Seizure in HIV-infected Patients: Clinical Presentation, Cause and Treatment Outcome in Ethiopia: A Retrospective Study

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Seizure occurs in 2 to 3 % and 6.1 % to 34.3% in patients with HIV infection and patients with neurological complications of HIV infection, respectively. Studies on HIV infection and seizure are rare in Ethiopia. The purpose of this study was to assess clinical presentation, cause and treatment outcome of patients with HIV infection presented with seizure. Methods : In this retrospective study, patients aged ≥ 13 years with HIV infection presented with seizure were included. Medical records were reviewed and demographic and clinical data were collected. Results : Records of 146 patients were analysed. Males were 55.5% and the mean age was 34 years. The diagnosis of HIV infection was made after current hospital admission in 69% of patients. Almost all patients (98.6 %) had stage 4 HIV infection with very low CD4 count (mean = 77/mm 3 ). In almost all patients seizure was a recent onset at current admission; either it started after admission (42.5%) or within 3 months prior to admission (52.5%). The types of seizures were: generalized tonic-clonic seizure [GTCS] (69.2%), focal motor with secondarily generalization [FMWSG] (19.9%) and simple focal motor (11%). The common causes of seizure were: cerebral toxoplasmosis (46%), tuberculous meningitis (35.6%) and cryptococcal meningitis (13.7%). Case-fatality was 53% and predictors of mortality were: seizure started after admission, change in mentation and comatose at initial evaluation. Conclusions : Most patients had stage 4 HIV infection with very low CD4 count and a recent onset seizure which started within 3 months at initial evaluation. GTCS was the commonest seizure type and most causes of seizure were central nervous system opportunistic infections. The case-fatality was high and change in sensorium was an independent predictor of mortality. To prevent the high mortality and morbidity prevention of HIV infection, early diagnosis and treatment, improving diagnostic facilities and access to non-enzyme inducing antiepileptic drugs are recommended. Infectious Diseases Africa HIV Seizure Epilepsy Antiretroviral therapy Antiepileptic drugs Figures Figure 1 Background The estimated number of adult patients living with HIV infection in Ethiopia in 2012 was approximately 800,000[ 1 ]. Neurologic complications occur in 39 to 75% of the patients with HIV infection [ 2 , 3 ]. The incidence of seizure in HIV- infected patients varies from 2 to 3% in prospective studies [ 3 , 4 ]. The incidence of seizure in HIV infected patients in retrospective studies varies from 6.1% -11% [ 5 , 6 ] and 19.8% -34.3% [ 7 , 8 ] in HIV infected patients with neurological complications. Seizure occurs principally in patients with advanced HIV disease [ 4 , 9 ]. The causes of seizure in HIV-infected patients include mass lesion, meningitis, HIV-encephalopathy, drug toxicity, metabolic derangements and idiopathic which might include incidental epilepsy or seizure due to the HIV itself [ 3 – 14 ]. Primarily generalized seizure was the most common type in most studies [ 4 – 7 , 9 , 12 , 13 ]. In a retrospective study which assessed the pattern and treatment outcome of HIV-infected patients with neurological complications seizure was an independent predictor of mortality [ 8 ]. The aims of this study were to assess the clinical presentation, cause and treatment outcome of patients with HIV-infection presented with seizure to Tikur Anbessa Specialized Hospital (TASH), the largest teaching hospital of Addis Ababa University in Ethiopia. Methods HIV infected patients aged ≥ 13 years with seizure who were admitted to TASH from September 2014 to August 2018 were included in this study. The study was started after getting ethical clearance from the Neurology department research and ethics committee. Medical records were retrospectively reviewed and the following data were collected: socio-demographic, symptoms and signs at presentation, type(s) of seizure, history of previous seizure/epilepsy, cause(s) of seizure, comorbidities, CD4 count(the most recent count), CSF analysis, imaging studies, complete blood count, treatment given, duration of hospital stay and treatment out come at discharge. Medical records with inadequate data to verify the diagnosis of seizure were excluded from the study. Each patient was given a unique number to assure confidentiality. Seizures were classified into focal, focal with secondary generalization and primarily generalized seizures [ 15 ]. Status epilepticus was defined as continuous seizure activity lasting 30 min or more, or intermittent seizure activity lasting 30 min or more during which consciousness is not regained [ 16 ]. Preexisting history of epilepsy was defined as two or more seizures in a life time. The clinical staging of HIV-infection was based on WHO staging system [ 17 ]. The following diagnostic criteria were used for the diagnosis of HIV-infection related diseases: Cerebral toxoplasmosis Presumed diagnosis based on some or all of the following: i) headache, fever, change in sensorium ii) focal neurologic deficit iii) seropositivity for anti-toxoplasma immunoglobulin G, iv) ring enhancing brain lesion(s) on computerized tomography(CT)/magnetic resonance Imaging (MRI), v) low CD4 count(< 200/mm3),and vi) response to toxoplasma treatment. Tuberculous meningitis Based on some or all of the following: i) headache, fever, neck rigidity, change in mentation ii) cerebrospinal fluid (CSF) lymphocytosis iii) Acid-fast bacilli on CSF smear iv) evidence of active tuberculosis in other part of the body (milliary tuberculosis, pulmonary tuberculosis etc.) v) CT/MRI showing meningeal enhancement vi) response to tuberculosis treatment. Cyptococcal meningitis CSF India ink positivity. Bacterial meningitis i) acute onset headache, fever, change in mentation, neck rigidity ii) CSF polymorph predominant pleocytosis iii) CSF culture and Gram stain showing bacteria iv) response to antibiotics. Neurosyphilis CSF Venereal Disease Research Laboratory (VDRL) reactive. Stroke Sudden onset of neurologic deficit which persisted for > 24 h of presumed vascular origin. Primary central nervous system (CNS) lymphoma i) headache, change in sensorium, focal neurologic deficit ii) low CD4 count (< 200/mm3) iii) CT/MRI enhancing mass lesion iv) no response to toxoplasmosis and tuberculosis treatment Progressive multifocal leukoencephalopathy (PML) i) multifocal progressive focal deficits, ii) CT/MRI multiple non-enhancing white matter lesions without edema or mass effect. Neurocyticercosis multiple cerebral calcified lesions on CT scan. HIV encephalopathy i) cognitive and motor abnormalities ii) CT/MRI showing brain atrophy iii) other opportunistic infections ruled out. The data was analysed using SPSS 13.0 for Windows (SPSS, Chicago IL, USA). Logistic regression was used to assess each possible prognostic factor. Odds ratios and significant levels were calculated along with 95% confidence interval. A p-value of less than 0.05 was considered significant. A multivariate logistic regression analysis was performed to determine which prognostic factors, when considered together, were the best predictors of hospital death. Results Data from 146 HIV infected patients with seizure were analyzed; their sociodemographic and medical characteristics are shown in Fig. 1 and Table 1 . Majority of the patients (80.8%) were from Addis Ababa. Most patients (93.8%) were admitted to general medical ward and 6.2% were admitted to intensive care unit (ICU). The mean hospital stay (± SD) was 23.3 ± 15.9 days (range, 1–76 days). The diagnosis of HIV-infection was made before current hospital admission in 31.5% and after current admission in 68.5%. Duration since the diagnosis of HIV-infection ranged from 7 days to 5 years (median 6 months). The clinical presentation of patients is shown in Table 2 . The initial presenting symptom was neurological in 131(95.8%) patients and 21(14.4%) patients presented with seizure as initial manifestation. The mean duration of initial symptom before presentation was 44.2 days (median = 21, range 1 day to 18.3 months). Almost all patients (98.6%) had stage 4 HIV infection at presentation. Duration of first seizure at presentation varies from 30 minutes to a year (mean 22 days, median 5 days). All patients had more than two episodes of seizure. In 84(57.5%) patients, seizure started before current hospital admission while in 62(42.5%) patients the first seizure occurred after current admission. In patients with seizure onset before hospital admission, the duration of seizure was ≤ 1 day in 18%, ≤ 1week in 64%, ≤ 2 weeks in 80%, ≤ 1 month in 88% and ≤ 3 months in 95% of the patients. The clinical seizure types were generalized tonic-clonic seizure (GTCS) in 101(69.2%), focal motor with secondary generalization (FMWSG) in 29(19.9%) and simple focal motor in 16(11%) patients. The causes of seizure in relation to outcome status are shown in Table 3 . Status epilepticus was present in 26(17.8%) patients. The duration of status epilepticus at presentation ranged from 