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Nature and Incidence of Peripheral Nerve Syndromes in HIV Infection J Neurol Neurosurg Psychiatry: First Published As 10.1136/Jnnp.56.4.372 on 1 April 1993

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Nature and Incidence of Peripheral Nerve Syndromes in HIV Infection J Neurol Neurosurg Psychiatry: First Published As 10.1136/Jnnp.56.4.372 on 1 April 1993 37232oumal of Neurology, Neurosurgety, anid Psychiatri 1993;56:372-381 Nature and incidence of peripheral nerve syndromes in HIV infection J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.4.372 on 1 April 1993. Downloaded from Geraint N Fuller, Jean M Jacobs, Roberto J Guiloff Abstract who attended hospitals and clinics in the East Fifty four patients with peripheral nerve Riverside area. Patients were excluded if they syndromes were seen during a 15 month had been exposed to neurotoxins (drugs such period in a population of about 1500 HIV as vincrinstine, isoniazid, or thalidomide or infected patients at all stages of the dis- regularly took more than 40 units of alcohol a ease. Distal symmetrical peripheral neu- week) or had other systemic conditions, not ropathies were seen in 38 of the 54 related to HIV, associated with peripheral patients, (11.5% of AIDS patients) and neuropathy (such as diabetes or uraemia) or could be distinguished into two forms. had a family history of peripheral neuropathy. The most common (n = 25) was a painful Patients were classified as having AIDS peripheral neuropathy during AIDS, according to the CDC criteria4; they were which is distinct clinically and pathologi- classified as having AIDS related complex if cally, having axonal atrophy, and is asso- they were HIV positive and had persistent ciated with cytomegalovirus infection at generalised lymphadenopathy, fever, oral other sites. The 13 non-painful neu- hairy leukoplakia, oral candidiasis, herpes ropathies seen were more heterogenous. zoster radiculitis, and foliculitis but lacked Lumbosacral polyradiculopathy associat- AIDS defining opportunistic infections or ed with cytomegalovirus and lymphoma- tumours. At the time of the study the neuro- tous mononeuritis multiplex occurred in toxic nucleoside analogues DDI and DDC fewer than 1% of AIDS patients. Mono- were not being used. neuropathies were seen in 3% of AIDS At the start of the study (September 1988) patients. No patients with acute or 1353 HIV positive patients were being fol- chronic inflammatory demyelinating lowed up at these clinics. A total of 748 had polyradiculoneuropathies were seen. The AIDS related complex and 261 had AIDS (C annual incidence of neuropathies during Dalton, personal communication). By the AIDS related complex stage was less September 1989 there were 1765 HIV posi- than 1%; none were seen in asympto- tive patients, of whom 778 had AIDS related matic HIV seropositive patients. complex and 297 had AIDS. Of the HIV pos- itive patients, 83% were homosexual or bisex- (3 Neurol Neurosurg Psychiatry 1993;56:372-38 1) ual, 4-4% were drug misusers, and 2 5% were heterosexual and did not misuse drugs. For http://jnnp.bmj.com/ 10% the risk factors were unknown. There A variety of peripheral nerve syndromes have were no haemophilics. Between September been described at different stages of HIV 1988 and 1 September 1989, 105 patients infection, from seroconversion to AIDS. died with AIDS in this population. Most described are case reports or small Patients were assessed with a standardised selected series which do not estimate the inci- neurological examination. The five found to dence. A large prospective study of HIV have bilateral upper motor neuron signs at on October 1, 2021 by guest. Protected copyright. positive patients found that peripheral neuro- presentation of peripheral neuropathy will be pathies were rare', and a cross sectional study considered separately to allow the clinical fea- of 40 hospitalised patients with AIDS found tures of the neuropathy to be studied in isola- Department of that 33% had peripheral neuropathies.2 We tion. The following HIV related and Neurology, report the nature and frequency of Westminster Hospital, peripheral nutritional data were collected in a standard- London nerve syndromes seen during a 15 month ised way: duration of AIDS, previous HIV G N Fuller prospective, population based, referral series related infections (using CDC criteria4), CD4 R J Guiloff from a population of about 1500 HIV posi- count (ACSCAN TM, Becton Dickinson), Department of tive patients3 and discuss the findings in rela- body mass index (weight divided bv height Neuropathology, Institute of Neurology, tion to current classifications of peripheral squared), serum B- 12 concentration (DICO- Queen Square, nerve syndromes. PAC radioimmunoassays; normal range London 210-900 pg/ml), and serum albumin concen- J M Jacobs tration. The same data were collected for the Correspondence to: R J Guiloff, Department of Methods neurologically asymptomatic AIDS controls Neurology, Westminster and PATIENTS and the series of sequential patients wvith Chelsea Hospital, 369 Fulham Road, London Patients were included if they had been AIDS admitted to hospital (see below). SW10 9NH, UK referred to the neurology department with Patients