Pain prevalence, characteristics and associated factors in human T-cell lymphotropic virus type 1 infected patients: a systematic review of the literature

Patient research priority setting partnership in human T-cell lymphotropic virus type I

INTRODUCTION

Human T-cell lymphotropic virus type 1 (HTLV-1) is a chronic infection affecting 5-10 million people worldwide. Ten percent develop HTLV-1-associated diseases, and 3%-5% develop HTLV-1-associated myelopathy (HAM)/tropical spastic paraparesis. Low health-related quality of life (HRQoL) is a significant concern for those with HTLV-1, and little is known about how it impacts daily life or what patients need from healthcare services. To address this, we report on patient involvement workshops aimed at identifying research priorities for HTLV-1 health service provision.

METHODS

Participants recruited through HTLV-1 clinics in England attended six 90-min virtual workshops over 10 months, and two 60-min consolidation workshops. Content developed iteratively from topic focussed group discussions. All workshops were video-recorded with consent, transcribed verbatim and thematically analysed. Using consensus voting rounds, participants individually ranked their top six and then collectively their top three research priorities from the themes inferred from the analysis. A final feedback session explored the experiences of participating in the workshops.

FINDINGS

Twenty-seven people with HTLV-1 engaged with the workshops with up to 22 participants attending each meeting. The majority were diagnosed with HAM (n = 22). The top three research priorities were identified as understanding disease progression, psychosocial wellbeing, and information and knowledge. Participants valued being asked to set research priorities that directly addressed their needs and enjoyed the workshops. They stressed the importance of patient advocates for promoting research that positively impacts everyday life.

CONCLUSION

This is the first of this type of research engagement with people with HTLV-1 in the United Kingdom. Participants identified several avenues of investigation that could lead to improvements in healthcare services and HRQoL. Participants believed the workshops signified the start of a conversation to progress person-centred and meaningful research in HTLV-1.

PATIENT OR PUBLIC CONTRIBUTION

People living with HTLV-1 were involved in the iterative design, conduct, analysis, writing and dissemination of this project through the patient involvement workshops. As a result of this engagement, a patient led advisory group has been set up to assist with the dissemination of the findings.

Impaired flexibility in patients with tropical spastic paraparesis/HTLV-associated myelopathy: evaluation via pendulum fleximeter

BACKGROUND

 Flexibility is crucial to the harmonious execution of joint movements. While skeletal muscle dysfunction in patients with HTLV-1 can interfere with mobility, it is unclear whether these patients experience reduced flexibility.

OBJECTIVE

 To evaluate the differences in flexibility between HTLV-1-infected individuals with and without myelopathy compared with uninfected controls. We also investigated whether age, sex, body mass index (BMI), physical activity level, or lower back pain influence flexibility in HTLV-1-infected individuals.

METHODS

 The sample consisted of 56 adults, of which 15 did not have HTLV-1, 15 had HTLV-1 without myelopathy, and 26 had TSP/HAM. Their flexibility was assessed using the sit-and-reach test and a pendulum fleximeter.

RESULTS

 No differences in flexibility were observed between the groups with and without myelopathy and controls without HTLV-1 infection using the sit-and-reach test. The pendulum fleximeter results of individuals with TSP/HAM presented the lowest flexibility among the groups with respect to trunk flexion, hip flexion and extension, knee flexion, and ankle dorsiflexion, even after adjusting for age, sex, BMI, level of physical activity, and lower back pain using multiple linear regression models. Additionally, HTLV-1-infected individuals without myelopathy demonstrated reduced flexibility in movements: knee flexion, dorsiflexion, and ankle plantar flexion.

CONCLUSIONS

 Individuals with TSP/HAM demonstrated reduced flexibility in most of the movements evaluated by the pendulum fleximeter. Additionally, HTLV-1-infected individuals without myelopathy demonstrated reduced knee and ankle flexibility, potentially representing a marker of myelopathic development.

High incidence of serious infections requiring hospitalisation in human T-cell leukaemia virus type 1-positive rheumatoid arthritis: A case-controlled observational study

OBJECTIVES

We aimed to assess the clinical features of human T-cell leukaemia virus type 1 (HTLV-1)-positive rheumatoid arthritis (RA) patients. Furthermore, we investigated the impact of HTLV-1 infection on incidences of serious infections requiring hospitalisation (SIH) and malignancies.