2hours to 7 days (mean = 31.1 hours, median = 24hours). The status epilepticus started before admission in 24 patients and after admission in 2 patients. It was generalized convulsive type of status epilepticus in 24(92.3%) patients and epilepsia partialis continua in 2 patients. The causes of status epilepticus were infectious in 25(96%) of patients and metabolic in 1 patient (hyperkalemia and uremic encephalopathy). Identified infectious causes include cerebral toxoplasmosis (n = 16), tuberculous meningitis (n = 4), cryptococcal meningitis(n = 2), PML (n = 2) and HIV encephalopathy(n = 1). Complications of status epilepticus were present in 13(50%) patients (aspiration pneumonia n = 12, acute renal failure n = 1). ‘ Table 1 Clinical profile of HIV-infected patients with seizure by outcome status, n = 146 Total(n = 146) Dead(n = 77) Alive(n = 69) Sex Male 81(55.5%) 42(51.9%) 39(48.1%) Female 65(44.5%) 35(53.8%) 30(46.2%) Age Mean[SD] 34[8.4] 33.78[8.6] 34.3[8.3] Median 33 32 34 Range 51 41 45 Seizure type Simple focal 16(11%) 11(68.8%) 5(31.3%) FWSG 29(19.9%) 12(41.4%) 17(58.6%) Prim gener 101(69.2%) 54(53.5%) 47(46.5%) Status epilepticus Yes 26(17.8%) 12(46.2%) 14(53.8%) No 120(82.2%) 65(54.2%) 55(45.8%) Level of consciousness at initial evaluation Alert 35(24%) 9(25.7%) 26(74.3%) Confused/stuporous 61(41.8%) 35(57.4%) 26(42.6%) comatose 50(34.2%) 33(66%) 17(34%) GCS at initial evaluation ≥ 13 13(8.9%) 5(38.5%) 8(61.5%) 9–12 26(17.8%) 16(61.5%) 10(38.5%) ≤ 8 48(32.9%) 33(68.8%) 15(31.3%) Unknown 59(40.4%) 23(39%) 36(61%) FWSG, focal with secondary generalization; prim gener, primarily generalized; GCS, Glasgow coma scale; Table 2 Clinical presentation of 146 patients with HIV infection and seizure presented to Tikur Anbessa Specialize Hospital. Symptom /sign Frequency (n) Percentage (%) Headache 111 76 Change in mentation 111 76 Fever 96 65.8 Focal deficit All types 75 51.4 Hemiparesis/plegia 44 30.1 MCN* deficit 9 6.2 Paraparesis/plegia 3 2 Monoparesis/plegia 3 2 Quadriparesis/plegia 2 1.4 Triparesis/plegia 1 0.7 Meningeal irritation sign 55 37.7 Papilledema 17 11.6 hemiballismus 2 1.4 *MCN, multiple cranial nerve deficit Table 3 The causes of seizure by outcome in 146 HIV infected patients. Cause of seizure Total (146) Dead (n = 77, 52.7%) Alive (n = 69,47.3%) Cerebral toxoplasmosis 67 29(43.3%) 38(56.7%) Tuberculous meningitis 52 34(65.4%) 18(34.6%) Cryptococcal meningitis 20 13(65%) 7(35%) PML 7 3(42.9%) 4(57.1%) neurosyphilis 4 2(50%) 2(50%) Bacterial meningitis 3 1(33.3%) 2(66.7%) stroke 3 2(66.7%) 1(33.3%) Uremic encephalopathy 2 2(100%) 0 Unknown(except HIV infection) 2 0 2(100%) others* 3 2(66.7%) 1(33.3%) * Others: HIV encephalopathy/dementia = 1, neurocysticercosis n = 1, primary CNS lymphoma n = 1 Note that more than one possible cause of seizure was possible in some patients. Table 4 Risk factor for case-fatality: logistic regression analysis Factor n % Unadjusted OR(95% CI) Adjusted OR(95% CI) Age(year) ≥ 40 20 54.1 1.00 1.00 < 40 57 52.3 0.932(0.441–1.968) 0.67o(0.274–1.641) Sex Female 35 53.8 1.00 1.00 Male 42 51.9 0.923(0.480–1.775) 0.922(0.429–1.983) Address Outside Addis Ababa 10 35.7 1.00 1.00 Addis Ababa 67 56.8 2.365(1.006–5.558) 3.428(1.240–9.479) Admitted to Intensive care unit 3 33.3 1.00 1.00 Ward 74 54 2.349(0.564–9.778) 2.818(0.506–15.686) Seizure started Before admission 37 44 1.00 1.00 After admission 40 64.5 2.310(1.175–4.538) 2.017(0.889–4.575) Status epilepticus No 65 54.2 1.00 1.00 Yes 12 46.2 0.725(0.310–1.698) 0.526(0.156–1.781) Change in mentation at initial evaluation No 9 25.7 1.00 1.00 Yes 68 61.3 4.568(1.955–10.675) 3.981(1.475–10.749) Comatose at initial evaluation No 44 45.8 1.00 1.00 Yes 33 66 2.294(1.128–4.664) 2.035(0.828–5.005) CD4 count ≥ 200 32 58.2 1.00 1.00 < 200 45 49.5 0.703(0.358–1.381) 0.730(0.313–1.703) Antiretroviral therapy No 48 57 1.00 1.00 yes 29 46.8 0.659(0.341–1.275) 0.632(0.268–1.493) Altered mental status was found in 111(76%) of patients and 50(34.2%) patients presented with coma. Glasgow coma scale (GCS) was documented in 87(59.6%) patients and 48(55.2%) had ≤ 8, 26(29.9%) had 9 to 12 and 13(14.9%) had ≥ 13. CD4 count per mm3 was obtained in 96(65.8%) patients and the mean was 77 ± 85 (median = 52, range 1 to 550). Lumbar puncture was done in 87(59.6%) patients. The mean and median CSF cell count per mm3 was 177.26 and 1.5, respectively (range 0 to 2500). CSF VDRL test was performed in 72 patients and 4 were reactive. India ink was done in 75 patients and 20 (26.7%) were positive. Brain imaging with CT-scan was performed for 76(50.1%) patients and 3 patients were additionally evaluated with brain MRI. Brain imaging showed mass lesion in 43(56.6%), normal findings in 19(25%), multiple white matter hypodense lesions in 7(9.2%), meningeal enhancement (n = 4), brain atrophy (n = 2) and hydrocephalus (n = 1). Hematologic findings were: leucopenia in 46(31.5%), anemia in 81(55.5%) and thrombocytopenia in 54(37%) patients. Erythrocyte sedimentation rate was obtained in 99(67.8%) patients and in 96(97%) patients it was 35 mm per hour or more (mean = 92.32, median = 94). One patient underwent electroencephalography (EEG) and it was normal. Serum antiepileptic medication level was determined in one patient and it showed low phenytoin level. Comorbidities identified were : oral thrush(n = 25), herpes zoster(n = 21),hypertension(n = 6), bleeding diathesis(5),drug induced hepatitis (n = 5),hypokalemia(n = 4), pneumonia(n = 4),chronic diarrhea (n = 4), diabetes mellitus (n = 4), congestive heart failure (n = 4),deep venous thrombosis(n = 3), pneumocystis carinii pneumonia (n = 2)and bed sore(n = 4). Antiepileptic drugs (AED) were given to 135(92.5%) after hospital admission and 11(7.5%) patients were on antiepileptic medications at admission. The AED used were: phenytoin in 137(93.8%), Phenobarbital (n = 15), carbamazepine(n = 5), and valproate(n = 3). Of the 69 patients who were discharged alive, 56(81.2%) were continued on the AED and in 13(18.8%) patients these were discontinued. Antiretroviral therapy (ART) was started before hospital admission in 24(16.4%) and after admission in 38(26%) patients. No ART was given to 84(57.5%) patients. The duration of ART before admission ranges from 1 to 30 months (mean = 6.09, median = 3). Prophylactic cotrimoxazole was started in 65(44.5%) patients (before admission = 10, after admission = 55). Treatment out comes at hospital discharge were: 77(52.7%) patients died, 60(41.1%) improved, 7(4.8%) deteriorated without death and 2 remained in the same clinical condition. In most patients, the immediate cause of death was attributed to the underlying disorder and seizure was not documented as an immediate cause of death. Discussion The objectives of this hospital-based retrospective study were to assess the clinical presentation, causes and treatment outcome of HIV-infected patients with seizure who presented to TASH which is the largest hospital in Ethiopia. The number of male (55.5%) and female were comparable (OR = 0.923, 95% CI = 0.565–2.07) which is similar to other study [ 3 ]. Unlike this study male predominance was reported in other studies [ 4 – 7 , 10 , 18 , 19 ]. The mean hospital stay in days was 23.3(± 15.9) which is longer compared to other study [ 10 ] which is partly due to the advanced stage of HIV infection in most of the patients. The mean age of patients was 34 ± 8.4 years. Majority (88%) of them were below the age of 45 years which is similar to other studies [ 4–7, 10]. This might be partly due to the fact that the Ethiopian population is young [ 19 ] where 86.2% were below the age of 45 years in 2007. Majority (69%) of the patients had primarily generalized type of seizure like in most other studies [ 4–7, 9, 11–13]. Even thought almost all patients (98.6%) had stage 4 HIV infections at presentation, in the majority (68.5%) the diagnosis of HIV infection was made after current hospital admission. Similar to other studies [ 4 , 9 ], seizure occurred in patients with advanced HIV infection in these patients. The initial presenting symptom/sign was neurological in almost all patients ( 96%) patients: headache( 76%), change in mentation(76%), focal deficit(51.