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ORIGINAL ARTICLE
Year : 2013  |  Volume : 61  |  Issue : 5  |  Page : 478-480

HIV neuropathy in pre-HAART patients and it's correlation with risk factors in Central India


Department of Medicine, Gandhi Medical College and Hamidia Hospital, Bhopal, Madhya Pradesh, India

Date of Submission20-Mar-2013
Date of Decision06-Jun-2013
Date of Acceptance11-Oct-2013
Date of Web Publication22-Nov-2013

Correspondence Address:
Himanshu Sharma
Department of Medicine, Gandhi Medical College and Hamidia Hospital, Bhopal, Madhya Pradesh
India
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DOI: 10.4103/0028-3886.121912

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 » Abstract 

Background: Peripheral neuropathy (PN) is the most common neurological complication of human immunodeficiency virus (HIV) infection and often goes unrecognized. This ailment has a significant debilitating impact on the quality of life of HIV/acquired immunodeficiency syndrome (AIDS) patients. HIV-associated sensory neuropathy (HIV-SN) is the most common PN in HIV infected patients. In India, although HIV has emerged as a public health menace, the burden of HIV-SN has not yet been well-defined. Materials and Methods: We used the Brief Peripheral Neuropathy Screening (BPNS) tool, validated by the AIDS Clinical Trial Group (ACTG) and carried out a cross-sectional study to determine the prevalence of HIV-SN and its associated factors among highly active antiretroviral therapy (HAART) naive HIV patients. HIV-SN is defined as the presence of neuropathic symptoms and at least an abnormal perception of vibrations of a 128 Hz tuning fork on the great toe or abnormal ankle reflexes or both. Results: Out of 75 patients studied, 40% had clinical HIV-SN and nerve conduction study (NCS) confirmed its presence in all of them. In patients with neuropathy, the mean hemoglobin was 10.76 g/dl (P < 0.0001), mean serum albumin 2.7 g/dl (P < 0.001), mean body mass index (BMI) 17.18 kg/m 2 (P < 0.0001), and mean CD4 T-cell count was 497/μl; whereas, in patients not having neuropathy the same values were 12.81 g/dl, 3.64 g/dl, 20.22 kg/m 2 , and 678/μl, respectively. Patients recall and clinical chart review showed that, 40% had symptoms even prior to HAART initiation. Conclusions: HIV-SN is more common among pre-HAART patients with low level of hemoglobin, serum albumin, BMI, and CD4 T-cell count. Hence, it is found that neuropathy can be prevented by improving immune as well as nutritional status of HIV infected patients. So, BPNS, being a simple diagnostic tool should therefore be routinely applied to screen the neuropathy, to minimize the negative impact it has on the quality of life in patients with HIV infection.


Keywords: Brief peripheral neuropathy screening, CD4 T-cell count, CD-4 count, highly active antiretroviral therapy, hemoglobin, HIV-associated sensory neuropathy, serum albumin


How to cite this article:
Dubey TN, Raghuvanshi SS, Sharma H, Saxena R. HIV neuropathy in pre-HAART patients and it's correlation with risk factors in Central India. Neurol India 2013;61:478-80

How to cite this URL:
Dubey TN, Raghuvanshi SS, Sharma H, Saxena R. HIV neuropathy in pre-HAART patients and it's correlation with risk factors in Central India. Neurol India [serial online] 2013 [cited 2014 Sep 1];61:478-80. Available from: http://www.neurologyindia.com/text.asp?2013/61/5/478/121912



