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Weng YW, Lee SSJ, Tsai HC, Hsu CH, Lin SH. Prediction of incidence of neurological disorders in HIV-infected persons in Taiwan: a nested case-control study. BMC Infect Dis 2023; 23:759. [PMID: 37924043 PMCID: PMC10625280 DOI: 10.1186/s12879-023-08761-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/27/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Neurological disorders are still prevalent in HIV-infected people. We aimed to determine the prevalence of neurological disorders and identify their risk factors in HIV-infected persons in Taiwan. METHODS We identified 30,101 HIV-infected people between 2002 and 2016 from the National Health Insurance Research Database in Taiwan, and analyzed the incidence of neurological disorders. We applied a retrospective, nested case-control study design. The individuals with (case group) and without (control group) a neurological disorder were then matched by age, sex and time. Factors associated with neurological disorders were analyzed using a conditional logistic regression model, and a nomogram was generated to estimate the risk of developing a neurological disorder. RESULTS The incidence of neurological disorders was 13.67 per 1000 person-years. The incidence remained stable during the observation period despite the use of early treatment and more tolerable modern anti-retroviral therapy. The conditional logistic regression model identified nine clinical factors and comorbidities that were associated with neurological disorders, namely age, substance use, traumatic brain injury, psychiatric illness, HIV-associated opportunistic infections, frequency of emergency department visits, cART adherence, urbanization, and monthly income. These factors were used to establish the nomogram. CONCLUSION Neurological disorders are still prevalent in HIV-infected people in Taiwan. To efficiently identify those at risk, we established a nomogram with nine risk factors. This nomogram could prompt clinicians to initiate further evaluations and management of neurological disorders in this population.
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Affiliation(s)
- Ya-Wei Weng
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Infectious Disease, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Susan Shin-Jung Lee
- Division of Infectious Disease, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Hung-Chin Tsai
- Division of Infectious Disease, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Chih-Hui Hsu
- Biostatistics Consulting Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Sheng-Hsiang Lin
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
- Biostatistics Consulting Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Abstract
PURPOSE OF REVIEW This article reviews the neurologic complications associated with human immunodeficiency virus (HIV) infection. RECENT FINDINGS Neurologic complications of HIV may be caused by direct virally mediated pathology, immune-mediated phenomena in response to viral infection, or opportunistic infections secondary to depletion of lymphocytes. These neurologic disorders may be influenced by the degree of immunosuppression (ie, CD4+ T-cell lymphocyte count) and stage of infection (early versus late), as well as use of antiretroviral therapy, and may manifest as a variety of central and peripheral neurologic syndromes, including the more commonly encountered HIV-associated cognitive disorders and length-dependent sensorimotor polyneuropathy, respectively. Immune dysregulation underlies the majority of these neurologic phenomena, as well as other HIV-associated conditions including immune reconstitution inflammatory syndrome (IRIS), CD8 lymphocytosis, and potentially the development of compartmentalized infection within the CSF, also referred to as CSF escape. SUMMARY This article reviews a spectrum of clinical syndromes and related neuropathologic states associated with HIV infection.
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Court R, Centner CM, Chirehwa M, Wiesner L, Denti P, de Vries N, Harding J, Gumbo T, Maartens G, McIlleron H. Neuropsychiatric toxicity and cycloserine concentrations during treatment for multidrug-resistant tuberculosis. Int J Infect Dis 2021; 105:688-694. [PMID: 33684562 PMCID: PMC8126338 DOI: 10.1016/j.ijid.2021.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/19/2021] [Accepted: 03/02/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Cycloserine, or its structural analogue terizidone, has been associated with neuropsychiatric toxicity (psychosis, depression, and neuropathy). Prospective clinical data on the incidence of and risk factors for neuropsychiatric toxicity in TB patients treated with cycloserine are limited. METHODS A prospective evaluation of neuropsychiatric toxicity was performed using validated screening tools in patients with multidrug-resistant tuberculosis treated with terizidone. Cox proportional hazard modelling was performed to explore the effects of clinical variables and measures of cycloserine pharmacokinetics in plasma. RESULTS A total 144 participants were recruited: 86 were male and 58 were female; their median age was 35.7 years and 91 (63%) were HIV-infected. Fifty-five (38%) participants developed at least one neuropsychiatric event (30 cases per 100 person-months): 50 (35%) neuropathy, 14 (10%) depression, and 11 (8%) psychosis. Neuropathy was independently associated with cycloserine clearance ((adjusted hazard ratio 0.34 (aHR), P = 0.03)) and high-dose pyridoxine (200 mg vs 150 mg daily, aHR: 2.79, P = 0.01). CONCLUSIONS A high incidence of early neuropsychiatric toxicity was observed in this cohort of patients treated with terizidone. Cycloserine clearance and higher doses of pyridoxine are associated with incident or worsening peripheral neuropathy.
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Affiliation(s)
- Richard Court
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - Chad M Centner
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa.
| | - Maxwell Chirehwa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | | | | | - Tawanda Gumbo
- Quantitative Preclinical and Clinical Sciences Department, Praedicare, Dallas, TX, USA.
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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4
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Yuan NY, Kaul M. Beneficial and Adverse Effects of cART Affect Neurocognitive Function in HIV-1 Infection: Balancing Viral Suppression against Neuronal Stress and Injury. J Neuroimmune Pharmacol 2021; 16:90-112. [PMID: 31385157 PMCID: PMC7233291 DOI: 10.1007/s11481-019-09868-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/23/2019] [Indexed: 02/07/2023]
Abstract
HIV-associated neurocognitive disorders (HAND) persist despite the successful introduction of combination antiretroviral therapy (cART). While insufficient concentration of certain antiretrovirals (ARV) may lead to incomplete viral suppression in the brain, many ARVs are found to cause neuropsychiatric adverse effects, indicating their penetration into the central nervous system (CNS). Several lines of evidence suggest shared critical roles of oxidative and endoplasmic reticulum stress, compromised neuronal energy homeostasis, and autophagy in the promotion of neuronal dysfunction associated with both HIV-1 infection and long-term cART or ARV use. As the lifespans of HIV patients are increased, unique challenges have surfaced. Longer lives convey prolonged exposure of the CNS to viral toxins, neurotoxic ARVs, polypharmacy with prescribed or illicit drug use, and age-related diseases. All of these factors can contribute to increased risks for the development of neuropsychiatric conditions and cognitive impairment, which can significantly impact patient well-being, cART adherence, and overall health outcome. Strategies to increase the penetration of cART into the brain to lower viral toxicity may detrimentally increase ARV neurotoxicity and neuropsychiatric adverse effects. As clinicians attempt to control peripheral viremia in an aging population of HIV-infected patients, they must navigate an increasingly complex myriad of comorbidities, pharmacogenetics, drug-drug interactions, and psychiatric and cognitive dysfunction. Here we review in comparison to the neuropathological effects of HIV-1 the available information on neuropsychiatric adverse effects and neurotoxicity of clinically used ARV and cART. It appears altogether that future cART aiming at controlling HIV-1 in the CNS and preventing HAND will require an intricate balancing act of suppressing viral replication while minimizing neurotoxicity, impairment of neurocognition, and neuropsychiatric adverse effects. Graphical abstract Schematic summary of the effects exerted on the brain and neurocognitive function by HIV-1 infection, comorbidities, psychostimulatory, illicit drugs, therapeutic drugs, such as antiretrovirals, the resulting polypharmacy and aging, as well as the potential interactions of all these factors.
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Affiliation(s)
- Nina Y Yuan
- School of Medicine, Division of Biomedical Sciences, University of California Riverside, 900 University Ave, Riverside, CA, 92521, USA
| | - Marcus Kaul
- School of Medicine, Division of Biomedical Sciences, University of California Riverside, 900 University Ave, Riverside, CA, 92521, USA.
- Sanford Burnham Prebys Medical Discovery Institute, Infectious and Inflammatory Disease Center, 10901 North Torrey Pines Road, La Jolla, CA, 92037, USA.
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5
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Basheer A, Kirubakaran R, Tan K, Vishnu VY, Fialho D. Disease-modifying therapy for HIV-related distal symmetrical polyneuropathy (including antiretroviral toxic neuropathy). Hippokratia 2020. [DOI: 10.1002/14651858.cd013716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Aneesh Basheer
- Department of Medicine; Pondicherry Institute of Medical Sciences; Pondicherry India
| | - Richard Kirubakaran
- Cochrane South Asia, Prof. BV Moses Centre for Evidence-Informed Healthcare and Health Policy; Christian Medical College; Vellore India
| | - Kevin Tan
- National Neuroscience Institute; Singapore Singapore
| | - Venugopalan Y Vishnu
- Department of Neurology; All India Institute of Medical Sciences; New Delhi India
| | - Doreen Fialho
- Department of Clinical Neurophysiology; King's College Hospital; London UK
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6
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Abstract
: Neurological conditions associated with HIV remain major contributors to morbidity and mortality and are increasingly recognized in the aging population on long-standing combination antiretroviral therapy (cART). Importantly, growing evidence shows that the central nervous system (CNS) may serve as a reservoir for viral replication, which has major implications for HIV eradication strategies. Although there has been major progress in the last decade in our understanding of the pathogenesis, burden, and impact of neurological conditions associated with HIV infection, significant scientific gaps remain. In many resource-limited settings, antiretrovirals considered second or third line in the United States, which carry substantial neurotoxicity, remain mainstays of treatment, and patients continue to present with severe immunosuppression and CNS opportunistic infections. Despite this, increased global access to cART has coincided with an aging HIV-positive population with cognitive sequelae, cerebrovascular disease, and peripheral neuropathy. Further neurological research in low-income and middle-income countries (LMICs) is needed to address the burden of neurological complications in HIV-positive patients, particularly regarding CNS viral reservoirs and their effects on eradication.