%), meningeal irritation signs( 37.7%) and papilledema ( 11.6%) which is consistent with other studies [ 5 – 8 ] in which the incidence of seizure is common in patients with neurological complications of HIV infection. Seizure as an initial manifestation was uncommon in this study (14%) similar to other studies [ 7 , 14 , 19 ]. In most patients, seizure was a recent onset at admission. It either started after current hospital admission (42.5%) or within 3 months prior to admission (52.5%). This indicates that most seizures were related to recent neurological complications of HIV infection. The common causes of seizure were cerebral toxoplasmosis (46%), tuberculos meningitis (35.6%) and cryptoccocal meningitis(13.7%) which is similar to most other studies [ 6,7,9, 11–13]. Toxic-metabolic (59%) and HIV encephalopathy (22%) were the commonest causes of seizure in other studies [ 4 , 5 ], respectively. HIV encephalopathy which is a common cause of seizure in developed countries [ 5 , 9 , 10 , 14 ] was rare in this study like most other studies done in developing countries [ 7 , 12 , 13 ]. This may be partly explained by the fact that early and effective treatment of HIV-infection is not optimal in developing countries; hence, HIV-infected patients have a higher incidence of CNS opportunistic infections. Status epilepticus occurred in 18% of the patients which is similar to some studies [ 4 , 6 , 14 ] but higher compared to other studies [ 7 , 19 ]. The cause of status epilepticus was CNS infection in almost all patients which is related to the advanced stage of HIV infection and low CD4 count (mean: 77 ± 85 per mm 3 ). The mean CD4 count in this study was lower compared to some studies [ 4 , 5 ] and higher compared to other studies [ 9, 10]. The most common abnormality identified on brain imaging (done in 52%) was mass lesion (n = 43, 57%) which was due to cerebral toxoplasmosis in almost all patients. EEG and serum AED serum level was done in one patient each which indicates the limitations of diagnostic facilities in the hospital. The AED of choice in patients with HIV infected patients is levetriracetam and where the newer AED are not available, valproic acid may be the treatment of choice [ 2 1]. In contrast to this recommendation, 94% of the patients were treated with phenytoin. Phenytoin drug reaction was not reported in these patients and was well tolerated as seen in other studies [ 4 , 13 ]. In contrast to this study, phenytoin drug reaction was seen in 25% and 14% of patients in other studies [ 6, 14], respectively. Even though almost all patients were having advanced HIV infection (stage 4), only 16% were on ART during current admission which indicates early diagnosis and timely treatment of HIV infection is suboptimal in this region. The over-all mortality was 52.7% which is higher compared to other studies [ 4 , 7 , 18 ] which reported mortality of 22% to 47%. Even though address from Addis Ababa ( the capital city where the hospital is found), seizure started after admission, change in mentation at initial evaluation and comatose at initial evaluation were predictors of mortality in the univariate analysis ( Table 4 ), only address from Addis Ababa and change in mentation at initial evaluation were independent predictors of mortality. The higher mortality in patients from Addis Ababa was unexpected finding. This might be partly due to the fact that patients who were critically ill were not able to travel to Addis Ababa from other parts of the country. Seizure as an immediate cause of death was not reported in this study and there was no relationship between status epilepticus and mortality similar to other study [ 4 ]. In contrast to this, other authors [ 22 ] reported that status epilepticus was a predictor of mortality. Unlike a study done in Zambia [ 18 ] which reported women to have a higher mortality, gender was not associated with mortality in this study. This study had several limitations. During chart review missing information may occur. The retrospective nature of the study may cause under-ascertainment of cases. No patient with complex partial seizure was reported. Given the advanced stage of illness, patients with subtle focal seizure may be missed. Patients who were treated as outpatient only were not included in this study. With limited service of EEG, patients with non-convulsive seizure may not be identified. With limited access to brain imaging, biopsy and CSF analysis, etiological diagnosis may be difficult in some patients. Since TASH is a tertiary referral hospital, chance of selectively admitting critically ill patients is high. To improve the high morbidity and mortality observed in patients with HIV-infection presented with seizure, prevention of HIV-infection, early diagnosis and treatment, early identification and treatment of neurological complications of HIV-infection are recommended. Improving diagnostic facilities (brain imaging, CSF analysis, EEG and biopsy) may improve treatment outcome. Replacing enzyme-inducer AEDs with non-enzyme-inducers may help improve effectiveness of ART. Conclusion The diagnosis of HIV-infection was made after current hospital admission in majority of patients, almost all were in stage IV HIV-infection with very low CD 4 count, case-fatality was higher than most other studies and change in sensorium was an independent predictor of mortality. To improve the high mortality, HIV prevention, early diagnosis and treatment, early identification and treatment of neurological complications of HIV-infection, improving diagnostic facilities ( brain imaging, EEG and CSF analysis) and improving access to non-enzyme inducing AEDs are recommended. Abbreviations AED Antiepleptic drugs ART Antiretroviral therapy CNS Central nervous system CSF Cerebrospinal fluid CT Computerized tomography EEG Electroencephalography FMWSG Focal motor with secondary generalization GCS Glasgow coma scale GTCS Generalized tonic-clonic seizure ICU Intensive care unit MRI Magnetic resonance imaging PML Progressive multifocal leukoencphalopathy TASH Tikur Anbessa Specialized Hospital VDRL Venereal Disease Research Laboratory Declarations Ethics approval and consent to participate: The study was started after getting ethical clearance from the Research and Ethics Committee of the Department of Neurology of College of Health Sciences, Addis Ababa University. Consent for publication: Not applicable. Availability of data and material: The data used during the current study are not publicly available but are available from the author on reasonable request. Competing interests : Not applicable. Funding: Expenses were covered by the author. 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Heart lung. 1989;18:526–9. Cite Share Download PDF Status: Published Journal Publication published 10 Aug, 2021 Read the published version in BMC Infectious Diseases → Version 1 posted Review # 2 received at journal 02 Jan, 2021 Editorial decision: Minor revision 02 Jan, 2021 Reviewer # 2 agreed at journal 12 Dec, 2020 Review # 1 received at journal 04 Nov, 2020 Reviewer # 1 agreed at journal 10 Oct, 2020 Reviewers invited by journal 20 Sep, 2020 Editor assigned by journal 02 Sep, 2020 Submission checks completed at journal 01 Sep, 2020 Editor invited by journal 01 Sep, 2020 First submitted to journal 29 Aug, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-66079","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":2029170,"identity":"b7d13cbb-f4a0-481a-bfad-b20ba9628f2f","order_by":0,"name":"Amanuel Amare","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIiWNgGAWjYPACCwYG9gYGZlK0SDAw8BwgWYtEApFa+KcdfvaYp0JC3uDmG8PPBRU2DPzt3Qn4jb+dZm7Mc0bCcMPtHGPpGWfSGCTOnN2A35rbCWbSvG0SjNtu5xgAGYcZDCRy8WuRv53+TZr3n4T9tptnjH8TpcXgdg7QlgaJxG03eMyIs8Xwdk6Z5JxjEsn7z6SVWfOcSeMh6Be52+nbJN7U2NjObD+8+TZPhY0cf3svAe8jAIcBiOQhVjkIsD8gRfUoGAWjYBSMIAAAe2BDj8G33aEAAAAASUVORK5CYII=","orcid":"","institution":"Addis Ababa University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Amanuel","middleName":"","lastName":"Amare","suffix":""}],"badges":[],"createdAt":"2020-08-26 10:45:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-66079/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-66079/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-021-06497-7","type":"published","date":"2021-08-10T10:51:56+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":2304293,"identity":"1ac32ac6-17a8-433f-bb46-97238364eebb","added_by":"auto","created_at":"2020-09-08 19:12:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":9244,"visible":true,"origin":"","legend":"Age and sex distribution of 146 HIV infected patients with seizure admitted to Tikur Anbessa Specialized Hospital.","description":"","filename":"Onlinefloatimage1.Png","url":"https://assets-eu.researchsquare.com/files/rs-66079/v1/Onlinefloatimage1.Png"},{"id":13589531,"identity":"675f5457-dbdf-4700-92d1-9ed989d1ca59","added_by":"auto","created_at":"2021-09-17 05:00:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":296937,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-66079/v1/e107de5d-469a-43e2-b97f-46f527ad8c55.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eSeizure in HIV-infected Patients: Clinical Presentation, Cause and Treatment Outcome in Ethiopia: A Retrospective Study\u003c/p\u003e","fulltext":[{"header":"Background","content":" \u003cp\u003eThe estimated number of adult patients living with HIV infection in Ethiopia in 2012 was approximately 800,000[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Neurologic complications occur in 39 to 75% of the patients with HIV infection [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The incidence of seizure in HIV- infected patients varies from 2 to 3% in prospective studies [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The incidence of seizure in HIV infected patients in retrospective studies varies from 6.1% -11% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and 19.8% -34.3% [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] in HIV infected patients with neurological complications. Seizure occurs principally in patients with advanced HIV disease [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe causes of seizure in HIV-infected patients include mass lesion, meningitis, HIV-encephalopathy, drug toxicity, metabolic derangements and idiopathic which might include incidental epilepsy or seizure due to the HIV itself [\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Primarily generalized seizure was the most common type in most studies [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn a retrospective study which assessed the pattern and treatment outcome of HIV-infected patients with neurological complications seizure was an independent predictor of mortality [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe aims of this study were to assess the clinical presentation, cause and treatment outcome of patients with HIV-infection presented with seizure to Tikur Anbessa Specialized Hospital (TASH), the largest teaching hospital of Addis Ababa University in Ethiopia.