 » Introduction Top


Peripheral neuropathy (PN) is the most common neurological complication in HIV infection and is widely under-detected and under-treated in limited resource settings. [1],[2] Clinically, there are at least six patterns of HIV associated PN. [3] Distal sensory PN which is the most common of all HIV-associated sensory neuropathy (HIV-SN), [4] exists as two major types: Primary HIV-associated distal sensory polyneuropathy (HIV-DSP), and antiretroviral toxic neuropathy (ATN). [5] HIV-DSP and ATN together involve approximately 30-67% of patients with advanced HIV disease. HIV-SN remains an important cause of morbidity among these patients as it considerably affects their quality of life. [6],[7] HIV-SN-related burning pain and paresthesia, is associated with loss of employment, depression, and dependency in daily life activities albeit successful highly active antiretroviral therapy (HAART). [6] More so, symptomatic relief therapy is usually not satisfactory. [8] Furthermore, HAART is still composed of first line drugs some of which have been demonstrated in other studies to increase the risk of PN. [5],[9],[10] We therefore planned to determine the prevalence of HIV-SN and its associated factors in HIV infected patients using an easy but validated screening tool, the Brief Peripheral Neuropathy Screening (BPNS). [11]


 » Materials and Methods Top


After obtaining prior ethical clearance, treatment naive PLHA (person living with HIV/acquired immunodeficiency syndrome (AIDS)) patients were included in the study and we carried out a cross-sectional study of the HIV seropositive patients in inpatient and outpatient clinic of the Gandhi Medical College, Bhopal, from December 2011 to December 2012. Patients on antitubercular therapy, on antiretroviral therapy, alcoholic, diabetes mellitus, vitamin B-12 deficiency, leprosy, chronic kidney disease, and with hereditary neuropathy were excluded from the study. The diagnosis of HIV was made according to National AIDS Control Program Guidelines. [12] Consecutively, each patient underwent a BPNS using the BPNS tool. [11] History and lower extremity examination was done to evaluate patient perception of vibrations for over 10 s using a 128 Hz tuning fork on the big toe. Ankle reflexes were also tested using a reflex hammer. Sociodemographic and anthropometric information relevant to the study were also obtained from each patient.

Unpaired t-test was used to compare the quantitative variables of interest under study namely; mean hemoglobin, mean body mass index (BMI), mean serum albumin, and mean CD4 T-cell count between clinically evident neuropathy and non-neuropathy group. HIV-SN was defined as the presence of symptoms and at least abnormal perception of vibration or ankle reflex or both. Evidence of association was considered for a two-sided P value of less than 0.05.


 » Results Top


Seventy-five HIV infected pre-HAART patients were included in the study, out of which, 30 (40%) patient had both symptoms and signs of neuropathy. All these patients had abnormal nerve conduction studies (NCSs). Twelve (16%) patients had no symptoms, but showed signs of neuropathy with abnormal NCSs, that is, subclinical neuropathy. Thirty-three (44%) patients had no symptoms, signs, or abnormal nerve conduction. Forty percent of patients had clinical neuropathy and the mean of age, BMI, hemoglobin, serum albumin, and CD4 T- cell count were 34.11 years, 17.18 kg/m 2 , 10.76 g/dl, 2.7 g/dl, and 497 cell/μl, respectively [Table 1]. Among patients with HIV-sensory neuropathy, the median duration of HIV infection was not taken into account because we took only World Health Organization (WHO) Stage-I patients.
Table 1: Distribution of variable in HIV positive cases and association with neuropathy

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 » Discussion Top


The definition of HIV-SN as per the BPNS tool assesses both subjective and objective findings consistent with PN. However, it is required that a patient must have both neuropathic symptoms and clinical signs to be diagnosed as HIV-SN. The prevalence of HIV-SN in our study population was 40% though, varying greatly among different studies between 19 and 42%. [13],[14],[15],[16],[17],[18],[19] Evans et al., reported the prevalence of neuropathy in pre-HAART patient to be 26.90%. [17] Cherry et al., reported 42% prevalence of HIV neuropathy. [13] We found that HIV-SN is more common among middle-age group patients, similar with findings in other studies. [20] These authors reported 21% prevalence of HIV neuropathy. [20] This suggests that some patients though asymptomatic, might have abnormal signs related to HIV-SN but do not meet the HIV-SN diagnostic criteria as per the BPNS tool. Some authors considered this group as asymptomatic PN who perhaps represent those with early HIV-SN who are more likely to become symptomatic when challenged with HAART or other risks for PN. [16],[17] Subclinical neuropathy in our study was 16% using NCS. According to Skopelitis and collaborators who used a model involving both clinical criteria and electrophysiological studies, two-thirds of HIV-SN is subclinical. [21] Therefore, caregiver should take into consideration individual patient's risk of PN and patient education before making the choice of drugs for the HAART regimen.