METHODS

A total of 150 sex- and age-matched HTLV-1-negative and 50 HTLV-1-positive RA patients were enrolled from the HTLV-1 RA Miyazaki Cohort Study. Clinical and laboratory data were collected from this cohort database. The incidence rate (IR) for SIH and malignancies from 2015 to 2020 was analysed.

RESULTS

The median age and female ratio in the study population were 70 years old and 80%, respectively. Although no differences were found in inflammatory marker values between the two groups, the patient global assessment and Health Assessment Questionnaire scores were higher in HTLV-1-positive RA patients. In HTLV-1-negative RA patients, the IR for SIH was 6.37/100 person-years (PY) and 1.32/100 PY for malignancies. In HTLV-1-positive RA patients, SIH occurred in 11.1/100 PY and malignancies in 2.46/100 PY. The crude IR ratio comparing SIH between two groups was 1.74 (95% confidence interval, 1.04-2.84), which was a significant increase.

CONCLUSIONS

HTLV-1-positive RA patients may worsen RA symptoms. HTLV-1 may be a risk factor for SIH.

Effect of HTLV-1 Infection on the Clinical Course of Patients with Rheumatoid Arthritis

Human T-cell leukemia virus type 1 (HTLV-1) is the causative agent of adult T-cell leukemia/lymphoma (ATL) and HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP). The effects of HTLV-1 on health are not fully elucidated. Epidemiological studies have shown that the prevalence of HTLV-1 infection is high in patients with rheumatic diseases. The prevalence of comorbidities, such as Sjögren’s syndrome and rheumatoid arthritis (RA), is higher in patients with HAM/TSP than the in general population. Studies have shown the effects of HTLV-1-infection on the clinical course of RA. Major questions on the association between HTLV-1 infection and RA: (1) Is it possible that HTLV-1 infection causes RA? (2) Do patients with RA who are infected with HTLV-1 have different clinical features? (3) Are immunosuppressants associated with an increased prevalence of HAM/TSP or ATL in RA patients with HTLV-1 infection? Is ATL an immunosuppressive therapy-associated lymphoproliferative disorder? No large-scale studies have investigated the incidence of ATL in patients with RA. However, several studies have reported the development of ATL in patients with RA who have HTLV-1 infection. This review aimed to shed light on the association between HTLV-1 infection and RA and summarize the unmet medical needs of RA patients with HTLV-1 infection.

Pain, psychoaffective symptoms, and quality of life in human T cell lymphotropic virus type 1 (HTLV-1): a cross-sectional study

The objective of this study is to describe the chronic pain characteristics in individuals infected with human T cell lymphotropic virus type 1 (HTLV-1) per subgroup (asymptomatic, oligosymptomatic, and HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP)) compared with controls with chronic pain without HTLV-1. This is a cross-sectional study investigating associations between pain profile, psychopathological symptoms, and quality of life. Individuals infected with HTLV-1 refer high-intensity pain compared with controls, with more severe characteristics being present in oligosymptomatic and HAM/TSP individuals. Oligosymptomatic individuals have a tendency of diffuse and frequent pain, mainly in the head/neck region and more depressive symptoms, resembling nociplastic pain. Neuropathic pain was localized in the lower limbs in all infected groups, worse in HAM/TSP individuals, and associated with a worse perception of quality of life. Pain was associated to higher levels of TNF-alpha and interferon-gamma. HTLV-1 pain is generally more severe when compared with other chronic pain syndromes, being present mainly in the lower limbs. Certain characteristics are typical, depending on the affected group. Oligosymptomatic and HAM/TSP individuals present more diffuse pain, with higher intensity and greater impact in quality of life. Increased levels of inflammatory cytokines are associated with HTLV-1-related pain.

Comparison of functioning and health-related quality of life among patients with HTLV-1, HIV, and HIV-HTLV-1-coinfection

INTRODUCTION:

Human immunodeficiency virus (HIV) and human T-cell leukemia virus-1 (HTLV-1) viruses are associated with a high global burden of disease, and coinfection is a frequently reported event. We aimed to compare the functioning and health-related quality of life (HRQoL) of patients infected with HTLV-1, HIV, and HIV-HTLV-1.

