Progressive polyradiculopathy is a rare, rapidly progressive condition that may resemble cauda equina syndrome. It can be seen in advanced HIV/AIDS, often associated with CMV infection. MRI is crucial to rule out a lesion compressing the cauda equina as well as to evaluate for the presence of lumbosacral nerve root enhancement. Cerebrospinal fluid testing most commonly reveals lymphocytic pleocytosis and positive CMV polymerase chain reaction. Early diagnosis and anti-viral treatment is crucial in preventing root necrosis and irreversible damage.
Mononeuritis multiplex presents as asymmetric, multifocal peripheral neuropathies affecting both motor and sensory modalities. Deep, aching pain or allodynia in affected regions is commonly described. Early on in the course of HIV, mononeuritis multiplex is typically an immune-mediated, self-limiting process. Opportunistic infections including CMV can be the cause in advanced HIV/AIDS and have a worse prognosis. Vasculitis is another possibility, which can be associated with HIV or coinfection with hepatitis C.
HIV infection is associated with a number of myopathies, although the mechanism by which HIV leads to muscle inflammation is not well understood. HIV-associated myopathy is the most common myopathy in these patients, typically presenting with a slowly progressive, symmetrical muscle pain and weakness affecting primarily proximal muscles. Laboratory results include elevated CK level, electrodiagnostic evidence of irritative myopathy and muscle biopsy revealing myofiber degeneration, often associated with inflammatory infiltrates. Although treatment guidelines have not been well established, immunomodulatory therapies including corticosteroids and IVIG have been successfully used.4 A similar condition, has been described in the setting of immune reconstitution inflammatory syndrome.
Additional inflammatory myopathies including dermatomyositis and inclusion body myositis has also been described.4 Furthermore, myopathy can be a rare adverse effect of zidovudine therapy. Infectious myopathies due to opportunistic infections such as Staphylococcus aureus can also occur.
Treatment of neuropathic pain
Pain, estimated to affect between 20% to 90% of HIV-infected individuals, is one of the most significant causes of disability in the HIV/AIDS population.5-7 Categorizing pain into two categories, nociceptive and neuropathic, is helpful in determining the appropriate treatment plan (Figure). Neuropathic pain results from abnormal neural transmission following an initial injury to the peripheral or CNS, which persists even in the absence of additional damaging stimuli. Aberrant reorganization of neural tissues after the initial injury can result in ongoing, abnormal signaling and chronic, neuropathic pain.
Pharmacologic therapy is the mainstay of treating neuropathic pain. Because of the lack of HIV-specific guidelines, current recommendations are based on those for other forms of peripheral neuropathy including diabetic neuropathy and post-herpetic neuralgia.
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