HIV Neuropathy
HIV-related neuropathic conditions include distal symmetric peripheral neuropathy (DSPN), often caused by HIV viremia, aging, diabetes, or certain drugs. Treatment involves discontinuing neurotoxic medications, using antiretroviral therapy, and managing symptoms with drugs like gabapentin and duloxetine. Other HIV-related neuropathies include acute and chronic inflammatory demyelinating polyneuropathies, progressive polyradiculopathy, and autonomic neuropathy, though the prevalence of autonomic neuropathy has decreased in the era of antiretroviral therapy.
2023-12-31 21:46:30 - Editor
Overview of Neuropathic Syndromes in HIV Infection
HIV infection is associated with a number of neuropathic syndromes, mainly including distal symmetric peripheral neuropathy (DSPN). Other HIV neuropathies include acute and chronic inflammatory demyelinating polyneuropathies, progressive polyradiculopathy, and autonomic neuropathy. (1)
Distal Symmetric Peripheral Neuropathy (DSPN)
Risk Factors and Symptoms
Risk factors for DSPN include level of HIV viremia, aging, diabetes, nutritional deficiencies, and certain antiretroviral agents, mainly stavudine, nevirapine, and didanosine. DSPN usually manifests as bilateral tingling and numbness in the lower extremities. Neuropathic pain is common and may be the presenting symptom. (1, 2, 3)
Treatment Options
Treatment options for DSPN are limited. Antiretroviral therapy (ART) appears to reduce the risk of DSPN. However, for patients with established DSPN, the effect of ART is unclear with some reports showing improved quantitative sensory measures in patients responding to ART. Also, if a potentially neurotoxic drug is being used, such as stavudine, nevirapine, and didanosine, it should be discontinued. (4)
Management of Polyneuropathy
Management of polyneuropathy is mainly symptomatic and usually aimed at ameliorating the painful dysesthesias. Gabapentin (Immediate release, 100 - 300 mg once to three times daily or extended release 300mg daily) is suggested as an initial therapy. If initial therapy is ineffective, second-line therapy with duloxetine (60 mg daily), or pregabalin (50- 100 mg daily) are effective. Also, antidepressant options include amitriptyline (starting at 10 mg at bedtime), or venlafaxine (37.5- 75 mg daily). Additionally, opioids, such as tramadol (50- 100 mg three times daily as needed), or oxycodone (5mg three times daily as needed) can be added to the above mentioned therapies for breakthrough pain. (5, 6)
Acute and Chronic Inflammatory Demyelinating Polyneuropathies
Acute inflammatory demyelinating polyneuropathy (AIDP) is similar to Guillain-Barre syndrome (GBS). Chronic inflammatory demyelinating polyneuropathy (CIDP) has relapsing motor and sensory symptoms that require ongoing immunomodulatory treatment. Patients present with monophasic, slowly progressive, multifocal, lower extremity symptoms associated with demyelination. For details, please refer to chronic Inflammatory Demyelinating Neuropathy. (7)
Progressive Polyradiculopathy
In addition to causing mononeuropathy multiplex, in the patient with advanced AIDS, CMV can infect the cauda equina leading to inflammation and necrosis of the lumbosacral nerve roots and a progressive polyradiculopathy. Patients present with a rapidly evolving cauda equina syndrome, with weakness and numbness in the lower extremities and sphincter dysfunction. Treatment is directed to CMV infection. Please review CMV encephalitis for details. (8)
Autonomic Neuropathy
Early reports from the pre-ART era suggested that autonomic neuropathy was common in HIV positive patients, but these results have not been consistently reproduced in the ART-era. (9)
References
1-Simpson DM, Kitch D, Evans SR, et al. HIV neuropathy natural history cohort study: Assessment measures and risk factors. Neurology. 2006;66(11):1679–1687.
2-Cherry CL, Skolasky RL, Lal L, et al. Antiretroviral use and other risks for HIV-associated neuropathies in an international cohort. Neurology. 2006;66(6):867–873.
3-Parry GJ. Peripheral neuropathies associated with human immunodeficiency virus infection. Ann Neurol. 1988;23(Suppl):S49–53.
4-Morgello S, Estanislao L, Simpson D, et al. HIV-associated distal sensory polyneuropathy in the era of highly active antiretroviral therapy: The Manhattan HIV brain bank. Arch Neurol. 2004;61(4):546–551.
5-Wallace VC, Blackbeard J, Pheby T, et al. Pharmacological, behavioural and mechanistic analysis of HIV-1 gp120 induced painful neuropathy. Pain. 2007;133(1–3):47–63.
6-Lesser H, Sharma U, LaMoreaux L, Poole RM. Pregabalin relieves symptoms of painful diabetic neuropathy: A randomized controlled trial. Neurology. 2004;63(11):2104–2110.
7-Cornblath DR, McArthur JC, Kennedy PG, Witte AS, Griffin JW. Inflammatory demyelinating peripheral neuropathies associated with human T-cell lymphotropic virus type III infection. Ann Neurol. 1987;21(1):32–40.
8-Miller RF, Fox JD, Thomas P, et al. Acute lumbosacral polyradiculopathy due to cytomegalovirus in advanced HIV disease: CSF findings in 17 patients. J Neurol Neurosurg Psychiatry. 1996;61(5):456–460.
9-Compostella C, Compostella L, D'Elia R. The symptoms of autonomic dysfunction in HIV-positive Africans. Clin Auton Res. 2008;18(1):6–12.