METHODS:

We conducted a cross-sectional study of patients older than 18 years who had an HTLV-1 infection (Group A), HIV infection (Group B), or HIV-HTLV-1 coinfection (Group C). The functioning profiles were evaluated using handgrip strength, Berg balance scale (BBS), timed “up and go” (TUG) test, and 5-m walk test (m/s). We used the World Health Organization Disability Assessment Schedule (WHODAS 2.0) questionnaire to measure disability. The HRQoL was evaluated using a 36-item short-form health survey. For data with parametric and non-parametric distribution, we used analysis of variance with Bonferroni correction and the Kruskal-Wallis test, followed by Dunn’s pairwise tests with Bonferroni correction.

RESULTS:

We enrolled 68 patients in Group A, 39 in Group B, and 29 in Group C. The scores for handgrip strength, BBS, TUG test, all the WHODAS domains, and HRQoL were poorer for Groups A and C than for Group B.

CONCLUSIONS:

Compared to patients with HIV infection, those with HIV-HTLV-1 coinfection and HTLV-1 infection had poor functioning and HRQoL scores. HTLV-1 infection was associated with reduced functioning and HRQoL in patients with a single HTLV-1 infection and HIV-HTLV-1 coinfection.

Potential for increased prevalence of neuropathic pain after the COVID-19 pandemic

Although coronavirus disease 2019 (COVID-19) most commonly manifests with acute respiratory symptoms, one very common symptom of COVID-19 is pain. As COVID-19 often causes peripheral or central neurological complications, it is anticipated that a number of the chronic pain complications of COVID-19 will be neuropathic. This review first examines the most common viral infections responsible for neurological complications including neuropathic pain. These encompass herpes zoster, HIV, poliovirus, enteroviruses, and several tropical viruses. Neurological complications of COVID-19 including in particular Guillain-Barré syndrome, myelitis, and stroke are reviewed with regards to their potential risk of chronic neuropathic pain. Prospective longitudinal cohorts of patients should be implemented to evaluate the exact risk of neuropathic pain after COVID-19.

Health state utility values in people living with HTLV-1 and in patients with HAM/TSP: The impact of a neglected disease on the quality of life

BACKGROUND

HTLV-1 is a neglected sexually transmitted infection despite being the cause of disabling neurological disease HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP). There is no treatment for this infection and public health policies are essential to reduce its transmission. However, there are no data to support adequate cost-effective analysis in this field. The aim of this study was to obtain health state utility values for individuals with HAM/TSP and HTLV-1 asymptomatic carriers (AC). The impact of both states on quality of life (QoL) is described and compared to other diseases.

METHODS

A cross-sectional observational study of 141 individuals infected with HTLV-1 (79 with HAM/TSP and 62 AC) from three Brazilian states (Rio de Janeiro, São Paulo and Alagoas) and from the United Kingdom. Participants completed a validated general health questionnaire (EQ-5D, Euroqol) from which country specific health state utility values are generated. Clinical and epidemiological data were collated.

PRINCIPAL FINDINGS

Health state utility value for HAM/TSP was 0.2991. QoL for 130 reported clinical conditions ranges from 0.35 to 0.847. 12% reported their quality of life as worse as death. Low QoL was associated with severity rather than duration of disease with a moderate inverse correlation between QoL and Osame's Motor Disability Score (-0.4933) Patients who are wheelchair dependent had lowest QoL whilst those still walking unaided had the highest. AC also reported impaired QoL (0.7121) compared to general population.

CONCLUSION

HTLV-1 and its associated neurological disease has a marked impact on QoL. This study provides robust data to support the development of cost-utility analysis of interventions for HTLV-1.