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7
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Abstract
Clinical neurophysiologic investigation of pain pathways in humans is based on specific techniques and approaches, since conventional methods of nerve conduction studies and somatosensory evoked potentials do not explore these pathways. The proposed techniques use various types of painful stimuli (thermal, laser, mechanical, or electrical) and various types of assessments (measurement of sensory thresholds, study of nerve fiber excitability, or recording of electromyographic reflexes or cortical potentials). The two main tests used in clinical practice are quantitative sensory testing and pain-related evoked potentials (PREPs). In particular, PREPs offer the possibility of an objective assessment of nociceptive pathways. Three types of PREPs can be distinguished depending on the type of stimulation used to evoke pain: laser-evoked potentials, contact heat evoked potentials, and intraepidermal electrical stimulation evoked potentials (IEEPs). These three techniques investigate both small-diameter peripheral nociceptive afferents (mainly Aδ nerve fibers) and spinothalamic tracts without theoretically being able to differentiate the level of lesion in the case of abnormal results. In routine clinical practice, PREP recording is a reliable method of investigation for objectifying the existence of a peripheral or central lesion or loss of function concerning the nociceptive pathways, but not the existence of pain. Other methods, such as nerve fiber excitability studies using microneurography, more directly reflect the activities of nociceptive axons in response to provoked pain, but without detecting or quantifying the presence of spontaneous pain. These methods are more often used in research or experimental study design. Thus, it should be kept in mind that most of the results of neurophysiologic investigation performed in clinical practice assess small fiber or spinothalamic tract lesions rather than the neuronal mechanisms directly at the origin of pain and they do not provide objective quantification of pain.
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Affiliation(s)
- Jean-Pascal Lefaucheur
- Excitabilité Nerveuse et Thérapeutique, Faculté de Médecine de Créteil, Université Paris-Est-Créteil, Hôpital Henri Mondor, Créteil, France; Service de Physiologie-Explorations Fonctionnelles, Hôpital Henri Mondor, Créteil, France.
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Detectable Plasma HIV RNA Is Associated With Sensory Neuropathy in Patients With HIV Treated Without Stavudine. J Acquir Immune Defic Syndr 2018; 79:e108-e110. [DOI: 10.1097/qai.0000000000001836] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bruce RD, Merlin J, Lum PJ, Ahmed E, Alexander C, Corbett AH, Foley K, Leonard K, Treisman GJ, Selwyn P. 2017 HIVMA of IDSA Clinical Practice Guideline for the Management of Chronic Pain in Patients Living With HIV. Clin Infect Dis 2018; 65:e1-e37. [PMID: 29020263 DOI: 10.1093/cid/cix636] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/19/2017] [Indexed: 12/27/2022] Open
Abstract
Pain has always been an important part of human immunodeficiency virus (HIV) disease and its experience for patients. In this guideline, we review the types of chronic pain commonly seen among persons living with HIV (PLWH) and review the limited evidence base for treatment of chronic noncancer pain in this population. We also review the management of chronic pain in special populations of PLWH, including persons with substance use and mental health disorders. Finally, a general review of possible pharmacokinetic interactions is included to assist the HIV clinician in the treatment of chronic pain in this population.It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The Infectious Diseases Society of American considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
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Affiliation(s)
- R Douglas Bruce
- Department of Medicine, Cornell Scott-Hill Health Center and Yale University, New Haven, Connecticut
| | - Jessica Merlin
- Divisions of Infectious Diseases and Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham
| | - Paula J Lum
- Division of HIV, Infectious Disease, and Global Medicine, University of California San Francisco
| | - Ebtesam Ahmed
- St. Johns University College of Pharmacy and Health Sciences, Metropolitan Jewish Health System Institute for Innovation in Palliative Care, New York
| | - Carla Alexander
- University of Maryland School of Medicine, Institute of Human Virology, Baltimore
| | - Amanda H Corbett
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Kathleen Foley
- Attending Neurologist Emeritus, Memorial Sloan Kettering Cancer Center, New York
| | - Kate Leonard
- Division of Neuroscience and Clinical Pharmacology, Cornell University, New York, New York
| | | | - Peter Selwyn
- Department of Family and Social Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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10
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Pillay P, Wadley AL, Cherry CL, Karstaedt AS, Kamerman PR. Psychological Factors Associated With Painful Versus Non-Painful HIV-Associated Sensory Neuropathy. AIDS Behav 2018; 22:1584-1595. [PMID: 28710709 DOI: 10.1007/s10461-017-1856-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
HIV-associated sensory neuropathy (HIV-SN) is a common, and frequently painful complication of HIV, but factors that determine the presence of pain are unresolved. We investigated: (i) if psychological factors associated with painful (n = 125) versus non-painful HIV-SN (n = 72), and (ii) if pain and psychological factors affected quality of life (QoL). We assessed anxiety and depression using the Hopkins Symptoms Checklist-25. Pain catastrophizing and QoL were assessed using the Pain Catastrophizing Scale and Euroqol-5D, respectively. Presence of neuropathy was detected using the Brief Neuropathy Screening Tool, and pain was characterised using the Wisconsin Brief Pain Questionnaire. Overall, there was a high burden of pain, depression and anxiety in the cohort. None of the psychological variables associated with having painful HIV-SN. Greater depressive symptoms and presence of pain were independently associated with lower QoL. In those participants with painful HIV-SN, greater depressive symptom scores were associated with increased pain intensity. In conclusion, in a cohort with high background levels of psychological dysfunction, psychological factors do not predict the presence of pain, but both depression and presence of pain are associated with poor quality of life.
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Affiliation(s)
- Prinisha Pillay
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, 7 York Rd, Parktown, Johannesburg, 2193, South Africa.
| | - Antonia L Wadley
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, 7 York Rd, Parktown, Johannesburg, 2193, South Africa
| | - Catherine L Cherry
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, 7 York Rd, Parktown, Johannesburg, 2193, South Africa
- International Clinical Research Laboratory, Centre for Biomedical Research, Burnet Institute, Melbourne, Australia
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
| | - Alan S Karstaedt
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, South Africa
| | - Peter R Kamerman
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, 7 York Rd, Parktown, Johannesburg, 2193, South Africa
- School of Biomedical Sciences, Faculty of Health Sciences, Curtin University, Perth, Australia
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Wright EJ, Thakur KT, Bearden D, Birbeck GL. Global developments in HIV neurology. HANDBOOK OF CLINICAL NEUROLOGY 2018; 152:265-287. [PMID: 29604981 DOI: 10.1016/b978-0-444-63849-6.00019-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Neurologic conditions associated with HIV remain major contributors to morbidity and mortality, and are increasingly recognized in the aging population on long-standing combination antiretroviral therapy (cART). Importantly, growing evidence suggests that the central nervous system (CNS) serves as a reservoir for viral replication with major implications for human immunodeficiency virus (HIV) eradication strategies. Though there has been major progress in the last decade in our understanding of the pathogenesis, burden, and impact of HIV-associated neurologic conditions, significant scientific gaps remain. In many low-income settings, second- and third-line cART regimens that carry substantial neurotoxicity remain treatment mainstays. Further, patients continue to present severely immunosuppressed with CNS opportunistic infections. Public health efforts should emphasize improvements in access and optimizing treatment of HIV-positive patients, specifically in resource-limited settings, to reduce the risk of neurologic sequelae.
