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HIV-1 Associated Distal Painful Sensorimotor Polyneuropathy: Differential Diagnoses & Workup

Author: Niranjan N Singh, MD, DNB, Fellow in Neurophysiology, Department of Neurology, St Louis University School of Medicine
Coauthor(s): Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Associate Program Director, Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Contributor Information and Disclosures

Updated: Feb 23, 2007

Differential Diagnoses

Acute Inflammatory Demyelinating Polyradiculoneuropathy
Nutritional Neuropathy
Chronic Inflammatory Demyelinating Polyradiculoneuropathy
Toxic Neuropathy
Diabetic Neuropathy
Uremic Neuropathy
HIV-1 Associated Multiple Mononeuropathies
Vitamin B-12 Associated Neurological Diseases

Other Problems to Be Considered

Other HIV-related neuropathies (differentiated by HIV-associated distal painful sensory neuropathy's slower progression)
Alcoholic neuropathy
Metabolic neuropathy
Paraneoplastic neuropathy
Paraneoplastic sensory neuropathy
Paraproteinemic neuropathy
Cytomegalovirus (CMV)–related mononeuropathy
Human T-cell leukemia virus type 2 (HTLV-2)–related neuropathy
Vasculitic neuropathy

Workup

Laboratory Studies

  • Cerebrospinal fluid
    • Mildly elevated protein
    • Mild pleocytosis
  • Consider the following peripheral neuropathy workup depending on the specific clinical situation:
    • HIV-RNA viral load
    • Complete blood cell count
    • Fasting blood sugar and 2-hour glucose tolerance test
    • Hemoglobin A1C
    • Antinuclear antibody screen
    • Extractable nuclear antibody screen
    • Erythrocyte sedimentation rate
    • Renal function test
    • Paraproteinemia workup
    • Angiotensin-converting enzyme level
    • Lyme serology
    • Thyroid function tests
    • Hepatitis workup
    • Vitamin B-12 and folic acid levels - In patients with B-12 levels below 350 pg/mL, homocysteine and methylmalonic acid levels are more sensitive indicators of a deficiency; intrinsic factor or parietal cell antibody testing and a Schilling test may be indicated.
  • Electromyography/nerve conduction study
    • Symmetric features
    • Sensory findings predominate over motor abnormalities
    • Greater involvement of lower than upper extremities
    • Distal axonal degeneration
    • Significantly reduced sensory and motor amplitudes
    • Normal-to-mildly reduced sensory and motor conduction velocities
    • Normal-to mildly increased sensory and motor distal latencies

Histologic Findings

Histologic findings include the following:

  • Axonal degeneration
  • Some demyelination
  • Prominent perivascular infiltration by T lymphocytes and macrophages
  • Mild loss of dorsal root ganglion neurons, some found to harbor HIV by in situ polymerase chain reaction
  • Occasional gracile tract degeneration
  • Reduced mtDNA in subcutaneous fat
  • Reduced HIV-RNA viral load
  • The intraepidermal nerve fiber density correlates inversely with the likelihood of neuropathic symptoms.

More on HIV-1 Associated Distal Painful Sensorimotor Polyneuropathy

Overview: HIV-1 Associated Distal Painful Sensorimotor Polyneuropathy
Differential Diagnoses & Workup: HIV-1 Associated Distal Painful Sensorimotor Polyneuropathy
Treatment & Medication: HIV-1 Associated Distal Painful Sensorimotor Polyneuropathy
Follow-up: HIV-1 Associated Distal Painful Sensorimotor Polyneuropathy
References

References

  1. Cornblath DR, McArthur JC. Predominantly sensory neuropathy in patients with AIDS and AIDS-related complex. Neurology. May 1988;38(5):794-6. [Medline].

  2. Cornblath DR, Hoke A. Recent advances in HIV neuropathy. Curr Opin Neurol. 2006;5:446-50. [Medline].

  3. Estanislao L, Carter K, McArthur J, et al. A randomized controlled trial of 5% lidocaine gel for HIV-associated distal symmetric polyneuropathy. J Acquir Immune Defic Syndr. Dec 15 2004;37(5):1584-6. [Medline].