were classified according to the Received 4 Februarv 1992 peripheral nerve syndromes between 1 stage of the disease and the pattern of the and in revised form 19 June 1992. September 1988 and 31 December 1989 peripheral nerve syndrome (distal symmetri- Accepted 6 August 1992. from the population of HIV infected patients cal peripheral neuropathv, mononeuritis mul- Natzure anid itncidenice ofperipheral nerve syndronies in HIV infection 373 tiplex, polyradiculopathy, or mononeuro- STATISTICS pathy). The distal symmetrical peripheral Normally distributed variables were com- J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.4.372 on 1 April 1993. Downloaded from neuropathies were distinguished as those with pared by using one sample Student's t test. pain and those without. Pain was defined as Non-normally distributed variables were an unpleasant sensory experience subjectively compared by using the Mann-Whitney U recognised by the patient and mentioned in test. Proportions were compared by using the the history. No formal pain scale was used. two tailed Fisher's exact test. All statistics This distinction is further considered in the were performed with the Statgraphics statisti- discussion. cal package (STSC Plusware, 1987). Standardised electrophysiological studies and pathological studies of the sural nerve were performed using previously described Results methods. Fifty four patients with peripheral nerve syn- dromes were seen. All were male. Thirty eight CONTROL GROUPS had distal symmetrical peripheral neuro- Neurologically asymptomatic AIDS patients- pathies; 25 (66%) of these were painful, 13 Patients with AIDS but without signs or painless. Eleven patients had mononeu- symptoms of peripheral neuropathy were ropathies, three had mononeuritis multiplex, assessed clinically (n = 30) and were studied and two had lumbosacral polyradiculopathy. electrophysiologically (n = 30) and pathologi- Table 1 gives the HIV and nutritional vari- cally (n = 5). Data related to HIV and nutri- ables for the control groups and for the tion were noted as described above. The patients with distal symmetrical peripheral group has previously been described in neuropathies. detail;7 and it provided electrophysiological and pathological control data (see table 4). PAINIFUL PERIPHERAL NEUROPATHIES Patients with AIDS admitted to hospital Twelve of 25 patients with painful peripheral sequentially (n = 30) were assessed separately neuropathies (PPN) were reported on previ- and the standardised HIV related data were ously.8 The variables related to HIV infection collected. This data has been published previ- and nutrition are given in table 1 and the pre- ously.8 Sequential patients, with or without ceding infections in table 2. The duration of neuropathies, were recruited to determine the AIDS, CD4 count, body mass index, albu- frequency of different opportunistic infections min concentration and percentage of patients in patients with AIDS from the population with abnormal vitamin B,2 did not differ from under study, unselected in relation to their those in the control groups. Five patients had neurological symptoms (see tables 1 and 2). clinical evidence of an associated myelopathy. Sudden death controls-The sural nerves from eight patients (mean age 42 (range Clinicalfeatures 21-58) years) without risk factors for HIV Pain was the most prominent symptom, com- infection and without history of peripheral monly described as burning (10/20) or neuropathy, all of whom died suddenly, were intense pins and needles (9/20). Two patients examined morphometrically and used as con- referred to it as frostbite and one as having trols for pathological data. They have been the soles of his feet beaten with bamboo described previously.57 sticks. Four patients with painful dysaesthesia http://jnnp.bmj.com/ Normal controls-Nerve conduction studies also had shooting pains to the feet. The pain have been carried out on 23 healthy men age was almost always made worse by contact matched (mean 31-2 (21-45) years) with the (19/20), often by as little as the weight of the neurologically asymptomatic AIDS patients; sheets on the bed. Most patients had to stop the results (see table 4) have been published wearing their normal shoes and usually had to previously.7 resort to slippers. One patient became wheel- on October 1, 2021 by guest. Protected copyright. Table I HIV infection and nutrition in patients with peripheral neuropathies and controls with AIDS Controls with AIDS Patients wuith Sequential Neurologically Patiehts with PPN admissions asymptomatic OPN (?u = 25) (n = 30) (n = 30) (n = 13) Mean(SD) age (years) 36 (6 5) 40 (9-4) 37 (9-1) 41 (7 3) HIV infection: Median (interquartile range) duration of AIDS 11-0 (3-17) 14-0 (3-23) 11-5 (3-20) 12-5 (3-24) Median (interquartile range) CD4 count (Oil) 4-0 (7-21) 18-5 (10-40) 20-5 (10-68) 12-0 (6-25) Nutritional indicators Mean(SD) body Mass Index 19-3* (2-8) 19 9** (2-1) 17-3 (2-5) (kg/m2; normal range 21-3-29-0) Mean(SD) albumin concentration 34 (5-6) 34 (5 9) 35 (5-4) (g/l; normal range 35-45 g/l) % of patients with abnormal 8-3 24 4 (31) serum B-12 PPN = painful peripheral neuropathy; OPN = other (non-painful) peripheral neuropathy.
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