\u003c/p\u003e "},{"header":"Methods","content":" \u003cp\u003eHIV infected patients aged\u0026thinsp;\u0026ge;\u0026thinsp;13\u0026nbsp;years with seizure who were admitted to TASH from September 2014 to August 2018 were included in this study. The study was started after getting ethical clearance from the Neurology department research and ethics committee. Medical records were retrospectively reviewed and the following data were collected: socio-demographic, symptoms and signs at presentation, type(s) of seizure, history of previous seizure/epilepsy, cause(s) of seizure, comorbidities, CD4 count(the most recent count), CSF analysis, imaging studies, complete blood count, treatment given, duration of hospital stay and treatment out come at discharge. Medical records with inadequate data to verify the diagnosis of seizure were excluded from the study. Each patient was given a unique number to assure confidentiality.\u003c/p\u003e \u003cp\u003eSeizures were classified into focal, focal with secondary generalization and primarily generalized seizures [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Status epilepticus was defined as continuous seizure activity lasting 30\u0026nbsp;min or more, or intermittent seizure activity lasting 30\u0026nbsp;min or more during which consciousness is not regained [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Preexisting history of epilepsy was defined as two or more seizures in a life time. The clinical staging of HIV-infection was based on WHO staging system [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The following diagnostic criteria were used for the diagnosis of HIV-infection related diseases:\u003c/p\u003e \u003cp\u003eCerebral toxoplasmosis\u003c/p\u003e \u003cp\u003ePresumed diagnosis based on some or all of the following: i) headache, fever, change in sensorium ii) focal neurologic deficit iii) seropositivity for anti-toxoplasma immunoglobulin G, iv) ring enhancing brain lesion(s) on computerized tomography(CT)/magnetic resonance\u003c/p\u003e \u003cp\u003eImaging (MRI), v) low CD4 count(\u0026lt;\u0026thinsp;200/mm3),and vi) response to toxoplasma treatment.\u003c/p\u003e \u003cp\u003eTuberculous meningitis\u003c/p\u003e \u003cp\u003eBased on some or all of the following: i) headache, fever, neck rigidity, change in mentation ii) cerebrospinal fluid (CSF) lymphocytosis iii) Acid-fast bacilli on CSF smear iv) evidence of active tuberculosis in other part of the body (milliary tuberculosis, pulmonary tuberculosis etc.) v) CT/MRI showing meningeal enhancement vi) response to tuberculosis treatment.\u003c/p\u003e \u003cp\u003eCyptococcal meningitis\u003c/p\u003e \u003cp\u003eCSF India ink positivity.\u003c/p\u003e \u003cp\u003eBacterial meningitis\u003c/p\u003e \u003cp\u003ei) acute onset headache, fever, change in mentation, neck rigidity ii) CSF polymorph predominant pleocytosis iii) CSF culture and Gram stain showing bacteria iv) response to antibiotics.\u003c/p\u003e \u003cp\u003eNeurosyphilis\u003c/p\u003e \u003cp\u003eCSF Venereal Disease Research Laboratory (VDRL) reactive.\u003c/p\u003e \u003cp\u003eStroke\u003c/p\u003e \u003cp\u003eSudden onset of neurologic deficit which persisted for \u0026gt;\u0026thinsp;24\u0026nbsp;h of presumed vascular origin.\u003c/p\u003e \u003cp\u003ePrimary central nervous system (CNS) lymphoma\u003c/p\u003e \u003cp\u003ei) headache, change in sensorium, focal neurologic deficit ii) low CD4 count (\u0026lt;\u0026thinsp;200/mm3) iii) CT/MRI enhancing mass lesion iv) no response to toxoplasmosis and tuberculosis treatment\u003c/p\u003e \u003cp\u003eProgressive multifocal leukoencephalopathy (PML)\u003c/p\u003e \u003cp\u003ei) multifocal progressive focal deficits, ii) CT/MRI multiple non-enhancing white matter lesions without edema or mass effect.\u003c/p\u003e \u003cp\u003eNeurocyticercosis\u003c/p\u003e \u003cp\u003emultiple cerebral calcified lesions on CT scan.\u003c/p\u003e \u003cp\u003eHIV encephalopathy\u003c/p\u003e \u003cp\u003ei) cognitive and motor abnormalities ii) CT/MRI showing brain atrophy iii) other opportunistic infections ruled out.\u003c/p\u003e \u003cp\u003eThe data was analysed using SPSS 13.0 for Windows (SPSS, Chicago IL, USA). Logistic regression was used to assess each possible prognostic factor. Odds ratios and significant levels were calculated along with 95% confidence interval. A p-value of less than 0.05 was considered significant. A multivariate logistic regression analysis was performed to determine which prognostic factors, when considered together, were the best predictors of hospital death.\u003c/p\u003e "},{"header":"Results","content":" \u003cp\u003eData from 146 HIV infected patients with seizure were analyzed; their sociodemographic and medical characteristics are shown in Fig.\u0026nbsp;1 and Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eMajority of the patients (80.8%) were from Addis Ababa. Most patients (93.8%) were admitted to general medical ward and 6.2% were admitted to intensive care unit (ICU). The mean hospital stay (\u0026plusmn;\u0026thinsp;SD) was 23.3\u0026thinsp;\u0026plusmn;\u0026thinsp;15.9\u0026nbsp;days (range, 1\u0026ndash;76\u0026nbsp;days). The diagnosis of HIV-infection was made before current hospital admission in 31.5% and after current admission in 68.5%. Duration since the diagnosis of HIV-infection ranged from 7\u0026nbsp;days to 5\u0026nbsp;years (median 6\u0026nbsp;months).\u003c/p\u003e \u003cp\u003eThe clinical presentation of patients is shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The initial presenting symptom was neurological in 131(95.8%) patients and 21(14.4%) patients presented with seizure as initial manifestation. The mean duration of initial symptom before presentation was 44.2\u0026nbsp;days (median\u0026thinsp;=\u0026thinsp;21, range 1\u0026nbsp;day to 18.3\u0026nbsp;months). Almost all patients (98.6%) had stage 4 HIV infection at presentation. Duration of first seizure at presentation varies from 30 minutes to a year (mean 22 days, median 5\u0026nbsp;days). All patients had more than two episodes of seizure. In 84(57.5%) patients, seizure started before current hospital admission while in 62(42.5%) patients the first seizure occurred after current admission. In patients with seizure onset before hospital admission, the duration of seizure was \u0026le;\u0026thinsp;1\u0026nbsp;day in 18%, \u0026le; 1week in 64%, \u0026le; 2 weeks in 80%, \u0026le; 1\u0026nbsp;month in 88% and \u0026le;\u0026thinsp;3\u0026nbsp;months in 95% of the patients. The clinical seizure types were generalized tonic-clonic seizure (GTCS) in 101(69.2%), focal motor with secondary generalization (FMWSG) in 29(19.9%) and simple focal motor in 16(11%) patients. The causes of seizure in relation to outcome status are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Status epilepticus was present in 26(17.8%) patients. The duration of status epilepticus at presentation ranged from 2hours to 7\u0026nbsp;days (mean\u0026thinsp;=\u0026thinsp;31.1 hours, median\u0026thinsp;=\u0026thinsp;24hours). The status epilepticus started before admission in 24 patients and after admission in 2 patients. It was generalized convulsive type of status epilepticus in 24(92.3%) patients and epilepsia partialis continua in 2 patients. The causes of status epilepticus were infectious in 25(96%) of patients and metabolic in 1 patient (hyperkalemia and uremic encephalopathy). Identified infectious causes include cerebral toxoplasmosis (n\u0026thinsp;=\u0026thinsp;16), tuberculous meningitis (n\u0026thinsp;=\u0026thinsp;4), cryptococcal meningitis(n\u0026thinsp;=\u0026thinsp;2), PML (n\u0026thinsp;=\u0026thinsp;2) and HIV encephalopathy(n\u0026thinsp;=\u0026thinsp;1). Complications of status epilepticus were present in 13(50%) patients (aspiration pneumonia n\u0026thinsp;=\u0026thinsp;12, acute renal failure n\u0026thinsp;=\u0026thinsp;1).\u003c/p\u003e \u003cp\u003e\u0026lsquo;\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical profile of HIV-infected patients with seizure by outcome status, n\u0026thinsp;=\u0026thinsp;146\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal(n\u0026thinsp;=\u0026thinsp;146)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDead(n\u0026thinsp;=\u0026thinsp;77)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAlive(n\u0026thinsp;=\u0026thinsp;69)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81(55.