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Affiliation(s)
- Edwina J Wright
- Department of Infectious Diseases, Alfred Health, Monash University, Melbourne, Australia; The Burnet Institute, Melbourne, Australia; Peter Doherty Institute for Infection and Immunity, Melbourne, Australia.
| | - Kiran T Thakur
- Division of Critical Care and Hospitalist Neurology, Columbia University Medical Center, New York, NY, United States
| | - David Bearden
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Gretchen L Birbeck
- Strong Epilepsy Center, Department of Neurology, University of Rochester, Rochester, NY, United States; Chikankata Epilepsy Care Team, Chikankata Hospital, Mazabuka, Zambia
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Abstract
PURPOSE OF REVIEW HIV-sensory neuropathy (HIV-SN) remains a common complication of HIV infection and may be associated with significant morbidity due to neuropathic pain. The overall purpose of this review is to discuss trends in the changing epidemiology in HIV-SN, new data regarding the pathophysiology of the condition, and discuss approaches to management. RECENT FINDINGS While HIV-SN has been historically considered the most common neurological complication of HIV infection, improved accessibility to effective combination antiretroviral therapy (cART), use of less neurotoxic antiretroviral medication regimens, and trends towards earlier introduction of treatment have impacted the condition: overall incident HIV-SN is likely decreased compared to prior rates and patients afflicted by HIV-SN may more frequently have asymptomatic or subclinical disease. Traditional predictors of HIV-SN have also changed, as traditional indices of severe immune deficiency such as low CD4 count and high viral load no longer predict HIV-SN. Emerging evidence supports the contention that both peripheral and central mechanisms underlying the generation as well as persistence of neuropathic pain in HIV-SN exist. It is important to recognize that even mild neuropathic pain in this clinical population is associated with meaningful impairment in quality of life and function, which emphasizes the clinical importance of recognizing and treating the condition. The general approach to management of neuropathic pain in HIV-SN is the introduction of symptomatic analgesic therapy. There exist, however, few evidence-based analgesic options for HIV-SN based on available clinical data. Symptomatic treatment trials are increasingly recognized to have been potentially confounded by more robust placebo response than that observed in other neuropathic pain conditions. In the authors' experience, use of analgesic therapies with proven efficacy in other neuropathic pain conditions is appropriate, bearing in consideration potential pharmacokinetic interactions with the cART regimen. Combination analgesic regimens may also achieve meaningful analgesic responses, particularly when drugs with differing mechanisms of action are utilized. It is paramount that the patient is appropriately counseled regarding expectations and the anticipated benefit of analgesic therapy, as pain relief is often incomplete but clinically meaningful improvement in pain and function can be achieved.
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Affiliation(s)
| | - Taylor B Harrison
- Department of Neurology, Emory University, Atlanta, GA, USA. .,Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, 80 Jesse Hill Jr., Drive Box 036, Atlanta, GA, 30303, USA.
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13
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Abstract
PURPOSE OF REVIEW Neurologic complications of human immunodeficiency virus (HIV) infection remain common, despite effective antiretroviral treatment (ART). Neurologic manifestations may be due to opportunistic infection, immune reconstitution, or the virus itself, posing diagnostic challenges for the neurologist. Neurologists are also asked to comment on the use of immunomodulatory agents in these patients and to manage long-term complications, such as neurocognitive disorders and peripheral neuropathy or the associated comorbidities. RECENT FINDINGS HIV enters the central nervous system (CNS) soon after infection and can cause atrophy of the brain within 3 months of infection. As patients are living longer, comorbidities such as stroke associated with metabolic syndrome, hepatitis C, and drug abuse are important contributory factors to the neurologic and neuropsychiatric manifestations of HIV infection. Immune-mediated syndromes are increasingly being recognized in patients with HIV infection on antiretroviral therapy. This includes a subacute T-cell-mediated encephalitis called CNS-immune reconstitution inflammatory syndrome, fulminant multiple sclerosis-like lesions, and unmasking of underlying opportunistic infections with profound inflammatory reaction. Our understanding of the most appropriate antiretrovirals for treating or preventing CNS HIV replication continues to improve. Major efforts are being made to understand how the CNS reservoirs are established and maintained, and new approaches are being developed to develop a functional cure or eradicate the virus. SUMMARY This article reviews the neurologic complications caused by HIV infection, associated comorbidities, or antiretroviral drugs that are commonly encountered by neurologists.
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Is HIV Painful? An Epidemiologic Study of the Prevalence and Risk Factors for Pain in HIV-infected Patients. Clin J Pain 2015; 31:813-819. [PMID: 25329144 DOI: 10.1097/ajp.0000000000000162] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the prevalence, impact, and risk factors for pain among a cohort of human immunodeficiency virus (HIV)-infected adults treated with combination antiretroviral therapy if indicated according to current guidelines. METHODS This was a cross-sectional epidemiological observational study. All patients attending 1 HIV-outpatient center in the United Kingdom in a 10-month period were eligible. Patients completed a validated questionnaire enquiring about demographics, HIV factors, and symptoms of pain. RESULTS Of 1050 eligible participants, 859 (82%) completed a questionnaire. The 1-month period prevalence of pain lasting >1 day was 62.8% among whom 63% reported current pain. The prevalence of pain at most anatomic sites was broadly similar to that observed in population studies using the same questionnaires except that we found considerably higher rates of foot/ankle pain. The median duration of pain was 3 years (range, 0 to 51 y) and the median pain score was 5.0 on an 11-point visual analogue score. Over 40% of people in pain had consulted their primary care physician and >20% were taking analgesics daily. Independent risk factors for current pain were older age (P=0.001), time since diagnosis of HIV infection (P=0.001), and receipt of a protease inhibitor-based regimen (P=0.04). DISCUSSION Pain, and notably foot/ankle pain, is common among adults living with prevalent HIV and is associated with substantial morbidity and health care utilization.
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Microglial content-dependent inhibitory effects of calcitonin gene-related peptide (CGRP) on murine retroviral infection of glial cells. J Neuroimmunol 2015; 279:64-70. [PMID: 25670002 PMCID: PMC4325278 DOI: 10.1016/j.jneuroim.2015.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 12/17/2014] [Accepted: 01/26/2015] [Indexed: 12/22/2022]
Abstract
C57BL/6 (B6) mice develop peripheral neuropathy post-LP-BM5 infection, a murine model of HIV-1 infection, along with the up-regulation of select spinal cord cytokines. We investigated if calcitonin gene-related peptide (CGRP) contributed to the development of peripheral neuropathy by stimulating glial responses. An increased expression of lumbar spinal cord CGRP was observed in vivo, post-LP-BM5 infection. Consequently, in vitro CGRP co-treatments led to a microglial content-dependent attenuation of viral loads in spinal cord mixed glia infected with selected doses of LP-BM5. This inhibition was neither caused by the loss of glia nor induced via the direct inhibition of LP-BM5 by CGRP.
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Peripheral neuropathy in primary HIV infection associates with systemic and central nervous system immune activation. J Acquir Immune Defic Syndr 2014; 66:303-10. [PMID: 24732871 DOI: 10.1097/qai.0000000000000167] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Peripheral neuropathy (PN) is a frequent complication of chronic HIV infection. We prospectively studied individuals with primary HIV infection (<1 year after transmission) to assess the presence of and laboratory associations with PN in this early stage. METHODS Standardized examination and analysis of blood and cerebrospinal fluid (CSF) was performed in participants with laboratory-confirmed primary HIV infection. PN was defined as ≥1 of the following unilateral or bilateral signs: decreased distal limb position, vibration, or temperature sense or hyporeflexia; symptomatic PN (SPN) was defined as the presence of these signs with symptoms. Analysis used nonparametric statistics. RESULTS Overall, 20 (35%) of 58 antiretroviral-naive male subjects without diabetes evaluated at a median of 107 days post HIV transmission met criteria for PN. Thirteen (65%) of 20 PN subjects met criteria for SPN; 6 (30%) of 20 had bilateral findings. PN subjects and no PN subjects (NPN) did not differ in median age, days post HIV transmission, blood CD4 or CD8 counts, CSF or plasma HIV RNA levels, CSF white blood cell counts, or CSF to blood albumin ratio. PN and SPN subjects had elevated CSF neopterin (P = 0.003 and P = 0.0005), CSF monocyte chemoattractant protein-1 (P = 0.006 and P = 0.01), and blood neopterin (P = 0.006 and P = 0.009) compared with NPN subjects. PN subjects had a higher percentage of activated phenotype CSF CD8 T lymphocytes than NPN subjects (P = 0.009). CONCLUSIONS Signs of PN were detected by detailed neurologic examination in 35% of men enrolled in a neurological study at a median of 3.5 months after HIV transmission. PN during this early period may be mediated by systemic and nervous system immune responses to HIV.
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Tumusiime DK, Musabeyezu E, Mutimurah E, Hoover DR, Shi Q, Rudakemwa E, Ndacyayisenga V, Dusingize JC, Sinayobye JD, Stewart A, Venter FWD, Anastos K. Over-reported peripheral neuropathy symptoms in a cohort of HIV infected and uninfected Rwandan women: the need for validated locally appropriate questionnaires. Afr Health Sci 2014; 14:460-7. [PMID: 25320598 DOI: 10.4314/ahs.v14i2.24] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Peripheral neuropathy symptoms (PNS) are commonly manifested in HIV-infected (HIV+) individuals, although data are limited on the prevalence and predictors of PNS in HIV+ patients from sub-Saharan Africa. OBJECTIVE To determine the prevalence and predictors of PNS in HIV+ and HIV-uninfected (HIV-) Rwandan women. METHODS Data were analysed from 936 (710 HIV+ and 226 HIV-) women from the Rwanda Women Interassociation Study and Assessment (RWISA), an observational prospective cohort study investigating the effectiveness and toxicity of ART in HIV+ women. RESULTS Of 936 enrolled, 920 (98.3%) were included in this analysis with 44% of HIV- and 52% of the HIV+ women reporting PNS (p=0.06). CD4+ count was not associated with PNS, although there was a non-significant trend towards higher prevalence in those with lower CD4+ counts. For the HIV- women, only alcohol and co-trimoxazole use were independently associated with PNS. WHO HIV stage IV illness and albumin ≤ 3.5 were associated with PNS in HIV+ women. CONCLUSIONS The rate of peripheral neuropathy symptoms reported in this cohort of HIV-infected African women seems implausible, and rather suggests that the screening tool for peripheral neuropathy in culturally diverse African settings be locally validated.
