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Guideline of the German Society of Neurology (DGN): "diagnosis and therapy of HIV-1-associated neurological disorders”

DGN · 2026 · Germany

Source and licence

Authors
Katrin Hahn, Gabriele Arendt, Christian Eggers et al.
Title
Guideline of the German Society of Neurology (DGN): "diagnosis and therapy of HIV-1-associated neurological disorders”
Journal
Neurological Research and Practice, 2026
DOI
10.1186/s42466-026-00519-y
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC13474671

Licence statement of the original publication

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This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Toxoplasma gondii infection

  • Pyrimethamine p.o. (200 mg on day 1; from day 2 onwards, 1 x 75 mg for body weight ≥ 60 kg; 1 x 50 mg for body weight < 60 kg) +
  • Sulfadiazine p. o. (≥ 60 kg body weight 2 x 3000 mg/d; < 60 kg body weight 2 x 2000 mg/d)
  • + folic acid p. o. (15 mg/d) [72, 113-116]
  • In case of sulphonamide intolerance: clindamycin (4 x 600 mg/day p.o.) + pyrimethamine (as above)
  • The second-line treatment is monotherapy with trimethoprim (TMP)/sulfamethoxazole (SMX) p.o. (2 x 5 mg TMP/kg body weight/day + 2 x 25 mg SMX/kg body weight)
  • Further alternatives: Azithromycin p.o. (1 x 0.5–1 g/day) together with pyrimethamine and folic acid; atovaquone p.o. (2 x 1500 mg/day) together with pyrimethamine and folic acid or sulphadiazine (as above)
  • Azithromycin p.o. (1 x 0.5–1 g/day) together with pyrimethamine and folic acid; atovaquone p.o. (2 x 1500 mg/day) together with pyrimethamine and folic acid or sulphadiazine (as above)
  • In patients with malabsorption or severe diarrhoea, treatment may be switched to intravenous cotrimoxazole 5 mg TMP/kg body weight twice daily, or, in cases of sulphonamide allergy, to clindamycin 4 x 600 mg intravenously + pyrimethamine and folic acid

JC-Virus-Infection (PML)

  • Newer drugs: Recent case series have demonstrated the potential efficacy of the checkpoint inhibitors pembrolizumab and nivolumab [117] and the CCR5-blocking antiretroviral substance maraviroc [118]. However, these compounds need to be studied in randomised controlled trials.
  • A new therapeutic approach involves the use of allogeneic virus-specific T cells [119].

Cytomegalovirus infection of the CNS

  • Standard treatment: Ganciclovir i.v. (2 × 5 mg/kg body weight/day) or Foscarnet i.v. (2 × 90 mg/kg body weight/day). Dosage should be adjusted according to renal function.
  • Following induction therapy, maintenance therapy with a reduced dose (foscarnet 90 mg/kg body weight/day + ganciclovir 5 mg/kg body weight/day) should be administered.
  • Alternatively: Cidofovir i.v. (1 × 5 mg/kg body weight/week) for at least 3 weeks if standard therapy is not tolerated.

Cryptococcal meningitis

  • Induction therapy: liposomal amphotericin B 3 mg/kg body weight plus flucytosine (100 mg/kg body weight per day, divided into 4 doses) over 2 weeks [68-70] Recently, a single dose of liposomal amphotericin B 10 mg/kg body weight with additional doses of flucytosine (100 mg/kg body weight/day, divided into 4 doses) and fluconazole (1200 mg four times daily for 14 days) has also been recommended as an alternative (https://eacs.sanfordguide.com/en/eacs-hiv/eacs-section4/ois/cryptococcosis) Alternatively, the combination of amphotericin B (0.7–1.0 mg/kg body weight/day) plus flucytosine (100 mg/kg body weight/day) may be considered. Alternatives for induction therapy include amphotericin B plus fluconazole, fluconazole plus flucytosine, and fluconazole and itraconazole as monotherapy. However, the effectiveness of these therapies is considered to be lower than that of standard therapy.
  • Recently, a single dose of liposomal amphotericin B 10 mg/kg body weight with additional doses of flucytosine (100 mg/kg body weight/day, divided into 4 doses) and fluconazole (1200 mg four times daily for 14 days) has also been recommended as an alternative (https://eacs.sanfordguide.com/en/eacs-hiv/eacs-section4/ois/cryptococcosis)
  • Alternatively, the combination of amphotericin B (0.7–1.0 mg/kg body weight/day) plus flucytosine (100 mg/kg body weight/day) may be considered.
  • Alternatives for induction therapy include amphotericin B plus fluconazole, fluconazole plus flucytosine, and fluconazole and itraconazole as monotherapy. However, the effectiveness of these therapies is considered to be lower than that of standard therapy.
  • This is followed by consolidation with fluconazole (400 mg/day orally) for 8 weeks and maintenance therapy with a reduced dose of fluconazole (200 mg/day) for at least 1 year.
  • If cART is successful, treatment may be discontinued once the CD4 cell count has risen to > 100 cells/µl and the viral load has been low or undetectable for at least 3 months.