Finally, our finding of low levels of hemoglobin, serum albumin, BMI, and CD4 level having strong association with HIV-SN, was in line with findings of many other studies. Likewise CM Shikuma M, Gercshenson et al., 2012 [22] shows that decreased BMI is a risk factor for neuropathy, but according to Konchalard et al., [23] there is no correlation in BMI and neuropathy. [21] Tagliati et al., showed lower the hemoglobin higher the HIV neuropathy. [24]

As HIV-SN is common among pre-HAART patients, it is advisable to screen these patients for neuropathy to minimize the negative impact it has on the quality of life of these patients. Our study had some limitations, being a cross-sectional design we were not able to determine the incidence of HIV-SN, which requires a longitudinal design and larger sample size.


 » Acknowledgements Top


The authors wish to sincerely thank all the member of the ART Plus Centre of the Hamidia Hospital, Bhopal, India.

 
 » References Top

1.Kamerman PR, Wadley AL, Cherry CL. HIV-associated sensory neuropathy: Risk factors and genetics. Curr Pain Headache Rep 2012;16:226-36.  Back to cited text no. 1
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3.Wulff EA, Wang AK, Simpson DM. HIV-associated peripheral neuropathy: Epidemiology, pathophysiology and treatment. Drugs 2000;59:1251-60.  Back to cited text no. 3
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4.Morgello S, Estanislao L, Simpson D, Geraci A, DiRocco A, Gerits P, et al. Manhattan HIV Brain Bank. HIV-associated distal sensory polyneuropathy in the era of highly active antiretroviral therapy: The manhattan HIV brain bank. Arch Neurol 2004;61:546-51.  Back to cited text no. 4
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5.Simpson DM, Tagliati M. Nucleoside analogue-associated peripheral neuropathy in human immunodeficiency virus infection. J Acquir Immune Defic Syndr Hum Retrovirol 1995;9:153-61.  Back to cited text no. 5
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6.Ellis RJ, Rosario D, Clifford DB, McArthur JC, Simpson D, Alexander T, et al. CHARTER Study Group. Continued high prevalence and adverse clinical impact of human immunodeficiency virus-associated sensory neuropathy in the era of combination antiretroviral therapy: The CHARTER study. Arch Neurol 2010;67:552-8.  Back to cited text no. 6
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12.Guidelines for HIV Testing-National AIDS Control Organisation. National HIV testing network operational guidelines NACO Document. Operational Characteristics of Commercially available Assays to Determine Antibodies to HIV-1 and/or HIV-2 in Human Sera.14. Available from: http//www.nacoonline.org  Back to cited text no. 12
    
13.Cherry CL, Affandi JS, Imran D, Yunihastuti E, Smyth K, Vanar S, et al. Age and height predict neuropathy risk in patients with HIV prescribed stavudine. Neurology 2009;73:315-20.  Back to cited text no. 13
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14.Evans D, Takuva S, Rassool M, Firnhaber C, Maskew M. Prevalence of peripheral neuropathy in antiretroviral therapy native HIV-positive patients and the impact on treatment outcomes-a retrospective study from a large urban cohort in Johannesburg, South Africa. J Neurovirol 2012;18:162-71.  Back to cited text no. 14
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20.Luma HN, Tchaleu BC, Doualla MS, Temfack E, Sopouassi VN, Mapoure YN, et al. HIV-associated sensory neuropathy in HIV-1 infected patients at the Douala General Hospital in Cameroon: A cross-sectional study. AIDS Res Ther 2012;9:35.  Back to cited text no. 20
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21.Skopelitis EE, Kokotis PI, Kontos AN, Panayiotakopoulos GD, Konstantinou K, Kordossis T, et al. Distal sensory polyneuropathy in HIV-positive patients in the HAART era: An entity underestimated by clinical examination. Int J STD AIDS 2006;17:467-72.  Back to cited text no. 21
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