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Tumusiime D, Stewart A, Venter F, Musenge E. The reliability of the modified lower extremity functional scale among adults living with HIV on antiretroviral therapy, in Rwanda, Africa. SAHARA J 2014; 11:178-86. [PMID: 25383643 PMCID: PMC4272140 DOI: 10.1080/17290376.2014.976249] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Peripheral neuropathy (PN) is common among people living with HIV (PLHIV) on antiretroviral therapy (ART), and affects their daily functional ability and quality of life. Lower extremity functional ability, which is most commonly compromised in patients with PN, has not been clearly evaluated in an African setting, with regard to functional limitations. The lower extremity functional scale (LEFS) was originally developed and validated among elderly people in the USA, where the environment and activities of daily life are very different from those in Rwanda. The purpose of this study was to adapt and establish the reliability of LEFS, among adults living with HIV on ART, in a Rwandan environment. The study translated LEFS from English to Kinyarwanda, the local language spoken in Rwanda, the LEFS was then modified accordingly, and tested for test-retest reliability among 50 adult PLHIV on ART. An average Spearman rank order correlation coefficient, ρ ≥ 0.7, was considered optimal for reliability. Prior to the modification of the LEFS and in the initial testing of the translated LEFS, none of the activities was strongly correlated (ρ ≥ 0.8); most of the activities (90%, 18/20) were moderately correlated (ρ ≥ 0.5) and 10% (2/20) were weakly correlated (ρ ≤ 0.5). The ρ of most of the functional activities improved after modification by an expert group to ρ ≥ 0.7, establishing reliability and validity of LEFS among PLHIV on ART with lower extremity functional limitations, in this environment. In conclusion, this study demonstrated the importance of modifying and establishing test - retest reliability of tools derived from developed world contexts to local conditions in developing countries, such as in Rwanda. The modified LEFS in this study can be used in Rwanda by clinicians, specifically at ART clinics to screen and identify people with functional limitations at an early stage of the limitations, for treatment, rehabilitation and/or referral to appropriate health care services.
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Affiliation(s)
- D.K. Tumusiime
- PhD, is a Director of Research Centre and Acting Vice Dean of School of Health Sciences, College of Medicine and Health Sciences – University of Rwanda, Rwanda
| | - A. Stewart
- PhD, is an Associate Professor, Department of Physiotherapy, School of Therapeutic Sciences, University of Witwatersrand – Johannesburg, South Africa
| | - F.W.D. Venter
- MD, is a Deputy Executive Director, Witwatersrand Reproductive Health and HIV Institute (WRHI), Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - E. Musenge
- PhD, is a Biostatistician, Division of Biostatistics and Epidemiology, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Ruiz M, Armstrong M, Reske T, Cefalu C, Anwar D. Antiretroviral therapy at the end of life: the experience of an academic HIV clinic. Am J Hosp Palliat Care 2013; 31:475-9. [PMID: 23838449 DOI: 10.1177/1049909113494459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION There are no guidelines regarding the discontinuation of antiretroviral therapy at the end of life. METHODS We retrospectively reviewed our databases and identified patients with HIV/AIDS who died over the last 12 months in our HIV clinic. RESULTS A total of 41 patients from our HIV clinic died in a period of 12 months. Seventy-three percent of the patients were on antiretroviral therapy during the last clinic visit. During the last 3 months of life, 32% (13 of 41) were off antiretroviral therapy, with 77% (10 of 13) of them having intermittent therapy due to noncompliance. The remaining 23% (3 of 13) decided to stop antiretroviral therapy after discussion among families, patients, and providers. CONCLUSION Discussions among providers, patients, and families are encouraged to establish goals of care and role of antiretrovirals during the last months of life.
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Affiliation(s)
- Marco Ruiz
- Department of Medicine, Section of Geriatric Medicine, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA, USA
| | - Megan Armstrong
- Department of Psychology, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA, USA
| | - Tom Reske
- Department of Medicine, Section of Geriatric Medicine, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA, USA
| | - Charles Cefalu
- Department of Medicine, Section of Geriatric Medicine, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA, USA
| | - Dominique Anwar
- Department of Medicine, Tulane School of Medicine, New Orleans, LA, USA
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Kranick SM, Nath A. Neurologic complications of HIV-1 infection and its treatment in the era of antiretroviral therapy. Continuum (Minneap Minn) 2013; 18:1319-37. [PMID: 23221843 DOI: 10.1212/01.con.0000423849.24900.ec] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW Neurologic complications of HIV infection are unfortunately common, even in the era of effective antiretroviral treatment (ART). The consulting neurologist is often asked to distinguish among neurologic deterioration due to opportunistic infection (OI), immune reconstitution, or the effect of the virus itself, and to comment on the role of immunomodulatory agents in patients with HIV infection. Additionally, as successful virologic control has extended the life span of patients with HIV infection, neurologists are called upon to manage long-term complications, such as neurocognitive disorders and peripheral neuropathy. RECENT FINDINGS Despite the use of ART, significant numbers of patients continue to be affected by HIV-associated neurocognitive disorders, although with milder forms compared to the pre-ART era. Regimens of ART have been ranked according to CNS penetration and are being studied with regard to neuropsychological outcomes. Nucleoside analogs with the greatest potential for peripheral neurotoxicity are no longer considered first-line agents for HIV treatment. Efavirenz, a non-nucleoside reverse transcriptase inhibitor, has the greatest frequency of neurologic side effects among newer ART regimens. The spectrum of clinical manifestations of immune reconstitution inflammatory syndrome (IRIS) continues to grow, including IRIS without underlying OI. A greater understanding of pathophysiology and risk factors has shown that while HIV should be treated early to prevent severe immunocompromise, delayed initiation of ART may be helpful while treating OIs. SUMMARY This article reviews the neurologic complications of HIV infection, or its treatment, most commonly encountered by neurologists.
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Affiliation(s)
- Sarah M Kranick
- National Institutes of Health, Building 10, 6-5700, Bethesda, MD 20892, USA.
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Aloe L, Rocco ML, Bianchi P, Manni L. Nerve growth factor: from the early discoveries to the potential clinical use. J Transl Med 2012. [PMID: 23190582 PMCID: PMC3543237 DOI: 10.1186/1479-5876-10-239] [Citation(s) in RCA: 305] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The physiological role of the neurotrophin nerve growth factor (NGF) has been characterized, since its discovery in the 1950s, first in the sensory and autonomic nervous system, then in central nervous, endocrine and immune systems. NGF plays its trophic role both during development and in adulthood, ensuring the maintenance of phenotypic and functional characteristic of several populations of neurons as well as immune cells. From a translational standpoint, the action of NGF on cholinergic neurons of the basal forebrain and on sensory neurons in dorsal root ganglia first gained researcher's attention, in view of possible clinical use in Alzheimer's disease patients and in peripheral neuropathies respectively. The translational and clinical research on NGF have, since then, enlarged the spectrum of diseases that could benefit from NGF treatment, at the same time highlighting possible limitations in the use of the neurotrophin as a drug. In this review we give a comprehensive account for almost all of the clinical trials attempted until now by using NGF. A perspective on future development for translational research on NGF is also discussed, in view of recent proposals for innovative delivery strategies and/or for additional pathologies to be treated, such as ocular and skin diseases, gliomas, traumatic brain injuries, vascular and immune diseases.
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Affiliation(s)
- Luigi Aloe
- Cellular Biology and Neurobiology Institute, CNR, via del Fosso di Fiorano 64, 00143, Rome, Italy
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Abstract
The human immunodeficiency virus (HIV) epidemic, now entering its fourth decade, affects approximately 33 million people living in both developed and resource-limited countries. Neurological complications of the peripheral nervous system are common in HIV-infected patients, and neuromuscular pathology is associated with significant morbidity. Peripheral neuropathy is the most common neuromuscular manifestation observed in HIV/AIDS, and in the antiretroviral era, its prevalence has increased. The purpose of this review was to describe the clinical spectrum of neuromuscular disorders in the setting of HIV infection and to provide an approach to diagnosis and management.
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Cherry CL, Wadley AL, Kamerman PR. Painful HIV-associated sensory neuropathy. Pain Manag 2012; 2:543-52. [DOI: 10.2217/pmt.12.67] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
SUMMARY Painful HIV-associated sensory neuropathy (HIV-SN) is an early recognized neurological complication of HIV. The introduction of effective HIV treatments saw increased rates of HIV-SN, with some antiretrovirals (notably stavudine) being neurotoxic. Although neurotoxic antiretrovirals are being phased out, the available data suggest that incident HIV-SN will remain common, impairing quality of life, mobility and ability to work. Despite its major clinical importance, the pathogenesis and determinants of pain in HIV-SN are poorly understood, and effective prevention and analgesic strategies are lacking. Here, we review what is known about the rates and risk factors for painful HIV-SN, the laboratory models informing our understanding of neuropathic pain in HIV, and the future clinical and laboratory work needed to fully understand this debilitating condition and provide effective management strategies for those affected.
