Although the development of HAART has reduced the incidence of opportunistic infections and tumours they can still complicate and alter the progression of HIV infection and precipitate a neurological emergency. Some patients are unable to take HAART and, in others, antiretroviral regimens have failed: for these prophylaxis against opportunistic infections is needed.57,58

A useful way to approach the different cerebral opportunistic infections is to divide them into those that cause focal lesions and those with a more diffuse picture of meningitis or encephalitis. Toxoplasmosis, primary CNS lymphoma, and progressive multifocal leukoencephalopathy (PML) cause over 90% of focal lesions in patients with a CD4 count of less than 50 per microlitre. Tuberculosis, nocardia, and aspergillosis can also present with focal CNS lesions. CMV, HSV, VZV, and syphilis are all frequent pathogens that may cause diffuse disease. Meningitis is usually caused by pathogens such as Cryptococcus neoformans, Mycobacterium tuberculosis, Streptococcus pneumoniae and Listeria monocytogenes. More than one syndrome may be present at any given time, confusing the clinical picture.

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