Tuberculosis of the CNS

  • Treatment adjustment based on resistance testing. In case of resistance, consult specialists.
  • After 2 months: dual or triple combination therapy for up to a total duration of 12 months (possibly longer in cases of persistent disease): INH p.o. (3–5 mg/kg body weight/day, maximum daily dose 300 mg) + rifampicin p.o. (600 mg/day)
  • Directly observed therapy (DOT) recommended, including, if necessary, a switch to 3-times-weekly therapy: INH p.o. (15 mg/kg body weight/day, maximum daily dose 900 mg) + rifampicin p.o. (600 mg/day)
  • Concomitant medication: Vitamin B6 (20–60 mg/day) for INH-associated polyneuropathy, possibly allopurinol 300 mg/day for pyrazinamide-induced hyperuricaemia; ophthalmological examinations due to possible ethambutol opticopathy.
  • Interactions between rifampicin and antiretroviral therapy are very common (protease inhibitors, non-nucleoside reverse transcriptase inhibitors, integrase inhibitors); if necessary rifampicin should be replaced by rifabutin.
  • IRIS occurs very frequently in cases of CNS tuberculosis. Antiretroviral therapy should not be started at the same time as TB treatment, but only after at least two weeks. If the CD4 cell count is below 100/µl, consider pre-emptive corticosteroids (prednisone 40 mg orally for 2 weeks, followed by 20 mg for 2 weeks) when starting cART.

Primary CNS lymphoma

  • Radiation: 30–60 Gy, whole neurocranium; improves the prognosis only slightly in patients in good general health.
  • Chemotherapy: Methotrexate (3 g/m2) administered systemically every 14 days or (if the patient is in good general health) polychemotherapy (vincristine, procarbazine and lomustine) prolongs median survival by approximately 12 months.
  • Antiviral agents: ganciclovir (sometimes in combination with IL-2) or hydroxyurea – single cases of remission have been reported.

Abstract

Epidemiology and treatment of HIV changed substantially within the last three decades. However, HIV-associated neurological disorders such as mild forms of HIV-associated neurocognitive disorder (HAND) as well as HIV-associated distal symmetrical sensory polyneuropathy are amongst the most frequent complications in patients with longstanding HIV infection. Opportunistic infections occur less frequently compared to former years, but especially in patients with late presentation of HIV progressive multifocal leukoencephalopathy (PML) (0.7 per 1,000 patient-years), toxoplasma encephalitis (0.4 per 1,000 patient-years) and cryptococcal meningitis (0.2 per 1,000 patient-years) remain the most common opportunistic infections. The guidelines for diagnosis and treatment of HIV-associated neurological disorders of the German Society of Neurology were revised addressing recent changes in treatment opportunities of HAND, HIV associated complications of the peripheral nervous system and muscles and opportunistic infections of the central nervous system (CNS).

Contents of the original publication

The section headings of the original.

  • What´s new
  • The most important recommendations
  • Introduction
  • Pathophysiology
  • Definition and classification
  • Aseptic leptomeningitis
  • HIV-associated neurocognitive disorder (HAND)
  • Screening
  • Risk factors for the development of HAND
  • HIV-1-associated myelopathy (HIVM) and HIV myelitis
  • HIVM
  • HIV-myelitis
  • Neuromuscular complications
  • HIV-1-associated neuropathies
  • HIV-DSP
  • Acute inflammatory demyelinating polyradiculoneuritis
  • Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP)
  • HIV-1-associated vasculitic polyneuropathy
  • Polyneuropathy in diffuse infiltrative lymphocytosis syndrome (DILS)
  • HIV-1-associated myopathies
  • Antiretroviral-induced myopathies
  • Inflammatory myopathies
  • Nemaline-myopathy
  • Myopathy in diffuse infiltrative lymphocytosis syndrome (DILS)
  • Opportunistic infections
  • Primary central nervous system lymphoma
  • Immune reconstitution syndrome (IRIS)
  • Diagnostics
  • Aseptic leptomeningitis
  • HIV-1-associated dementia
  • Mandatory investigations
  • Tests required in individual cases
  • HIV-1-associated myelopathy
  • Mandatory investigations
  • HIV-1- associated neuropathies
  • Mandatory investigations
  • Tests required in individual cases
  • HIV-1-associated myopathies
  • Mandatory investigations
  • Tests required in individual cases
  • Opportunistic cerebral infections
  • Mandatory investigations
  • Primary CNS lymphoma
  • Mandatory investigations
  • Immune reconstitution syndrome (IRIS)
  • Mandatory investigations
  • Treatment
  • HIV-1-associated dementia and its prodromal stages
  • Recommendations
  • Highly active antiretroviral combination therapy (cART)
  • HIV-1-associated myelopathy
  • HIV-1- associated neuropathies
  • HIV-1-associated myopathies
  • Opportunistic CNS diseases
  • Toxoplasma gondii infection
  • JC-Virus-Infection (PML)
  • Cytomegalovirus infection of the CNS
  • Cryptococcal meningitis
  • Tuberculosis of the CNS
  • Neurosyphilis
  • Primary CNS lymphoma
  • Immune reconstitution syndrome (IRIS)

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