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Affiliation(s)
- Catherine Louise Cherry
- Infectious Diseases Unit, The Alfred Hospital, Centre for Virology, Burnet Institute; and Faculty of Medicine, Nursing & Health Sciences, Monash University, Commercial Road, Melbourne, Victoria 3004, Australia
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of Witwatersrand, South Africa
| | - Antonia L Wadley
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of Witwatersrand, South Africa
| | - Peter R Kamerman
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of Witwatersrand, South Africa
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Abstract
HIV-associated sensory neuropathy (HIV-SN) remains a common neurological complication of HIV infection despite the introduction of effective antiretroviral therapies. Exposure to neurotoxic antiretroviral drugs and increasing age have consistently been identified as risk factors for HIV-SN, while comorbid conditions with underlying predisposition to cause peripheral neuropathy (eg, diabetes mellitus, malnutrition, isoniazid exposure), ethnicity, and increasing height also have been implicated. Genetic association studies have identified genes affecting mitochondrial function and genes involved in the inflammatory response that modify the risk for HIV-SN among patients exposed to neurotoxic antiretrovirals. However, there is a lack of data on clinical, demographic, and genetic risk factors for HIV-SN in the modern era, with the rate of HIV-SN remaining unacceptably high despite the introduction of safer medications. Thus, more work is required to identify the principal factors that increase an individual's risk for HIV-SN so that effective preventative or therapeutic strategies can be implemented.
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Lehmann HC, Chen W, Borzan J, Mankowski JL, Höke A. Mitochondrial dysfunction in distal axons contributes to human immunodeficiency virus sensory neuropathy. Ann Neurol 2010; 69:100-10. [PMID: 21280080 DOI: 10.1002/ana.22150] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Revised: 06/13/2010] [Accepted: 07/02/2010] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Accumulation of mitochondrial DNA (mtDNA) damage has been associated with aging and abnormal oxidative metabolism. We hypothesized that in human immunodeficiency virus-associated sensory neuropathy (HIV-SN), damaged mtDNA accumulates in distal nerve segments, and that a spatial pattern of mitochondrial dysfunction contributes to the distal degeneration of sensory nerve fibers. METHODS We measured levels of common deletion mutations in mtDNA and expression levels of mitochondrial respiratory chain complexes of matched proximal and distal nerve specimens from patients with and without HIV-SN. In mitochondria isolated from peripheral nerves of simian immunodeficiency virus (SIV)-infected macaques, a model of HIV-SN, we measured mitochondrial function and generation of reactive oxygen species. RESULTS We identified increased levels of mtDNA common deletion mutation in postmortem sural nerves of patients with HIV-SN as compared to uninfected patients or HIV patients without sensory neuropathy. Furthermore, we found that common deletion mutation in mtDNA was more prevalent in distal sural nerves compared to dorsal root ganglia. In a primate model of HIV-SN, freshly isolated mitochondria from sural nerves of macaques infected with a neurovirulent strain of SIV showed impaired mitochondrial function compared to mitochondria from proximal nerve segments. INTERPRETATION Our findings suggest that mtDNA damage accumulates in distal mitochondria of long axons, especially in patients with HIV-SN, and that this may lead to reduced mitochondrial function in distal nerves relative to proximal segments. Although our findings are based on HIV-SN, if confirmed in other neuropathies, these observations could explain the length-dependent nature of most axonal peripheral neuropathies.
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Affiliation(s)
- Helmar C Lehmann
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
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Ellis RJ, Rosario D, Clifford DB, McArthur JC, Simpson D, Alexander T, Gelman BB, Vaida F, Collier A, Marra CM, Ances B, Atkinson JH, Dworkin RH, Morgello S, Grant I. Continued high prevalence and adverse clinical impact of human immunodeficiency virus-associated sensory neuropathy in the era of combination antiretroviral therapy: the CHARTER Study. ACTA ACUST UNITED AC 2010; 67:552-8. [PMID: 20457954 DOI: 10.1001/archneurol.2010.76] [Citation(s) in RCA: 238] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To provide updated estimates of the prevalence and clinical impact of human immunodeficiency virus-associated sensory neuropathy (HIV-SN) and neuropathic pain due to HIV-SN in the combination antiretroviral therapy (CART) era. DESIGN Prospective, cross-sectional analysis. Clinical correlates for HIV-SN and neuropathic pain, including age, exposure to CART, CD4 levels, plasma viral load, hepatitis C virus infection, and alcohol use disorders, were evaluated in univariate and multivariate models. SETTING Six US academic medical centers. PATIENTS One thousand five hundred thirty-nine HIV-infected individuals enrolled in the CNS (Central Nervous System) HIV Anti-Retroviral Therapy Effects Research study. MAIN OUTCOME MEASURES The presence of HIV-SN, defined by 1 or more clinical signs (diminished vibration or sharp sensation in the legs and feet; reduced ankle reflexes) in a distal, symmetrical pattern. Neuropathic pain was defined as aching, stabbing, or burning in a similar distribution. The effect on quality of life was assessed with the Medical Outcomes Study HIV Health Survey. RESULTS We found HIV-SN in 881 participants. Of these, 38.0% reported neuropathic pain. Neuropathic pain was significantly associated with disability in daily activities, unemployment, and reduced quality of life. Risk factors for HIV-SN after adjustment were advancing age (odds ratio, 2.1 [95% confidence interval, 1.8-2.5] per 10 years), lower CD4 nadir (1.2 [1.1-1.2] per 100-cell decrease), current CART use (1.6 [1.3-2.8]), and past "D-drug" use (specific dideoxynucleoside analogue antiretrovirals) (2.0 [1.3-2.6]). Risk factors for neuropathic pain were past D-drug use and higher CD4 nadir. CONCLUSIONS Neuropathic pain and HIV-SN remain prevalent, causing substantial disability and reduced quality of life even with successful CART. The clinical correlates of HIV-SN have changed with the evolution of treatment. These findings argue for redoubled efforts to determine HIV-SN pathogenesis and the development of symptomatic and neuroregenerative therapies.
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Affiliation(s)
- Ronald J Ellis
- HIV Neurobehavioral Research Center, Department of Neurosciences, University of California, San Diego, San Diego, CA 92103, USA.
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Quantitative Sensory Testing in Measurement of Neuropathic Pain Phenomena and Other Sensory Abnormalities. Clin J Pain 2009; 25:641-7. [DOI: 10.1097/ajp.0b013e3181a68c7e] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Viral load, clinical disease severity and cellular immune responses in primary varicella zoster virus infection in Sri Lanka. PLoS One 2008; 3:e3789. [PMID: 19023425 PMCID: PMC2582489 DOI: 10.1371/journal.pone.0003789] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2008] [Accepted: 10/22/2008] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In Sri Lanka, varicella zoster virus (VZV) is typically acquired during adulthood with significant associated disease morbidity and mortality. T cells are believed to be important in the control of VZV replication and in the prevention of reactivation. The relationship between viral load, disease severity and cellular immune responses in primary VZV infection has not been well studied. METHODOLOGY We used IFNgamma ELISpot assays and MHC class II tetramers based on VZV gE and IE63 epitopes, together with quantitative real time PCR assays to compare the frequency and phenotype of specific T cells with virological and clinical outcomes in 34 adult Sri Lankan individuals with primary VZV infection. PRINCIPAL FINDINGS Viral loads were found to be significantly higher in patients with moderate to severe infection compared to those with mild infection (p<0.001) and were significantly higher in those over 25 years of age (P<0.01). A significant inverse correlation was seen between the viral loads and the ex vivo IFNgamma ELISpot responses of patients (P<0.001, r = -0.85). VZV-specific CD4+ T cells expressed markers of intermediate differentiation and activation. CONCLUSIONS Overall, these data show that increased clinical severity in Sri Lankan adults with primary VZV infection associates with higher viral load and reduced viral specific T cell responses.
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Hung CF, Gibson SA, Letendre SL, Lonergan JT, Marquie-Beck JA, Vaida F, Ellis RJ. Impact of long-term treatment with neurotoxic dideoxynucleoside antiretrovirals: implications for clinical care in resource-limited settings. HIV Med 2008; 9:731-7. [PMID: 18651859 DOI: 10.1111/j.1468-1293.2008.00615.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES A minority of HIV-infected patients taking an antiretroviral (ARV) regimen containing dideoxynucleosides (d-drugs) such as stavudine (d4T) and didanosine (DDI) experiences dose-limiting neuropathic pain and paraesthesias, usually within weeks of starting these drugs. Because d-drugs are among the few affordable options available in developing countries, continuing d-drug therapy would be a desirable strategy for many HIV-infected individuals. Therefore, we evaluated the safety of continuing d-drug therapy. METHODS In a US cohort, we compared the rates of worsening neuropathic symptoms and signs in HIV-infected individuals on stable ARV regimens that did (n=252) or did not (n=250) include d-drugs. Rates of worsening were compared using proportional hazards model and the log-rank test. RESULTS The risk ratios (RR) were not significantly larger for worsening neuropathy signs [0.94; 95% confidence interval (CI) 0.84-1.07] or symptoms (0.99; 95% CI 0.88-1.14) in patients taking d-drugs continuously compared to those not taking d-drugs. CONCLUSIONS Continued d-drug exposure among patients tolerating an initial trial did not increase the risk of worsening neuropathy compared to non-d-drug-containing regimens. If applicable in developing countries, these findings suggest that in most patients d-drugs can be continued safely in the long term without increasing the risk of worsening neuropathy.