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42(51.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39(48.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65(44.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35(53.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30(46.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean[SD]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34[8.4]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.78[8.6]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.3[8.3]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSeizure type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSimple focal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16(11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11(68.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5(31.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFWSG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29(19.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12(41.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17(58.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrim gener\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e101(69.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54(53.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47(46.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStatus epilepticus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26(17.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12(46.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14(53.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e120(82.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65(54.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55(45.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eLevel of consciousness at initial evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlert\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35(24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9(25.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26(74.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConfused/stuporous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61(41.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35(57.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26(42.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecomatose\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50(34.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33(66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17(34%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eGCS at initial evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13(8.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5(38.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8(61.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26(17.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16(61.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10(38.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48(32.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33(68.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15(31.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59(40.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23(39%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36(61%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eFWSG, focal with secondary generalization; prim gener, primarily generalized; GCS, Glasgow coma scale;\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical presentation of 146 patients with HIV infection and seizure presented to Tikur Anbessa Specialize Hospital.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSymptom /sign\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHeadache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eChange in mentation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eFocal deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll types\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHemiparesis/plegia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMCN* deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParaparesis/plegia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMonoparesis/plegia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuadriparesis/plegia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTriparesis/plegia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMeningeal irritation sign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePapilledema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ehemiballismus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*MCN, multiple cranial nerve deficit\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe causes of seizure by outcome in 146 HIV infected patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCause of seizure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal (146)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDead (n\u0026thinsp;=\u0026thinsp;77, 52.7%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAlive (n\u0026thinsp;=\u0026thinsp;69,47.3%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebral toxoplasmosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29(43.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38(56.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTuberculous meningitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34(65.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18(34.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCryptococcal meningitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13(65%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7(35%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePML\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(42.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(57.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eneurosyphilis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(50%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBacterial meningitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(66.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003estroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUremic encephalopathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown(except HIV infection)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eothers*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e* Others: HIV encephalopathy/dementia\u0026thinsp;=\u0026thinsp;1, neurocysticercosis n\u0026thinsp;=\u0026thinsp;1, primary CNS lymphoma n\u0026thinsp;=\u0026thinsp;1\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote that more than one possible cause of seizure was possible in some patients.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRisk factor for case-fatality: logistic regression analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnadjusted OR(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdjusted OR(95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge(year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.932(0.441\u0026ndash;1.968)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.67o(0.274\u0026ndash;1.641)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.923(0.480\u0026ndash;1.775)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.922(0.429\u0026ndash;1.983)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAddress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOutside Addis Ababa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAddis Ababa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.365(1.006\u0026ndash;5.558)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.428(1.240\u0026ndash;9.479)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAdmitted to\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntensive care unit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWard\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.349(0.564\u0026ndash;9.778)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.818(0.506\u0026ndash;15.686)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSeizure started\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfter admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.310(1.175\u0026ndash;4.538)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.017(0.889\u0026ndash;4.575)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStatus epilepticus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.725(0.310\u0026ndash;1.698)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.526(0.156\u0026ndash;1.781)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eChange in mentation at initial evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e61.