  4. Ferrari S, Vento S, Monaco S, et al. Human immunodeficiency virus-associated peripheral neuropathies. Mayo Clin Proc. Feb 2006;81(2):213-9. [Medline].

  5. Freeman R, Roberts MS, Friedman LS, Broadbridge C. Autonomic function and human immunodeficiency virus infection. Neurology. Apr 1990;40(4):575-80. [Medline].

  6. Gendelman HE, Lipton SA, Epstein L. The Neurology of AIDS. New York: Chapman & Hall;1998.

  7. Hart AM, Wilson AD, Montovani C, et al. Acetyl-l-carnitine: a pathogenesis based treatment for HIV-associated antiretroviral toxic neuropathy. AIDS. Jul 23 2004;18(11):1549-60. [Medline].

  8. Kieburtz K, Simpson D, Yiannoutsos C, et al. A randomized trial of amitriptyline and mexiletine for painful neuropathy in HIV infection. AIDS Clinical Trial Group 242 Protocol Team. Neurology. Dec 1998;51(6):1682-8. [Medline].

  9. Luciano CA, Pardo CA, McArthur JC. Recent developments in the HIV neuropathies. Curr Opin Neurol. Jun 2003;16(3):403-9. [Medline].

  10. Maschke M, Kastrup O, Esser S, et al. Incidence and prevalence of neurological disorders associated with HIV since the introduction of highly active antiretroviral therapy (HAART). J Neurol Neurosurg Psychiatry. Sep 2000;69(3):376-80. [Medline].

  11. 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. Apr 2004;61(4):546-51. [Medline].

  12. Said G, Saimont AG, Lacroix C. Neurological Complications of HIV and AIDS. Philadelphia, Pa: WB Saunders;1998.

  13. Schifitto G, McDermott MP, McArthur JC, et al. Incidence of and risk factors for HIV-associated distal sensory polyneuropathy. Neurology. Jun 25 2002;58(12):1764-8. [Medline].

  14. Simpson DM, Olney RK. Peripheral neuropathies associated with human immunodeficiency virus infection. Neurol Clin. Aug 1992;10(3):685-711. [Medline].

  15. Simpson DM, Kitch D, Evans SR, et al. HIV neuropathy natural history cohort study: assessment measures and risk factors. Neurology. Jun 13 2006;66(11):1679-87. [Medline].

  16. Watters MR, Poff PW, Shiramizu BT, et al. Symptomatic distal sensory polyneuropathy in HIV after age 50. Neurology. Apr 27 2004;62(8):1378-83. [Medline].

  17. de Gans J, Portegies P. Neurological complications of infection with human immunodeficiency virus type 1. A review of literature and 241 cases. Clin Neurol Neurosurg. 1989;91(3):199-219. [Medline].

Further Reading

Keywords

acquired immunodeficiency syndrome, AIDS, HIV-1 associated peripheral neuropathy, HIV infection, neurotoxic drugs, vitamin deficiencies, nutritional deficiencies, drug toxicity, didanosine, stavudine, zalcitabine, lamivudine

Contributor Information and Disclosures

Author

Niranjan N Singh, MD, DNB, Fellow in Neurophysiology, Department of Neurology, St Louis University School of Medicine
Niranjan N Singh, MD, DNB is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Coauthor(s)

Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Associate Program Director, Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Paraplegia Society, and National Multiple Sclerosis Society
Disclosure: Nothing to disclose.

Medical Editor

William J Nowack, MD, Associate Professor, Department of Neurology, Epilepsy Center, University of Kansas Medical Center
William J Nowack, MD is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, American Medical Electroencephalographic Association, American Medical Informatics Association, and Biomedical Engineering Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Glenn Lopate, MD, Associate Professor, Department of Neurology, Division of Neuromuscular Diseases, Washington University School of Medicine; Chief of Neurology, St Louis ConnectCare, Consulting Staff, Barnes Jewish Hospital
Glenn Lopate, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

 
 
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