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Affiliation(s)
- C F Hung
- University of California, San Diego, CA, USA
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Initiation of antiretroviral therapy at CD4 cell counts >/=350 cells/mm3 does not increase incidence or risk of peripheral neuropathy, anemia, or renal insufficiency. J Acquir Immune Defic Syndr 2008; 47:27-35. [PMID: 17971714 DOI: 10.1097/qai.0b013e31815acacc] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND US guidelines recommend deferring initiation of highly active antiretroviral therapy (HAART) for most patients with CD4 counts >350 cells/mm in part because of concerns about antiretroviral toxicity. METHODS Incidence rates of peripheral neuropathy, anemia, and renal insufficiency in a cohort of 2165 patients followed more than 3 years (mean) were analyzed in multivariate Cox proportional hazards models by CD4 cell counts at initiation of HAART. A nested cohort of 895 patients restricted to study participants who did or did not start HAART within a CD4 cell count stratum were also compared. RESULTS Incidence and risks of all 3 comorbidities decreased with initiation of HAART at CD4 counts >200 cells/mm versus <200 cells/mm. Incidence and risks of renal insufficiency were similar with HAART initiation at CD4 counts >/=350 cells/mm versus 200 to 349 cells/mm, but risk of peripheral neuropathy and anemia were further decreased in persons starting HAART at a CD4 count >/=350 cells/mm. The incidence of these conditions was highest during the first 6 months of treatment at any CD4 cell count and declined up to 19-fold with further therapy. DISCUSSION Initiating HAART at CD4 cell counts >/=200 cells/mm reduced the incidence and risk of the 3 comorbid conditions and for anemia and peripheral neuropathy as well by starting at CD4 counts >/=350 cells/mm. The incidence of each condition decreased rapidly and remained low with increasing time on HAART.
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Abstract
Nucleoside analogue reverse transcriptase inhibitors (NRTIs), used as part of highly active antiretroviral therapy for the treatment of HIV and AIDS, disrupt neuronal mitochondrial DNA synthesis, resulting in antiretroviral toxic neuropathy (ATN). Acetyl-L-carnitine (ALC) enhances neurotrophic support of sensory neurons, potentially causing symptom relief and nerve regeneration, and in addition has numerous other effects on metabolic function that might be of benefit in such patients.ALC has been given to HIV patients with symptomatic ATN in a number of clinical studies administered either twice daily intramuscularly or as oral sachets or tablets. It has been shown to significantly reduce a variety of validated pain ratings, and is generally safe and well tolerated. Using a measure of neuronal innervation in standardised skin biopsies of the affected area, cutaneous nerve density has been improved by the administration of ALC in subjects with symptomatic ATN and reduced epidermal and dermal innervation, associated with clinical improvement, which was maintained over a 4-year period. Improvements were seen in both the structure and function of small sensory fibres, which were sustained over time whilst subjects received ALC. Other open-label, non-randomised studies have shown similar benefits in patients with ATN in terms of pain reduction over the short term. Further placebo-controlled studies of both treatment and prophylaxis have been completed and are under analysis to characterise further the usefulness of this pathogenesis-based therapy for ATN.
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Affiliation(s)
- Mike Youle
- Royal Free Centre for HIV Medicine, Royal Free Hospital, London, UK.
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Youle M, Osio M. A double-blind, parallel-group, placebo-controlled, multicentre study of acetyl l-carnitine in the symptomatic treatment of antiretroviral toxic neuropathy in patients with HIV-1 infection. HIV Med 2007; 8:241-50. [PMID: 17461852 DOI: 10.1111/j.1468-1293.2007.00467.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Nucleoside reverse transcriptase inhibitors (NRTIs) disrupt neuronal mitochondrial DNA synthesis, resulting in antiretroviral toxic neuropathy (ATN). Acetyl-L-carnitine (ALCAR) enhances neurotrophic support of sensory neurones, potentially providing symptom relief and nerve regeneration. OBJECTIVE The objective of the study was to assess the safety and efficacy compared to placebo of intramuscular ALCAR in HIV-positive patients with symptomatic distal symmetrical polyneuropathy. METHODS Ninety patients were enrolled and randomized to receive ALCAR [500 mg twice a day (bid); n=43] or placebo (n=47) intramuscularly twice daily for 14 days followed by 42 days of oral ALCAR 1000 mg bid. Assessment of pain was obtained using the Visual Analogue Scale (VAS), Total Symptom Score (TSS), Clinical Global Impression of Change, McGill Pain Questionnaire (MPQ), and the need for rescue analgesics. RESULTS There was no statistically significant difference in changes in VAS over 14 days between groups for the intent-to-treat (ITT) population, but for the efficacy-evaluable (EE) population ALCAR treatment produced a significantly greater reduction in pain compared with placebo (P=0.022). The proportion of patients with an improvement in TSS over 14 days was greater in the ALCAR group compared with the placebo group, but the differences were not statistically significant. During the open-label phase, patients experienced an improvement in pain, as measured by the VAS, TSS and McGill Pain Questionnaire. CONCLUSION ALCAR, administered twice a day intramuscularly to HIV-1-infected patients with symptomatic ATN, significantly reduced weekly mean pain ratings on the VAS compared with placebo. Treatment with oral ALCAR improved symptoms for the patient group as a whole. Intramuscular and oral ALCAR was generally safe and well tolerated.
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Affiliation(s)
- M Youle
- Royal Free Centre for HIV Medicine, Royal Free Hospital, London, UK.
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Assessment of neuroAIDS in the international setting. J Neuroimmune Pharmacol 2007; 2:105-11. [PMID: 18040833 DOI: 10.1007/s11481-006-9052-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2006] [Accepted: 12/01/2006] [Indexed: 10/23/2022]
Abstract
The global burden of the HIV epidemic is staggering, but in the short term, it is largely unfelt in the developed world. Almost one million people have been infected with HIV in North America, and the results of effective antiretroviral therapy have dramatically improved survival and quality of life. However, there are 25 million infected in sub-Saharan Africa alone, and antiretroviral treatment is scarce. Ninety-five percent of new infections occur in the developing world where resources are limited. Very little is known about NeuroAIDS in the developing world where few studies have been conducted on the neurologic and neurocognitive effects of antiretroviral treatment. HIV Clade differences and other factors could have dramatic effects on treatment effectiveness. There are a number of barriers in the assessment of neurological and neurocognitive effects in resource limited settings and some of these will be addressed.
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Pettersen JA, Jones G, Worthington C, Krentz HB, Keppler OT, Hoke A, Gill MJ, Power C. Sensory neuropathy in human immunodeficiency virus/acquired immunodeficiency syndrome patients: protease inhibitor-mediated neurotoxicity. Ann Neurol 2006; 59:816-24. [PMID: 16634006 DOI: 10.1002/ana.20816] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Human immunodeficiency virus-associated sensory neuropathy (HIV-SN) is a common and disabling disorder, often associated with antiretroviral therapy (ART) use. We investigated the clinical features and associated pathogenic determinants of HIV-SN in a neurological cohort of HIV-infected patients, together with a novel model of HIV-SN. METHODS HIV-infected patients with neurological disease were investigated in terms of clinical and laboratory aspects together with ART exposure focusing on symptomatic HIV-SN. Rat-derived dorsal root ganglion (DRG) cultures, transgenic for human CD4 and CCR5 treated with ARTs or HIV infected, or both, were studied with respect to quantitative neuronal injury. RESULTS Among 221 patients assessed from 1998 to 2004, 120 had no sensory neuropathy, whereas 101 displayed HIV-SN, including 64 with distal sensory neuropathy and 37 with antiretroviral toxic neuropathy. HIV-SN patients exhibited significantly greater mean age, peak plasma viral loads, and exposure to neurotoxic dideoxynucleosides and protease inhibitors, including indinavir, saquinavir, or ritonavir. HIV-infected DRG cultures exposed to indinavir or didanosine showed significant neuronal atrophy, neurite retraction, and process loss, compared with controls. Indinavir was selectively cytotoxic to DRG macrophages compared with other ARTs. INTERPRETATION Protease inhibitor exposure is an unrecognized risk factor for the development of HIV-SN, which may potentiate neuronal damage in HIV-infected DRGs, possibly through the loss of macrophage-derived trophic factors.