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.568(1.955\u0026ndash;10.675)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.981(1.475\u0026ndash;10.749)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eComatose at initial evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.294(1.128\u0026ndash;4.664)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.035(0.828\u0026ndash;5.005)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCD4 count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.703(0.358\u0026ndash;1.381)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.730(0.313\u0026ndash;1.703)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAntiretroviral therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.659(0.341\u0026ndash;1.275)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.632(0.268\u0026ndash;1.493)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAltered mental status was found in 111(76%) of patients and 50(34.2%) patients presented with coma. Glasgow coma scale (GCS) was documented in 87(59.6%) patients and 48(55.2%) had\u0026thinsp;\u0026le;\u0026thinsp;8, 26(29.9%) had 9 to 12 and 13(14.9%) had\u0026thinsp;\u0026ge;\u0026thinsp;13.\u003c/p\u003e \u003cp\u003eCD4 count per mm3 was obtained in 96(65.8%) patients and the mean was 77\u0026thinsp;\u0026plusmn;\u0026thinsp;85 (median\u0026thinsp;=\u0026thinsp;52, range 1 to 550). Lumbar puncture was done in 87(59.6%) patients. The mean and median CSF cell count per mm3 was 177.26 and 1.5, respectively (range 0 to 2500). CSF VDRL test was performed in 72 patients and 4 were reactive. India ink was done in 75 patients and 20 (26.7%) were positive.\u003c/p\u003e \u003cp\u003eBrain imaging with CT-scan was performed for 76(50.1%) patients and 3 patients were additionally evaluated with brain MRI. Brain imaging showed mass lesion in 43(56.6%), normal findings in 19(25%), multiple white matter hypodense lesions in 7(9.2%), meningeal enhancement (n\u0026thinsp;=\u0026thinsp;4), brain atrophy (n\u0026thinsp;=\u0026thinsp;2) and hydrocephalus (n\u0026thinsp;=\u0026thinsp;1).\u003c/p\u003e \u003cp\u003eHematologic findings were: leucopenia in 46(31.5%), anemia in 81(55.5%) and thrombocytopenia in 54(37%) patients. Erythrocyte sedimentation rate was obtained in 99(67.8%) patients and in 96(97%) patients it was 35\u0026nbsp;mm per hour or more (mean\u0026thinsp;=\u0026thinsp;92.32, median\u0026thinsp;=\u0026thinsp;94). One patient underwent electroencephalography (EEG) and it was normal. Serum antiepileptic medication level was determined in one patient and it showed low phenytoin level.\u003c/p\u003e \u003cp\u003eComorbidities identified were : oral thrush(n\u0026thinsp;=\u0026thinsp;25), herpes zoster(n\u0026thinsp;=\u0026thinsp;21),hypertension(n\u0026thinsp;=\u0026thinsp;6), bleeding diathesis(5),drug induced hepatitis (n\u0026thinsp;=\u0026thinsp;5),hypokalemia(n\u0026thinsp;=\u0026thinsp;4), pneumonia(n\u0026thinsp;=\u0026thinsp;4),chronic diarrhea (n\u0026thinsp;=\u0026thinsp;4), diabetes mellitus (n\u0026thinsp;=\u0026thinsp;4), congestive heart failure (n\u0026thinsp;=\u0026thinsp;4),deep venous thrombosis(n\u0026thinsp;=\u0026thinsp;3), pneumocystis carinii pneumonia (n\u0026thinsp;=\u0026thinsp;2)and bed sore(n\u0026thinsp;=\u0026thinsp;4).\u003c/p\u003e \u003cp\u003eAntiepileptic drugs (AED) were given to 135(92.5%) after hospital admission and 11(7.5%) patients were on antiepileptic medications at admission. The AED used were: phenytoin in 137(93.8%), Phenobarbital (n\u0026thinsp;=\u0026thinsp;15), carbamazepine(n\u0026thinsp;=\u0026thinsp;5), and valproate(n\u0026thinsp;=\u0026thinsp;3). Of the 69 patients who were discharged alive, 56(81.2%) were continued on the AED and in 13(18.8%) patients these were discontinued. Antiretroviral therapy (ART) was started before hospital admission in 24(16.4%) and after admission in 38(26%) patients. No ART was given to 84(57.5%) patients. The duration of ART before admission ranges from 1 to 30 months (mean\u0026thinsp;=\u0026thinsp;6.09, median\u0026thinsp;=\u0026thinsp;3). Prophylactic cotrimoxazole was started in 65(44.5%) patients (before admission\u0026thinsp;=\u0026thinsp;10, after admission\u0026thinsp;=\u0026thinsp;55).\u003c/p\u003e \u003cp\u003eTreatment out comes at hospital discharge were: 77(52.7%) patients died, 60(41.1%) improved, 7(4.8%) deteriorated without death and 2 remained in the same clinical condition. In most patients, the immediate cause of death was attributed to the underlying disorder and seizure was not documented as an immediate cause of death.\u003c/p\u003e "},{"header":"Discussion","content":" \u003cp\u003eThe objectives of this hospital-based retrospective study were to assess the clinical presentation, causes and treatment outcome of HIV-infected patients with seizure who presented to TASH which is the largest hospital in Ethiopia. The number of male (55.5%) and female were comparable (OR\u0026thinsp;=\u0026thinsp;0.923, 95% CI\u0026thinsp;=\u0026thinsp;0.565\u0026ndash;2.07) which is similar to other study [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Unlike this study male predominance was reported in other studies [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The mean hospital stay in days was 23.3(\u0026plusmn;\u0026thinsp;15.9) which is longer compared to other study [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] which is partly due to the advanced stage of HIV infection in most of the patients. The mean age of patients was 34\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4\u0026nbsp;years. Majority (88%) of them were below the age of 45\u0026nbsp;years which is similar to other studies [ 4\u0026ndash;7, 10]. This might be partly due to the fact that the Ethiopian population is young [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] where 86.2% were below the age of 45\u0026nbsp;years in 2007.\u003c/p\u003e \u003cp\u003eMajority (69%) of the patients had primarily generalized type of seizure like in most other studies [ 4\u0026ndash;7, 9, 11\u0026ndash;13]. Even thought almost all patients (98.6%) had stage 4 HIV infections at presentation, in the majority (68.5%) the diagnosis of HIV infection was made after current hospital admission. Similar to other studies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], seizure occurred in patients with advanced HIV infection in these patients. The initial presenting symptom/sign was neurological in almost all patients ( 96%) patients: headache( 76%), change in mentation(76%), focal deficit(51.%), meningeal irritation signs( 37.7%) and papilledema ( 11.6%) which is consistent with other studies [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] in which the incidence of seizure is common in patients with neurological complications of HIV infection. Seizure as an initial manifestation was uncommon in this study (14%) similar to other studies [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In most patients, seizure was a recent onset at admission. It either started after current hospital admission (42.5%) or within 3 months prior to admission (52.5%). This indicates that most seizures were related to recent neurological complications of HIV infection.\u003c/p\u003e \u003cp\u003eThe common causes of seizure were cerebral toxoplasmosis (46%), tuberculos meningitis (35.6%) and cryptoccocal meningitis(13.7%) which is similar to most other studies [ 6,7,9, 11\u0026ndash;13]. Toxic-metabolic (59%) and HIV encephalopathy (22%) were the commonest causes of seizure in other studies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], respectively. HIV encephalopathy which is a common cause of seizure in developed countries [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] was rare in this study like most other studies done in developing countries [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This may be partly explained by the fact that early and effective treatment of HIV-infection is not optimal in developing countries; hence, HIV-infected patients have a higher incidence of CNS opportunistic infections.\u003c/p\u003e \u003cp\u003eStatus epilepticus occurred in 18% of the patients which is similar to some studies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] but higher compared to other studies [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The cause of status epilepticus was CNS infection in almost all patients which is related to the advanced stage of HIV infection and low CD4 count (mean: 77\u0026thinsp;\u0026plusmn;\u0026thinsp;85 per mm\u003csup\u003e3\u003c/sup\u003e). The mean CD4 count in this study was lower compared to some studies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and higher compared to other studies [ 9, 10]. The most common abnormality identified on brain imaging (done in 52%) was mass lesion (n\u0026thinsp;=\u0026thinsp;43, 57%) which was due to cerebral toxoplasmosis in almost all patients. EEG and serum AED serum level was done in one patient each which indicates the limitations of diagnostic facilities in the hospital.\u003c/p\u003e \u003cp\u003eThe AED of choice in patients with HIV infected patients is levetriracetam and where the newer AED are not available, valproic acid may be the treatment of choice [ 2 1]. In contrast to this recommendation, 94% of the patients were treated with phenytoin. Phenytoin drug reaction was not reported in these patients and was well tolerated as seen in other studies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In contrast to this study, phenytoin drug reaction was seen in 25% and 14% of patients in other studies [ 6, 14], respectively. Even though almost all patients were having advanced HIV infection (stage 4), only 16% were on ART during current admission which indicates early diagnosis and timely treatment of HIV infection is suboptimal in this region.