eMedicine Specialties > Neurology > Neurological Infections

HIV-1 Associated Myopathies: 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

Dermatomyositis/Polymyositis
Endocrine Myopathies
Focal Muscular Atrophies
Inclusion Body Myositis

Other Problems to Be Considered

Hereditary adult-onset myopathies
Viral myositis
Deep venous thrombosis
Rhabdomyolysis caused by severe illness
Non-Hodgkin lymphoma

Workup

Laboratory Studies

  • Serum creatine kinase
    • Polymyositis and dermatomyositis - Normal or high
    • AZT myopathy and rhabdomyolysis - High
    • HIV wasting syndrome - Normal
    • Infectious or neoplastic focal myopathy - Normal or high
  • Possible elevation of other muscle enzymes (aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase)
  • Electromyography and nerve conduction studies
    • Myopathic (brief, low-amplitude, polyphasic) motor unit potentials, increased insertional activity and spontaneous activity
    • Positive sharp waves
    • Fibrillation potentials
    • Often associated neuropathic features
  • Blood cultures occasionally positive in pyomyositis
  • Minor salivary gland biopsy and gallium Ga 67 scintigraphy - Major diagnostic help when DILS is suspected

Imaging Studies

  • Radiologic studies (eg, CT, MRI with contrast,67 Ga scan, ultrasound) are helpful when pyomyositis is suggested.
  • MRI may distinguish infectious and neoplastic myopathies.
    • Infection - No changes in subcutaneous tissue
    • Lymphoma and Kaposi sarcoma - Cutaneous and subcutaneous involvement

Procedures

  • Muscle biopsy may be required to distinguish different etiologies and guide treatment.
  • Needle aspiration may be diagnostic in pyomyositis.

Histologic Findings

Muscle biopsy permits histologic differentiation of various clinical phenotypes and identification of causative infectious agents by staining and culture. HIV rarely is identified by in situ hybridization or electron microscopy in infiltrating inflammatory cells and never in muscle fibers. Several types of pathology may coexist (eg, polymyositis, AZT myopathy).

  • Polymyositis - Fiber necrosis, inflammatory infiltrates of CD8+ lymphocytes and macrophages
  • AZT myopathy - Myopathic changes, dose-dependent numbers of ragged red fibers, cytochrome C oxidase-negative fibers, rods, lipid and glycogen accumulation, inflammatory infiltrates, paracrystalline mitochondrial inclusions, decreased numbers of mitochondria (reversible over several months, if AZT administration is stopped)
  • Nemaline rod myopathy - Muscle fiber necrosis, variable inflammation, red-blue cytoplasmic structures in small type I fibers best observed in Gomori trichrome stain
  • Neoplastic myopathy - Evidence of lymphoma or Kaposi sarcoma
  • Infectious myopathy - Histologic evidence for the responsible organism, frank pus, or positive cultures; necrotic or degenerating fibers; inflammatory infiltrates
  • Diffuse infiltrative lymphocytosis syndrome - Histological confirmation of CD8 T-cell infiltration; presence of thin intranuclear inclusion helps distinguish DILS-associated myositis from polymyositis

More on HIV-1 Associated Myopathies

Overview: HIV-1 Associated Myopathies
Differential Diagnoses & Workup: HIV-1 Associated Myopathies
Treatment & Medication: HIV-1 Associated Myopathies
Follow-up: HIV-1 Associated Myopathies
References
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References

  1. Attarian S, Mallecourt C, Donnet A. Myositis in infiltrative lymphocytosis syndrome: clinicopathological observations and treatment. Neuromuscul Disord. Nov 2004;14(11):740-3. [Medline].

  2. Authier FJ, Chariot P, Gherardi RK. Skeletal muscle involvement in human immunodeficiency virus (HIV)-infected patients in the era of highly active antiretroviral therapy (HAART). Muscle Nerve. 2005;32(3):247-60. [Medline].

  3. Behbahani R, Moshfeghi M, Baxter JD. Therapeutic approaches for AIDS-related toxoplasmosis. Ann Pharmacother. Jul-Aug 1995;29(7-8):760-8. [Medline].

  4. Chariot P, Gherardi R. Myopathy and HIV infection. Curr Opin Rheumatol. Nov 1995;7(6):497-502. [Medline].

  5. Colmegna I, Koehler JW, Garry RF, Espinoza LR. Musculoskeletal and autoimmune manifestations of HIV, syphilis and tuberculosis. Curr Opin Rheumatol. 2006;18(1):88-95. [Medline].

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

  7. Johnson RW, Williams FM, Kazi S, et al. Human immunodeficiency virus-associated polymyositis: a longitudinal study of outcome. Arthritis Rheum. Apr 15 2003;49(2):172-8. [Medline].

  8. Klepser ME, Klepser TB. Drug treatment of HIV-related opportunistic infections. Drugs. Jan 1997;53(1):40-73. [Medline].

  9. Moyle G. Clinical manifestations and management of antiretroviral nucleoside analog-related mitochondrial toxicity. Clin Ther. Aug 2000;22(8):911-36; discussion 898. [Medline].

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

  11. Whitley RJ, Jacobson MA, Friedberg DN. Guidelines for the treatment of cytomegalovirus diseases in patients with AIDS in the era of potent antiretroviral therapy: recommendations of an international panel. International AIDS Society-USA. Arch Intern Med. May 11 1998;158(9):957-69. [Medline].

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Further Reading

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Keywords

acquired immunodeficiency syndrome, AIDS, polymyositis, dermatomyositis, zidovudine myopathy, AZT myopathy, rhabdomyolysis, nemaline rod myopathy, HIV wasting syndrome with type II muscle fiber atrophy, local neoplasm, local infection, myasthenic syndrome and chronic fatigue, diffuse infiltrative lymphocytosis syndrome, DILS

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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

Neil A Busis, MD, Chief, Division of Neurology, Department of Medicine, University of Pittsburgh Medical Center - Shadyside, Clinical Associate Professor, Department of Neurology, University of Pittsburgh School of Medicine
Neil A Busis, MD is a member of the following medical societies: American Academy of Neurology and American Association of Neuromuscular and Electrodiagnostic Medicine
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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