Page 320 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 2 of 6 Original Research

The inclusion criteria for patient selection were as follows: limbs. Sensory testing for all modalities was normal and
HIV-infected patients older than 18 years with lower motor sphincters were normal.
neuron weakness involving exclusively the lower limbs,
normal sensation, preserved sensory nerve action potentials CD4 counts are listed in Table 1 (median CD4 count of
(SNAPs) and lumbosacral root enhancement on magnetic 327 cells/µL, IQR 146–457). None of the patients were on
resonance imaging (MRI). Exclusion criteria were as follows: antiretroviral therapy (ART) at the time of diagnosis. However,
abnormal sensation on clinical examination, upper limb or all patients were referred to ART clinics for monitoring or
truncal involvement, upper motor neuron signs, sensory initiation of ARTs according to the South African ART
nerve action potential on nerve conduction studies that were guidelines applicable during the study period. Blood
less than 70% of normal values, compressive or intra-spinal investigations, which included routine tests such as full
lesions accounting for the weakness, polyradiculopathies blood count, urea and electrolytes, autoimmune screen (anti-
due to infective, malignant or paraneoplastic aetiology, nuclear factor, anti-neutrophil cytoplasmic antibodies),
clinical features of DILS or raised creatinine kinase levels paraneoplastic antibodies, creatinine kinase, rapid plasma
with electrophysiological or histological features of a reagin test, vitamin B12 and folate, glucose and serum protein
myopathy, and electrolyte abnormalities, for example electrophoresis, did not reveal any abnormalities.
hypokalaemia accounting for weakness and areflexia.
The CSF median polymorphocyte count and lymphocyte
Data extracted from patient records included clinical count were 0 cells/µL (IQR 0–2) and 16 cells/µL
findings, laboratory results, electrodiagnostic findings (IQR 1 cells/µL – 18 cells/µL), respectively. The CSF median
(nerve conduction and needle electromyography), MRI of glucose and protein was 3.1 mmol/L (IQR 2.8 mmol/L –
the thoracolumbar and lumbosacral spine, duration of 3.4 mmol/L) and 1.02 g/dL (IQR 0.98 g/dL – 3.4 g/dL),
therapy and response to therapy. respectively (Table 1). The CSF tested negative for viruses
(CMV, HSV, HTLV1, EBV and VZV), TB, syphilis and
Tests that were conducted to exclude infective or neoplastic cryptococcus. CSF cytology was negative. Five patients had
causes of a polyradiculopathy included CSF polymerase negative antiganglioside antibodies, which were not tested
chain reaction (PCR) for VZV, CMV, HSV, EBV; CSF Ziehl– for in the other six patients.
Neelson (ZN) stain, culture and gene expert for TB; CSF
Venereal Disease Research Laboratory (VDRL), fluorescent Motor and sensory electrophysiological tests are listed in
treponemal antibody absorption (FTA-ABS) for syphilis; Tables 2 and 3, respectively. Normal values for IALCH
CSF cytology for malignancy (lymphoma); CSF cryptoccocal electrophysiology laboratory are listed in Table 4. The
antigen, India ink stain and cryptococcal culture; chest compound muscle action potential (CMAP) of the tibial and
radiograph for pulmonary tuberculosis (TB), CSF cytology, peroneal nerves were reduced in amplitude, with median
paraneoplastic antibodies and MRI spine for structural and CMAP of 3.6 mV (IQR 2.2–4.2) and 3.5 mV (IQR 2.6–4.2),
inflammatory and/or infective lesions. respectively. The distal motor latency (DML) and conduction
velocity (CV) were within the normal range for both the tibial
Patients were followed up and scored according to the and peroneal nerves. The F responses were either absent or
Modified Rankin Scale (mRS) to assess for relapses and prolonged, with median 62 ms (IQR 59–70.5) and 68 ms
response to therapy at 3-month intervals for 6 months and (IQR 64–70) for the peroneal and tibial nerves, respectively,
thereafter 6 monthly up to 18 months. compared to the respective F estimates of 53 ms (IQR 50–55)
and 54 ms (IQR 52–55). There were no conduction blocks
Ethical considerations or temporal dispersion. The sural and superficial peroneal
SNAPs were present in all patients, although amplitudes
This article followed all ethical standards for research without were marginally reduced, most likely because of coexistent
direct contact with human or animal subjects. HIV peripheral neuropathy. The median sural and superficial
peroneal SNAP was 12.5 µV (IQR 10–13) and 6.5 µV
Results (IQR 5.7–7.1), respectively, which is greater than 80% the
Clinical features, cerebrospinal fluid, expected lower limit of normal (Table 4). The peak sensory
electrophysiological and magnetic latencies for both nerves were normal: median 4.1 ms
(IQR 3.9–4.2) and 3.1 ms (IQR 2.27–3.3) for the sural and
resonance imaging findings
superficial peroneal, respectively. The upper limb motor and
Eleven patients met the inclusion criteria. There were six sensory nerve conduction tests were performed in 7 of the
women. The median age was 29 years (interquartile range 11 patients (63%) and were normal (Tables 2 and 3).
[IQR] 23–41 years). All patients were of black African
ancestry. The mean duration of symptom progression Needle electromyography (EMG) findings are listed in Table 5.
(continuous and not stepwise) was 6.5 months (IQR 3–7.5 Muscles examined included the lumbar paraspinals (lower
months). No patients had preceding flu-like illness, sensory and mid lumbar), gluteus medius, quadriceps, tibialis
complaints or upper limb symptoms. Examination revealed anterior and gastrocnemius. These muscles demonstrated
that they had flaccid, symmetrical areflexic paraparesis with neurogenic changes as evidenced by increased insertional
normal assessment of mental state, cranial nerves and upper activity, positive sharp waves, fibrillation potentials, and

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