\u003c/p\u003e \u003cp\u003eThe over-all mortality was 52.7% which is higher compared to other studies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] which reported mortality of 22% to 47%. Even though address from Addis Ababa ( the capital city where the hospital is found), seizure started after admission, change in mentation at initial evaluation and comatose at initial evaluation were predictors of mortality in the univariate analysis ( Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), only address from Addis Ababa and change in mentation at initial evaluation were independent predictors of mortality. The higher mortality in patients from Addis Ababa was unexpected finding. This might be partly due to the fact that patients who were critically ill were not able to travel to Addis Ababa from other parts of the country. Seizure as an immediate cause of death was not reported in this study and there was no relationship between status epilepticus and mortality similar to other study [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In contrast to this, other authors [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] reported that status epilepticus was a predictor of mortality. Unlike a study done in Zambia [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] which reported women to have a higher mortality, gender was not associated with mortality in this study.\u003c/p\u003e \u003cp\u003eThis study had several limitations. During chart review missing information may occur. The retrospective nature of the study may cause under-ascertainment of cases. No patient with complex partial seizure was reported. Given the advanced stage of illness, patients with subtle focal seizure may be missed. Patients who were treated as outpatient only were not included in this study. With limited service of EEG, patients with non-convulsive seizure may not be identified. With limited access to brain imaging, biopsy and CSF analysis, etiological diagnosis may be difficult in some patients. Since TASH is a tertiary referral hospital, chance of selectively admitting critically ill patients is high.\u003c/p\u003e \u003cp\u003eTo improve the high morbidity and mortality observed in patients with HIV-infection presented with seizure, prevention of HIV-infection, early diagnosis and treatment, early identification and treatment of neurological complications of HIV-infection are recommended. Improving diagnostic facilities (brain imaging, CSF analysis, EEG and biopsy) may improve treatment outcome. Replacing enzyme-inducer AEDs with non-enzyme-inducers may help improve effectiveness of ART.\u003c/p\u003e "},{"header":"Conclusion","content":" \u003cp\u003eThe diagnosis of HIV-infection was made after current hospital admission in majority of patients, almost all were in stage IV HIV-infection with very low CD 4 count, case-fatality was higher than most other studies and change in sensorium was an independent predictor of mortality. To improve the high mortality, HIV prevention, early diagnosis and treatment, early identification and treatment of neurological complications of HIV-infection, improving diagnostic facilities ( brain imaging, EEG and CSF analysis) and improving access to non-enzyme inducing AEDs are recommended.\u003c/p\u003e "},{"header":"Abbreviations","content":" \u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAED\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAntiepleptic drugs\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eART\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAntiretroviral therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCNS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCentral nervous system\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCSF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCerebrospinal fluid\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputerized tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEEG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eElectroencephalography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFMWSG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFocal motor with secondary generalization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGCS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGlasgow coma scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGTCS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneralized tonic-clonic seizure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntensive care unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic resonance imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePML\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProgressive multifocal leukoencphalopathy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTASH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTikur Anbessa Specialized Hospital\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVDRL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVenereal Disease Research Laboratory\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e The study was started after getting ethical clearance from the Research and Ethics Committee of the Department of Neurology of College of Health Sciences, Addis Ababa University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication: \u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material: \u003c/strong\u003eThe data used during the current study are not publicly available but are available from the author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding: \u003c/strong\u003eExpenses were covered by the author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions: \u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements: \u003c/strong\u003eI would like to acknowledge all staff members of the Department of Neurology of Addis Ababa University.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e \u003cdiv class=\"InstitutionalAuthorName\"\u003eFMOH Ethiopia\u003c/div\u003e \u003cspan\u003eFMOH Ethiopia. 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AIDS Res Ther. 2012;9:11.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eDore GJ, Law MG, Brew BJ. Prospective analysis of seizures occurring in human immunodeficiency virus type-1 infection. Journal of neuro-AIDS. 1996;1(4):59\u0026ndash;69.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003ePesola GR, Westfall RE. New-onset generalized seizures in patients with AIDS presenting to an emergency department. Acad Emerg Med. 1998;5:905\u0026ndash;11.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eVan Paesschen W, Bodian C, Maker H. Metabolic abnormalities and new-onset seizures in human immunodeficiency virus-seropositive patients. Epilepsia. 1995;36(2):146\u0026ndash;50.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eModi G, Modi M, Martinus I, Saffer D. New-onset seizures associated with HIV infection Neurology. 2000;55:1558-61.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eChadha DS, Handa A, Sharma SK, Varadarajulu P, Singh AP. Seizures in patients with human immunodeficiency virus infection. J Assoc Physicians India. 2000;48:573-6.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eHoltzman DM, Kaku DA, So YT. \u003cem\u003eNew-onset seizures associated with human immunodeficiency virus infection: causation and clinical features in 100 cases. Am J Med\u003c/em\u003e 1989; \u003cem\u003e87: 173-7.\u003c/em\u003e.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eInternational League Against Epilepsy (ILAE), Commission on Classification and Terminology. Proposal for revised clinical and electroencephalographic classification of epileptic seizures. Epilepsia. 1981;22:489\u0026ndash;501.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eGastaut H. Classification of status epilepticus. In: Delgado-Escueta AV, Wasterlain CG, Treiman DM, Porter RJ, editors. Status epilepticus: Mechanisms of brain damage and treatment. Vol.\u0026nbsp;34. New York: Raven Press; 1983. pp.\u0026nbsp;15\u0026ndash;35. Adv Neurol .\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eWHO case definitions of HIV for. Surveillance and revised clinical staging and immunological classification of HIV-related disease in adults and children. 2007, 10\u0026ndash;38.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eSikazwe I, Elafros MA, Bositis CM, Siddiqi OK, KoraInik IJ, Kalungwana L, Theodore WH, Okulicz JF, Potchen MJ, Birbeck GL. HIV and new onset seizures: slipping through the cracks in HIV care and treatment. HIV Med. 2016 Feb;17(2):118\u0026ndash;23.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eKim HK, Chin BS, Shin HS. Clinical Features of Seizures in Patients with Human Immunodeficiency Virus Infection. J Korean Med Sci. 2015;30:694\u0026ndash;9.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eFederal Democratic Republic of Ethiopia (FDRE). Census Commission: Summary and Statistical report of the 2007 population and housing census. 