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Osio M, Muscia F, Zampini L, Nascimbene C, Mailland E, Cargnel A, Mariani C. Acetyl-l-carnitine in the treatment of painful antiretroviral toxic neuropathy in human immunodeficiency virus patients: an open label study. J Peripher Nerv Syst 2006; 11:72-6. [PMID: 16519785 DOI: 10.1111/j.1085-9489.2006.00066.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Antiretroviral toxic neuropathy causes morbidity in human immunodeficiency virus (HIV) patients under dideoxynucleoside therapy, benefits only partially from medical therapy, and often leads to drug discontinuation. Proposed pathogeneses include a disorder of mitochondrial oxidative metabolism, eventually related to a reduction of mitochondrial DNA content, and interference with nerve growth factor activity. Carnitine is a substrate of energy production reactions in mitochondria and is involved in many anabolic reactions. Acetyl carnitine treatment promotes peripheral nerve regeneration and has neuroprotective properties and a direct analgesic role related to glutamatergic and cholinergic modulation. The aim of this study was to evaluate acetyl-l-carnitine in the treatment of painful antiretroviral toxic neuropathy in HIV patients. Twenty subjects affected by painful antiretroviral toxic neuropathy were treated with oral acetyl-l-carnitine at a dose of 2,000 mg/day for a 4-week period. Efficacy was evaluated by means of the modified Short Form McGill Pain Questionnaire with each item rated on an 11-point intensity scale at weekly intervals and by electromyography at baseline and final visit. Mean pain intensity score was significantly reduced during the study, changing from 7.35 +/- 1.98 (mean +/- SD) at baseline to 5.80 +/- 2.63 at week 4 (p = 0.0001). Electrophysiological parameters did not significantly change between baseline and week 4. In this study, acetyl-l-carnitine was effective and well tolerated in symptomatic treatment of painful neuropathy associated with antiretroviral toxicity. On the contrary, no effect was noted on neurophysiological parameters.
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Affiliation(s)
- Maurizio Osio
- Clinica Neurologica, Università degli Studi di Milano, Milano, Italy.
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37
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Estanislao LB, Morgello S, Simpson DM. Peripheral neuropathies associated with HIV and hepatitis C co-infection: a review. AIDS 2005; 19 Suppl 3:S135-9. [PMID: 16251810 DOI: 10.1097/01.aids.0000192082.41561.49] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Co-infection with HIV and hepatitis C has become increasingly prevalent. It is a major source of morbidity in HIV-infected populations. Distal symmetric polyneuropathy is the most common form of peripheral neuropathy in HIV as well as hepatitis C mono-infection. There is considerable overlap in the symptoms and signs of HIV and hepatitis C neuropathy. It is not known whether there are additive or synergistic effects on the peripheral nerve by these two viruses. There is a need for studies to further elucidate the mechanisms involved.
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Affiliation(s)
- Lydia B Estanislao
- Department of Neurology (NeuroAIDS Research Program), Mount Sinai Medical Center, New York, NY 10029, USA
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38
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Youle M. HIV-Associated Antiretroviral Toxic Neuropathy (ATN): A Review of Recent Advances in Pathophysiology and Treatment. Antivir Ther 2005. [DOI: 10.1177/135965350501002s14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Mike Youle
- Royal Free Centre for HIV Medicine, Royal Free Hospital, London
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39
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Modification of the incidence of drug-associated symmetrical peripheral neuropathy by host and disease factors in the HIV outpatient study cohort. Clin Infect Dis 2004; 40:148-57. [PMID: 15614705 DOI: 10.1086/426076] [Citation(s) in RCA: 123] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2004] [Accepted: 08/08/2004] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND We sought to identify factors associated with the clinical diagnosis of symmetrical peripheral neuropathy (SPN) during the era of highly active antiretroviral therapy (HAART) in a retrospective, longitudinal cohort analysis. METHODS Patients infected with human immunodeficiency virus type 1 were evaluated for clinical signs of SPN and its association with immunologic, virologic, clinical, and drug treatment factors by means of univariate and multivariate logistic regression analyses. RESULTS Of 2515 patients, 329 (13.1%) received a diagnosis of SPN. In the logistic regression analysis, statistically significant non-drug-based risk factors for SPN were age >40 years (adjusted odds ratio [aOR], 1.17), diabetes mellitus (aOR, 1.79), white race (aOR, 1.33), nadir CD4(+) T lymphocyte count <50 cells/mm(3) (aOR, 1.64), CD4(+) T lymphocyte count 50-199 cells/mm(3) (aOR, 1.40), and viral load >10,000 copies/mL at first measurement (aOR, 1.44). Although initial use of didanosine, stavudine (40 mg b.i.d.), nevirapine, or 4 protease inhibitors was associated with SPN (ORs for all 4 treatments, >1.41), the strength of association decreased with continued use of all medications studied. CONCLUSION Since HAART was introduced, the incidence of SPN has decreased. Host factors and signs of increased disease severity were associated with an increased risk of developing SPN during the initial period of exposure to drug therapy. Immunity improved and the risk of SPN decreased with continued use of HAART. Delaying the initiation of therapy may select those individuals who will be more likely to develop SPN, and earlier initiation of HAART may decrease the risk of developing this common problem, as well as increase the therapeutic effects and decrease the toxic effects of the drugs.
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40
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Holmberg SD, Palella FJ, Lichtenstein KA, Havlir DV. The case for earlier treatment of HIV infection. Clin Infect Dis 2004; 39:1699-704. [PMID: 15578373 DOI: 10.1086/425743] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2004] [Accepted: 07/14/2004] [Indexed: 11/03/2022] Open
Abstract
Current US guidelines advise that antiretroviral therapy for asymptomatic HIV patients should definitely be started for those who have CD4(+) cell counts of >200 cells/ microL, but antiretroviral therapy is often not started at CD4(+) cell counts much above that level. Guidelines advocating later therapy for HIV infection have been based mainly on sparse and limited cross-sectional data and have been predicated on avoiding drug-related toxicity and viral drug resistance. However, emerging data about factors that contribute to survival and the availability of newer, less toxic drugs are eroding this position. Earlier initiation of antiretroviral therapy--namely, for patients with CD4(+) cell counts of >350 cells/ microL--may, in fact, be associated with lower mortality, better immune improvement, and less drug-related toxicity. These findings coincide with the introduction of antiretroviral drugs that have become more effective and less difficult to take. Earlier initiation of therapy may also reduce HIV transmission, an important public health consideration, and may be beneficial in terms of overall therapeutic cost-effectiveness. Given these accumulating data, we believe reconsideration of the "when-to-start" question is timely and justified.
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Affiliation(s)
- Scott D Holmberg
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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41
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Abstract
Physical and mental changes resulting from HIV infection and its treatment can affect a patient's quality of life (QOL). Some of the most commonly reported symptoms affecting QOL in HIV-infected patients are fatigue, pain, anxiety/depression, and sleep disturbances. Fatigue often has a multifactorial etiology, including advanced HIV disease, opportunistic infections, poor nutrition, hormonal insufficiency, and anemia. Pain is one of the most overlooked factors by clinicians. Anxiety/depression and sleep disturbances are experienced by many HIV-infected individuals and are highly correlated with the perception and progression of disease. Although these common clinical symptoms impact QOL in HIV-positive patients, there are no established guidelines for treating them. As pain, anxiety/depression, and sleep disturbances can influence fatigue, as well as each other, the HIV care provider should monitor them closely because their severity reflects the clinical course of HIV as well as the overall well-being of the patient.
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Abstract
Neuropathic pain is associated with numerous systemic illnesses, including HIV infection. The diagnosis and management of peripheral neuropathy presents diagnostic and therapeutic challenges. Among various forms of HIV-associated peripheral neuropathies, distal symmetrical polyneuropathy (DSP) is the most common. DSP may be caused or exacerbated by neurotoxic antiretrovirals, particularly the dideoxynucleoside analogues (d-drugs). Selection of appropriate pharmacologic intervention for peripheral neuropathy should be based on efficacy, safety, ease of administration, and cost. We review treatment options for painful HIV neuropathy, including experimental agents studied in recent and ongoing clinical trials.
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Affiliation(s)
- Susama Verma
- Department of Neurology, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029, USA
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43
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Abstract
Symptom management has always been a focus of nursing care. Assessing and managing symptoms is an important component of HIV nursing practice. When effective, interventions to relieve symptoms may improve quality of life (QoL), potentially increase adherence to highly active antiretroviral therapy, and improve other outcomes such as functional status. Common underrecognized and/or undertreated symptoms that may influence the QoL of persons living with HIV include fatigue, pain, anxiety/depression, and sleep disturbances. These symptoms may also contribute to the difficulty of adhering to HAART When evaluating a patient's symptoms, the nurse attempts to understand the symptom experience from the patient's perspective because symptoms are subjective experiences. Together, the nurse and patient work to determine feasible interventions. Symptom management plans are evaluated frequently. Fundamentally, symptom management aims to decrease the frequency, intensity, and distress of symptoms, with the ultimate goal of improving QoL.
