethamine or sulfonamides (rash or thrombocytopenia), clindamycin may be of value Recently it has been suggested that thallium isotope singlephoton emission computed tomography (SPECT) and positron emission tomography (PET) can reliably exclude lymphoma as the cause of a mass lesion in the AIDS patient The less frequent possibilities of tuberculous or bacterial brain abscess should be kept in mind if none of the other avenues allow a con dent diagnosis Cytomegalovirus Among the nonfocal neurologic complications of AIDS, the most common are CMV and cryptococcal infections At autopsy, about one-third of AIDS patients are found to be infected with CMV However, the contribution of this infection to.

Enable/disable recording of debugging information Enable/disable local address reuse Enable/disable keep connections alive Enable/disable routing bypass for outgoing messages Linger on close if data is present Enable/disable permission to transmit broadcast messages Enable/disable reception of out-of-band data in band Set buffer size for output Set buffer size for input

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To get the current options, use getsockopt: