Page 323 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 5 of 6 Original Research

pleocytosis as seen in our cohort, which may reflect HIV showed spontaneous recovery before corticosteroid therapy.
viral replication in the CSF space rather than immunological However, it is likely that ART-induced immune reconstitution
changes that occur with the subacute motor lumbosacral may have prevented relapses as all patients on ART at
radiculopathy. 17,18 The axonal variant of GBS, associated with 18 months follow-up had CD4 counts above 350 cells/µL.
a high rate of preceding Campylobacter jejuni infection, may
19
present as a pure motor axonopathy. Our patients may meet Since the South African government’s rollout programme in
19
some of the criteria for a ‘variant GBS’. Benatar et al. 2017 which commenced all HIV-infected patients on ART at
described four patients with similar clinical findings. They the time of diagnosis irrespective of CD4 counts, we rarely
described these patients as a possible variant of GBS or a encounter the above group of patients. This further supports
distinct clinical entity. However, the unusual features include an immune basis for the disease which may improve with
8
duration of progression, limitation of signs to the lower changes in tolerance.
limbs, CSF pleocytosis and response to corticosteroid therapy,
which is known not to be of benefit in GBS. 20,21 Limitations of this study include retrospective design, small
patient numbers and lack of a control arm.
The above cohort may therefore be consistent with a proximal
motor variant of CIDP involving demyelination of the Conclusion
ventral roots rather than GBS. Evidence for the above
includes prolonged or absent F responses with normal Studies are required to understand the pathogenesis of this
DMLs, neurogenic changes in the paraspinals, ventral root disease in order to identify the possible antigenic targets.
gadolinium enhancement on MRI, raised CSF protein and This may help refine therapy in HIV-uninfected patients
rapid response to corticosteroid therapy with no relapses. with pure immune-mediated motor polyradiculopathy, for
Denervation on needle EMG may suggest secondary axonal example paraneoplastic and other immune ventral root
loss. Moodley et al. described CIDP in the setting of HIV. In radiculopathies. 5,6,7,26,27,28
that particular cohort of patients, demyelination was distal
rather than proximal, patients had sensory and motor Acknowledgements
symptoms rather than exclusively motor manifestations, and Competing interests
both upper and lower limbs were involved. 22,23
The authors declare that they have no financial or personal
The rapid response to corticosteroid therapy and the relationships that may have inappropriately influenced them
predilection for ventral roots may suggest an antibody- in writing this article.
mediated process that targets the ventral roots only. The
production of these antibodies may be a transient Authors’ contributions
phenomenon during the course of HIV infection as none of
the patients relapsed during the 18-month follow-up despite K.M. developed the study concept, collected and analysed
stopping corticosteroid therapy for 6 months or less. We the data, and wrote the manuscript. V.B.P.M. developed the
hypothesise that immune reconstitution with ART may concepts and helped with planning analysis and review of
have prevented relapses by induction of tolerance, by the manuscript. P.L.A.B. was responsible for the review of the
increasing the number of functional T regulatory cells and manuscript.
hence maintaining remission. Some diseases associated
with HIV may recover with immune reconstitution, for Funding
example HIV-associated CIDP, HIV-associated motor
neuron syndrome or even myasthenia gravis, despite there This research received no specific grant from any funding
being insufficient literature to support the above. 22,24 agency in the public, commercial or not-for-profit sectors.
Therefore, variable or unexpected patterns can occur in HIV
immune reconstitution, with exacerbation of some diseases Data availability statement
and improvement of others. Data sharing is not applicable to this article as no new data
were created or analysed in this study.
The wide range of CD4 counts may also support an immune-
mediated process, which is independent of the stage of HIV.
The high CD4 counts in some patients were not explained by Disclaimer
concomitant DILS as the patients had no clinical features of The views and opinions expressed in this article are
DILS. 1,25 those of the authors and do not necessarily reflect the
official policy or position of any affiliated agency of the
Seven of the 11 patients were on ARTs at 18-month follow-up. authors.
However, only three patients started ART at 4 months
after presentation. These three patients had recovered prior References
to commencing ART on corticosteroid therapy alone. By
6 months all patients had recovered. Hence, the recovery was 1. Centner CM, Bateman KJ, Heckmann JM. Manifestations of HIV infection in the
peripheral nervous system. Lancet Neurol. 2013;12:295–309. https://doi.org/
likely induced by corticosteroid therapy as no patients 10.1016/S1474-4422(13)70002-4

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