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Affiliation(s)
- Anne Hughes
- Laguna Honda Hospital and Rehabilitation Center, San Francisco Department of Public Health, USA
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44
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Nolan D, Mallal S. Complications Associated with Nrti Therapy: Update on Clinical Features and Possible Pathogenic Mechanisms. Antivir Ther 2004. [DOI: 10.1177/135965350400900609] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The availability of durable, effective antiretroviral therapy for HIV-infected patients has fundamentally altered the prognosis of this disease and has also increased awareness that long-term drug toxicities have the potential to cause significant morbidity and even mortality in this patient population. The long-term use of nucleoside analogue reverse transcriptase inhibitor (NRTI) drugs has been associated with a number of clinically relevant toxicities including hyperlactataemia and lactic acidosis, neuropathy, pancreatitis and, more recently, a syndrome of pathological loss of subcutaneous fat tissue (lipoatrophy). Importantly, the toxicity profile of each NRTI drug within this class is unique in terms of the overall risk of long-term complications, as well as the tissue specificity of its toxic effects. In this review, the clinical manifestations, risk factors and pathological basis for NRTI-associated toxicity syndromes are explored, with an emphasis on clinical assessment and management.
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Affiliation(s)
- David Nolan
- Centre for Clinical Immunology and Biomedical Statistics, Royal Perth Hospital and Murdoch University, Western Australia, Australia
| | - Simon Mallal
- Centre for Clinical Immunology and Biomedical Statistics, Royal Perth Hospital and Murdoch University, Western Australia, Australia
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45
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Hart AM, Wilson ADH, Montovani C, Smith C, Johnson M, Terenghi G, Youle M. Acetyl-l-carnitine: a pathogenesis based treatment for HIV-associated antiretroviral toxic neuropathy. AIDS 2004; 18:1549-60. [PMID: 15238773 DOI: 10.1097/01.aids.0000131354.14408.fb] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Nucleoside analogue reverse transcriptase inhibitors (NRTI) disrupt neuronal mitochondrial DNA synthesis, impairing energy metabolism and resulting in a distal symmetrical polyneuropathy (DSP), an antiretroviral toxic neuropathy (ATN) that causes significant morbidity in HIV disease. Serum acetyl-l-carnitine (ALCAR) levels are decreased in neuropathy associated with NRTI therapy. ALCAR enhances neurotrophic support of sensory neurons and promotes energy metabolism, potentially causing nerve regeneration and symptom relief. OBJECTIVE To assess the efficacy of oral ALCAR (1500 mg twice daily) for up to 33 months in an open cohort of 21 HIV-positive patients with established ATN. METHODS Skin biopsies were excised from the leg before ALCAR treatment, at 6-12 month intervals thereafter and from HIV-negative non-neuropathic controls. Fibre types in epidermal, dermal and sweat gland innervation were quantified immunohistochemically. RESULTS After 6 month's treatment, mean immunostaining area for small sensory fibres increased (epidermis 100%, P = 0.006; dermis 133%, P < 0.05) by more than that for all fibre types (epidermis 16%, P = 0.04; dermis 49%, P < 0.05; sweat glands 60%, P < 0.001) or for sympathetic fibres (sweat glands 41%, P < 0.0003). Compared with controls, epidermal, dermal and sweat gland innervation reached 92%, 80% and 69%, respectively, after 6 month's treatment. Innervation improvements continued (epidermis and dermis) or stabilized (sweat glands) after 24 month's treatment. Neuropathic grade improved in 76% of patients and remained unchanged in 19%. HIV RNA load, CD4 and CD8 cell counts did not alter significantly throughout the study. CONCLUSIONS ALCAR treatment improves symptoms, causes peripheral nerve regeneration and is proposed as a pathogenesis-based treatment for DSP.
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Affiliation(s)
- Andrew M Hart
- Blond McIndoe Centre, Royal Free and University College Medical School, London, UK
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46
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Abstract
Neuropathic pain is associated with numerous systemic illnesses, including HIV infection. The diagnosis and management of peripheral neuropathy presents diagnostic and therapeutic challenges. Among various forms of HIV-associated peripheral neuropathies, distal symmetrical polyneuropathy (DSP) is the most common. DSP may be caused or exacerbated by neurotoxic antiretrovirals, particularly the dideoxynucleoside analogues (d-drugs). Selection of appropriate pharmacologic intervention for peripheral neuropathy should be based on efficacy, safety, ease of administration, and cost. We review treatment options for painful HIV neuropathy, including experimental agents studied in recent and ongoing clinical trials.
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Affiliation(s)
- Susama Verma
- Department of Neurology, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029, USA.
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47
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Höke A, Cornblath DR. Chapter 22 Peripheral neuropathies in human immunodeficiency virus infection. ADVANCES IN CLINICAL NEUROPHYSIOLOGY, PROCEEDINGS OF THE 27TH INTERNATIONAL CONGRESS OF CLINICAL NEUROPHYSIOLOGY, AAEM 50TH ANNIVERSARY AND 57TH ANNUAL MEETING OF THE ACNS JOINT MEETING 2004; 57:195-210. [PMID: 16106620 DOI: 10.1016/s1567-424x(09)70358-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Ahmet Höke
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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Dou H, Kingsley JD, Mosley RL, Gelbard HA, Gendelman HE. Neuroprotective strategies for HIV-1 associated dementia. Neurotox Res 2004; 6:503-21. [PMID: 15639783 DOI: 10.1007/bf03033447] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The human immunodeficiency virus-1 (HIV-1) commonly affects cognitive, behavioral and motor functions during the disease course. The neuropathogenesis of viral infection revolves around neurotoxins produced from infected and immune-activated mononuclear phagocytes (MP; perivascular macrophages and microglia). Direct infection of neurons occurs rarely, if at all. Neurologic disease arises in part as a consequence of MP metabolic dysfunction. Although the advent of highly active antiretroviral therapy (HAART) has attenuated the incidence and severity of neurologic disease, it, nonetheless, remains a common and disabling problem for those living with HIV-1 infection. Adjunctive therapies are currently designed to ameliorate clinical outcomes and are included in the therapeutic armamentarium. Anti-inflammatory drugs that inhibit cytokines, chemokines and interferons linked to neurodegenerative processes can significantly ameliorate neuronal function. HIV-1 neurotoxins have the unique ability to up-regulate glycogen synthase kinase-3beta (GSK-3beta) activity that in turn elicits neuronal apoptosis. GSK-3beta inhibitors are neuroprotective in animal models of Neuro AIDS. They are also currently in Phase 1 clinical trials designed for safety and tolerability in patients with HIV-1 infection. Neurotrophins are only beginning to be realized for their therapeutic potential in HIV-1 associated neurologic disease. This review article provides a broad overview of neuroprotective strategies for HIV-1 infection and details how such strategies act and may be implemented for treatment of human disease.
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Affiliation(s)
- Huanyu Dou
- Center for Neurovirology and Neurodegenerative Disorders, Department of Pharmacology, University of Nebraska Medical Center, Omaha, NE 68198-5215, USA
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Brew BJ. The peripheral nerve complications of human immunodeficiency virus (HIV) infection. Muscle Nerve 2003; 28:542-52. [PMID: 14571455 DOI: 10.1002/mus.10484] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Peripheral nerve complications occurring in patients with human immunodeficiency virus (HIV) infection are frequent and challenging. This review discusses these various complications according to the degree of advancement of HIV disease. Particular emphasis is placed upon emerging causes of neuropathy found in the context of HIV disease, such as infection with hepatitis C and human T-lymphotropic virus type I, as well as neuropathies related to antiretroviral medications.
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Affiliation(s)
- B J Brew
- Departments of Neurology and HIV Medicine, St Vincent's Hospital and National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Darlinghurst, Sydney 2010, Australia.
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50
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Selwyn PA, Rivard M. Palliative care for AIDS: challenges and opportunities in the era of highly active anti-retroviral therapy. J Palliat Med 2003; 6:475-87. [PMID: 14509497 DOI: 10.1089/109662103322144853] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
In contrast to the first decade of the AIDS epidemic, the past decade has seen an increasing separation between AIDS care and palliative care services. While this may be due in part to the perception that AIDS is no longer a uniformly fatal illness, AIDS in fact remains an important cause of morbidity and mortality for young adult populations in the United States, particularly among certain racial-ethnic minorities. Death rates have remained steady since the dramatic decreases noted in the mid-1990s, and causes of death now increasingly include co-morbidities such as hepatitis B, C, end-organ failure, and various malignancies. Moreover, as AIDS has been transformed into a more manageable, chronic disease in the era of 'highly active antiretroviral therapy' (HAART), the opportunities for palliative care interventions have only increased. Patients with AIDS continue to experience a high burden of pain and other chronic symptoms, over a longer period of time, with a disease course marked by more cumulative exacerbations and remissions than when AIDS was a stereotypic, rapidly fatal illness. Advance care planning and discussions of goals of care are more complex and involve more uncertainty than was the case when prognosis was clear-cut and treatment options were more limited. For all of these reasons, it is important for the distance which has developed between HIV and palliative care providers to be bridged. Contrary to popular perceptions, palliative medicine continues to have much to offer in the HAART era for the care of patients and families with HIV/AIDS, for whom treatment outcomes will only benefit from greater integration of disease-specific and palliative interventions. The challenge for care providers is now to implement successful strategies for integrating AIDS and palliative care services in all relevant clinical environments.
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Affiliation(s)
- Peter A Selwyn
- HIV Palliative Care Program, Department of Family Medicine and Community Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York 10467, USA.
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