Peripheral neuropathy in HIV

Intentntional lournal of STD A AIDS 7997;8:7612

CONTINUING MEDICAL EDUCATION

Peripheral neuropathy in HIV M Sadler

PhD MRCP

and M Nelson MA

MRCP

Directorate of HIV/GUM, Chelsea and Westruinster NHS Trust, London, UK

Keywords: Peripheral neuropathies, HIV infection, review, treatment, cytomegalovirus

INTRODUCTION A wide variety of peripheral nerve syndromes have been described in patients with HIV infection from seroconversion

to the late stages of AIDS.

The

incidence of peripheral nerve involvement increases with falling CD4 count, and subclinical evidence of peripheral neuropathy may be found in up to 90%

of AIDS patientsl.

The type of peripheral neuropathy affecting

a

patient depends on the stage of HIV infection and CD4 count. Syndromes which are immune mediated, such as inflammatory demyelinating

polyneuropathy (IDP) or mononeuritis multiplex (MM) occur early in HIV infection and may occur at seroconversion, whereas syndromes caused by viral infections, such as those related to the action of cytomegalovirus (CMV) occur late in AIDS. Table 1 shows the major categories of peripheral nerve syndromes, the approximate CD4 count at which they occur and an estimation of their frequency in HlV-infected patients. It is of note that the most common neuropathy is a distal symmetrical polyneuropathy (DSP) which accounts for over 90% of all HlV-related neuropathies2.

INFLAMMATORY DEMYELINATING POLYNEUROPATHY (IDP) Acute inflammatory demyelinating polyradiculoneuropathy (AIDP)

An AIDP, clinically very similar to Guillain-Barr6 syndrome (GBS), has been reported in early HIV infection either as a seroconversion i1hess3,4 or during the asymptomatic phase of infections. Although a rare disease in HIV, in a study in Zimbabwe, 59% of consecutive patients with AIDP were found to be HlV-positive on testing6. Certainly this association between AIDP and HIV is stronger than expected by chance alone5,7, and is strong enough to suggest HIV testing in all patients

presenting with GBS. As AIDP is an immune mediated disorder it occurs early in the course of HIV disease rather than in the later stages of immune depletion. There are temporal associations between the occurrence of AIDP in HIV and infection with mycoplasma, campylobacters, hepatitise and CMV5,7, either at the time of presentation

Table 1. Major peripheral nerzte syndromes, CD4 (/mm3) count nt ruhich they are likely and relatiae frequertcy of occurrcttce in HIV patients

Type of neuropathy

CD4

count/ mm3

Frequency of occurrence

>500 >500

< 1% (Ref 2) 500,