2008, Addis Ababa: FDRE census commission. Population size by Age and Sex.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eSiddiqi O, Birbeck GL. Safe Treatment of Seizures in the Setting of HIV/AIDS. Curr Treat Options Neurol. 2013 August: 15(4) 529\u0026ndash;543.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eRosenbaum GS, Klein NC, Cunha BA. Early Seizures in patients with acquired immunodeficiency syndrome without mass lesions. Heart lung. 1989;18:526\u0026ndash;9.\u003c/span\u003e \u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Africa, HIV, Seizure, Epilepsy, Antiretroviral therapy, Antiepileptic drugs","lastPublishedDoi":"10.21203/rs.3.rs-66079/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-66079/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe estimated number of adult patients living with HIV infection in Ethiopia in 2012 was approximately 800,000. Seizure occurs in 2 to 3 % and 6.1 % to 34.3% in patients with HIV infection and patients with neurological complications of HIV infection, respectively. Studies on HIV infection and seizure are rare in Ethiopia. The purpose of this study was to assess clinical presentation, cause and treatment outcome of patients with HIV infection presented with seizure. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: In this retrospective study, patients aged ≥ 13 years with HIV infection presented with seizure were included. Medical records were reviewed and demographic and clinical data were collected.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Records of 146 patients were analysed. Males were 55.5% and the mean age was 34 years. The diagnosis of HIV infection was made after current hospital admission in 69% of patients. Almost all patients (98.6 %) had stage 4 HIV infection with very low CD4 count (mean = 77/mm\u003csup\u003e3\u003c/sup\u003e). In almost all patients seizure was a recent onset at current admission; either it started after admission (42.5%) or within 3 months prior to admission (52.5%). The types of seizures were: generalized tonic-clonic seizure [GTCS] (69.2%), focal motor with secondarily generalization [FMWSG] (19.9%) and simple focal motor (11%). The common causes of seizure were: cerebral toxoplasmosis (46%), tuberculous meningitis (35.6%) and cryptococcal meningitis (13.7%). Case-fatality was 53% and predictors of mortality were: seizure started after admission, change in mentation and comatose at initial evaluation. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Most patients had stage 4 HIV infection with very low CD4 count and a recent onset seizure which started within 3 months at initial evaluation. GTCS was the commonest seizure type and most causes of seizure were central nervous system opportunistic infections. The case-fatality was high and change in sensorium was an independent predictor of mortality. To prevent the high mortality and morbidity prevention of HIV infection, early diagnosis and treatment, improving diagnostic facilities and access to non-enzyme inducing antiepileptic drugs are recommended.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Seizure in HIV-infected Patients: Clinical Presentation, Cause and Treatment Outcome in Ethiopia: A Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-09-08 19:12:43","doi":"10.21203/rs.3.rs-66079/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2021-01-03T00:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after discretionary revisions\nForm responses:\n---\n\nComments to Author:\n---\nThe retrospective study presented by Dr Amare, which addresses an interesting point in the study of HIV - the effects on the CNS, under a scenario of a health system in a developing country, a complex situation that is not taken into account. counts in developed countries. HIV + patients are at increased risk for developing seizures due to the vulnerability of the central nervous system to HIV-associated diseases, immune dysfunction and metabolic disturbances. And the author describes in a general way the clinical picture of the study patients and clearly marks the limitations of the study.\n\n\nTop points\n_Treatment of HIV infection is not optimal in developing countries\n_HIV + patients have a higher incidence of CNS opportunistic infections.\n_So the development of epileptic seizures goes hand in hand with factors such as the low amount of CD4 cells\n\nMinor comments\n---It would be interesting to attach a table in supplementary material where the pharmacological treatment of the patients is indicated, the same scheme shown in the graph could be used (by age groups) and indicating the main ARTs or AED drugs\n---Thoroughly describe the MRI imaging findings and attach a representative pair of images\n---In the CSF analysis, other neurological markers of interest were not addressed (lactate, Anti-N-methyl-D-aspartate), something in this line has been seen\n---Viral load of patients who showed neurological symptoms?\n---There is literature that should be attached to the paper:\n*Garg RK. HIV infection and seizures. Postgrad Med J. 1999 Jul; 75 (885): 387-90. doi: 10.1136 / pgmj.75.885.387. PMID: 10474720; PMCID: PMC1741302.\n*Satishchandra P, Sinha S. Seizures in HIV-seropositive individuals: NIMHANS experience and review. Epilepsy. 2008 Aug; 49 Suppl 6: 33-41. doi: 10.1111 / j.1528-1167.2008.01754.x. PMID: 18754959.\nAnd other references published in the last year that can contribute more weight to the results presented\n\n\nCongratulations to the author for the effort made* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **There is no conflict of interest**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"decision","content":"Minor revision","date":"2021-01-03T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-12-13T00:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-11-05T00:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\n\n\nWe have carefully reviewed the article INF-D-20-03045\n\n\"Seizure in HIV-infected patients: clinical presentation, cause and treatment outcome in Ethiopia: a retrospective study\"\n\n\nOur comments and review questions to the authors:\n1. The text specifies the CD4 level, but not the percentage of CD4 T lymphocytes, which is an insufficient information of the immunological status, since a large percentage of patients have leukopenia, which would alter the absolute number of CD4s. It would be interesting to know the HIV viral load of the patients, which is not provided.\n2. The number of neuroimaging studies is very limited (50% of cases), so the diagnosis is mainly based on clinical criteria and therapeutic response, which can be a confounding factor.\n3. The number of patients undergoing CSF analysis is greater than the number of neuroimaging studies. Among the fatal cases, are there related to complications of lumbar puncture?\n4.We know that the capital of Ethiopia is a malaria-free zone, but not other areas of the country, where a certain percentage of patients could come from. Cerebral malaria would be included in the differential diagnosis of new-onset seizures, especially with fever. Is this data provided in the revised series?\n5. The presence of fever, which is important for the differential diagnosis, as well as the presence of hypoglycemia (metabolic cause of seizure) and uremia, are not detailed in the clinical characteristics tables of the patients.\n6. Eye fundus to detect choroidal tuberculomas (pathognomonic for miliary and cerebral tuberculosis) or papilledema (that contraindicates lumbar puncture) are current practice in this patients. Was it performed?\n7. Which antiretroviral treatment was used in the few patients who had access to it?\n\n\nIn any case, we believe that it is a very interesting work, because it shows the \"real life\" management of patients with HIV infection and seizures, a serious neurological complication in a developing country.\n\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests'**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-10-10T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-09-20T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-09-02T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-09-01T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-09-01T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-08-29T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c8a80869-180c-4719-a686-4ecee439e5c8","owner":[],"postedDate":"September 8th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":450560,"name":"Infectious Diseases"}],"tags":[],"updatedAt":"2021-08-10T10:51:56+00:00","versionOfRecord":{"articleIdentity":"rs-66079","link":"https://doi.org/10.1186/s12879-021-06497-7","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2021-08-10 10:51:56","publishedOnDateReadable":"August 10th, 2021"},"versionCreatedAt":"2020-09-08 19:12:43","video":"","vorDoi":"10.1186/s12879-021-06497-7","vorDoiUrl":"https://doi.org/10.1186/s12879-021-06497-7","workflowStages":[]},"version":"v1","identity":"rs-66079","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-66079","identity":"rs-66079","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}