eMedicine Specialties > Neurology > Neurological Infections

HIV-1 Associated Myopathies

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

Introduction

Background

HIV-associated myopathies fall into several categories, including polymyositis and dermatomyositis, zidovudine (AZT) myopathy and rhabdomyolysis, nemaline (rod) myopathy, HIV wasting syndrome with type II muscle fiber atrophy, myopathy caused by local neoplasm, myopathy caused by local infection, myasthenic syndrome and chronic fatigue, and diffuse infiltrative lymphocytosis syndrome (DILS). HIV-wasting syndrome and opportunistic muscle infections are encountered in untreated patients, while treated patients may develop inflammatory myopathy related to immune restoration or drug-induced muscle involvement.

Pathophysiology

HIV induces muscle fibers to express major histocompatibility complex 1 (MHC-1) triggering cell-mediated muscle fiber injury. Particular types of myopathies reflect the clinical stage of the patient.

Possible disease mechanisms include the following:

  • Polymyositis and dermatomyositis - Autoimmunity
  • Drug effect - AZT and didanosine
  • Secondary neoplasm - Lymphoma and Kaposi sarcoma
  • Myasthenic syndrome and chronic fatigue - Autoimmune
  • Rhabdomyolysis - Opportunistic infection, HIV, didanosine, lamivudine
  • Secondary infection - Viruses (eg, cytomegalovirus [CMV]), parasites (eg, Toxoplasma gondii), fungi (eg, Cryptococcus neoformans, microsporidia), and bacteria (eg, Staphylococcus aureus, Mycobacterium avium-intracellulare, Escherichia coli)
  • Malnutrition and vitamin deficiencies
  • HIV muscle wasting syndrome - Elevated levels of 2 proinflammatory cytokines produced by macrophages and induced by HIV, cachectin, and tumor necrosis factor (may interfere with lipid metabolism in muscle)
  • Diffuse infiltrative lymphocytosis syndrome - Persistent CD8 hyperlymphocytosis and multivisceral CD8 T-cell infiltration

Frequency

United States

According to some studies, up to 25% of AIDS patients suffer from a myopathic disease. In one study, mild inflammation, type II fiber atrophy, or evidence of denervation was detected in more than half of asymptomatic, untreated, HIV-seropositive patients without weakness. In another study, myalgias were present in 8% of patients treated with AZT. Other estimates of the frequency of AZT myopathy reach 17%.

Clinical

History

  • Early HIV infection
    • Nemaline rod myopathy - Slowly progressive weakness and wasting, negative family history, possibly autoimmune
    • Immune-mediated polymyositis and dermatomyositis - Similar presentation as in non-HIV patients; usually generalized symptoms, occasionally focal ;polymyositis also possible as part of highly active antiretroviral therapy (HAART)–associated immune reconstitution syndrome
  • Early or late HIV infection
    • AZT myopathy - Fatigue, proximal muscle pain, and weakness, especially after a lifetime dose greater than 200 g
    • Rhabdomyolysis - Same as in non-HIV population; caused by didanosine, other drugs, intercurrent illnesses (eg, CMV), or possibly HIV itself; at times associated with seroconversion
  • Late HIV infection
    • Myopathy caused by local infection - Focal or multifocal painful swollen muscles, fever
    • Myopathy caused by local neoplasm - Painful swollen muscles, low-grade fever, HIV wasting syndrome (painless proximal weakness, fatigue)

Physical

  • Polymyositis and dermatomyositis - Physical findings as in non-HIV patients
  • Nemaline rod myopathy - Weakness and atrophy
  • AZT myopathy - Proximal weakness and atrophy, myalgia, muscle tenderness
  • Rhabdomyolysis - Same as in non-HIV population
  • HIV wasting syndrome - Proximal weakness and atrophy in the setting of significant weight loss, diarrhea, and fever
  • Myopathy caused by local neoplasm - Local or multifocal pain and swelling, fever
  • Myopathy caused by local infection
    • Local or multifocal pain and swelling, fever
    • Sepsis, fluctuance, and destruction of involved muscles in late stages
    • Myasthenic syndrome-myasthenia gravis - Reported occasionally; manifests as fluctuating weakness improving with immunosuppression
  • Diffuse infiltrative lymphocytosis syndrome - Parotid gland enlargement, multiorgan infiltration, polyneuropathy, and 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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