Effectiveness of virtual reality games for falls, postural oscillations, pain and quality of life of individual HAM/TSP: a randomized, controlled, clinical trial

People with HTLV-1 associated myelopathy or tropical spastic paraparesis (HAM/TSP) have sensorimotor losses and postural instability, resulting in frequent falls. These findings stimulate the use of exercise protocols associated with postural control. This study investigated the effectiveness of a balance training exercise protocol through a virtual game. This is a randomized crossover clinical trial performed in subjects with imbalance disorders (HAM/TSP). To evaluate postural oscillations by baropodometry (total area, anterior, posterior and lateral projection), the Footwork® system was used and by cinemetry (angle of the body, hip and ankle alignment in the lateral view), the CVMob system. In addition, the Brief Pain Inventory and the WHOQoL Bref were used to measure pain intensity and quality of life. Comparison tests of the averages (intra and inter groups) and correlations were applied considering an alpha of 5% and power of 80%. The study was approved by the Ethics Committee of the Catholic University of Salvador and registered in the Clinical Trials database (NCT02877030). The final sample consisted of 26, predominantly female subjects. An increase in the postural oscillations of the control subjects (p < 0.05), a reduction in the occurrence of falls (p = 0.039) and an improvement in the quality of life of the control-test group (p < 0.05) were observed. Virtual game training did not improve the static balance, promoting an increase in postural oscillations. Immediately after the application of the protocol, there was a reduction in fall occurrence and improvement in the quality of life.

Latin American and Caribbean consensus on noninvasive central nervous system neuromodulation for chronic pain management (LAC2-NIN-CP)

Supplemental Digital Content is Available in the Text.

Introduction:

Chronic pain (CP) is highly prevalent and generally undertreated health condition. Noninvasive brain stimulation may contribute to decrease pain intensity and influence other aspects related to CP.

Objective:

To provide consensus-based recommendations for the use of noninvasive brain stimulation in clinical practice.

Methods:

Systematic review of the literature searching for randomized clinical trials followed by consensus panel. Recommendations also involved a cost-estimation study.

Results:

The systematic review wielded 24 transcranial direct current stimulation (tDCS) and 22 repetitive transcranial magnetic stimulation (rTMS) studies. The following recommendations were provided: (1) Level A for anodal tDCS over the primary motor cortex (M1) in fibromyalgia, and level B for peripheral neuropathic pain, abdominal pain, and migraine; bifrontal (F3/F4) tDCS and M1 high-definition (HD)-tDCS for fibromyalgia; Oz/Cz tDCS for migraine and for secondary benefits such as improvement in quality of life, decrease in anxiety, and increase in pressure pain threshold; (2) level A recommendation for high-frequency (HF) rTMS over M1 for fibromyalgia and neuropathic pain, and level B for myofascial or musculoskeletal pain, complex regional pain syndrome, and migraine; (3) level A recommendation against the use of anodal M1 tDCS for low back pain; and (4) level B recommendation against the use of HF rTMS over the left dorsolateral prefrontal cortex in the control of pain.

Conclusion:

Transcranial DCS and rTMS are recommended techniques to be used in the control of CP conditions, with low to moderate analgesic effects, and no severe adverse events. These recommendations are based on a systematic review of the literature and a consensus made by experts in the field. Readers should use it as part of the resources available to decision-making.

Identification of the key genes associated with neuropathic pain

Neuropathic pain is a chronic pain state associated with multiple etiologies that results in considerable social and economic burden. The identification of key genes associated with neuropathic pain is important for the development of novel therapies. Therefore, the present study downloaded the gene expression profile GSE15041 from the Gene Expression Omnibus database. The unverified gene chip was removed and the microarray data was normalized following quality control. The limma package in R was used to screen the differentially expressed genes (DEGs), followed by Gene Ontology and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis. Furthermore, a protein‑protein interaction (PPI) network based on the identified DEGs was constructed to select hub proteins, and reverse transcription‑quantitative polymerase chain reaction was performed to detect the expression of these proteins in a mouse model of neuropathic pain. In total, 86 common DEGs were identified. DEGs were significantly enriched in ̔extracellular space̓ and KEGG pathway enrichment analysis demonstrated that the DEGs were significantly enriched in inflammatory diseases and the mitogen‑activated protein kinase signaling pathway. The PPI network consisted of 27 nodes (proteins) and 47 PPI edges (interactions). Interleukin (IL)‑6, transcription factor AP‑1 (c‑Jun) and urikinase‑type plasminogen activator (Plau) were identified as hub proteins and key genes in neuropathic pain. The mRNA expression of these hub proteins was significantly increased in the neuropathic pain model, compared with the sham group. IL‑6, c‑Jun, and Plau may be involved in development of neuropathic pain and further research investigating the exact role of these key genes is required.