HIV-related Neuropathy

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Original Editor - Melissa Coetsee
Top Contributors - Melissa Coetsee, Kim Jackson and Pacifique Dusabeyezu

Epidemiology

The estimated pooled frequency of DSN in the pre ART era in Africa was 27% (11–37%)149,152,153. A much lower frequency of 3.9% was reported in a single large study from SA154. The worldwide prevalence during the same period ranged between 20–57%149. A frequency of 50% was reported in HIV2 in one study in West Africa using just one sign+/- symptoms45. In the post ART era in Africa there was a significant increase in frequency of DSN with pooled frequencies of DSN of 52% (36–60%)149,150,152,153,155–159. This increase was attributed to the widespread use of dideoxynucleoside reverse transcriptase inhibitors as a first line ART, in particular stavudine with the neuropathy typically beginning 5–6 months post starting ART153,158,160. In a recent study from SA involving a cohort of patients 2 years after starting ART (60% on stavudine) a slight increase in the frequency of symptomatic DSN from baseline 16% to 18% was reported with a 50% decrease in significant pain161. The rate of symptomatic DSN decreased from 22 to 17% in another study in SA involving 2nd line ART patients with an almost 2 year follow up period, notably the rate of asymptomatic DSN in that study increased from 21% to 29%162. Some studies from West Africa report a decrease in the frequency of DSN at three months post starting ART which may have been too early to observe this side effect of stavudine163,164.

Clinically Relevant Anatomy

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Pathological Process

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ART drugs associated with peripheral neuropathy: Didanosine, Zalcitabine, Stavudine

Clinical Presentation

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Symptoms:

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Diagnostic Procedures

Based on medical history, clinical examination and laboratory tests

EMG

Outcome Measures

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Types

Distal Sensory Neuropathy (DSN)

DSN is the most common type of neuropathy in PLWH. It affects the distal extremities (more commonly the feet) and is caused by axonal damage secondary to dorsal root inflammation.

Signs and symptoms include:

• Burning pain and numbness in the soles of the feet/palms of the hands - this ascends symmetrically
• Reduced or absent reflexes
• Impaired light touch sensation
• Impaired proprioception of the affected region

Risk factors for developing DSN:

• Advanced HIV disease

• Lower CD4 count and high viral load
• A history of prior TB or alcohol abuse
• ART regime that includes Dideoxynucleoside revers transcriptase inhibitors (NRTIs), especially Stavudine

Mononeuropathy

The most common mononeuropathy are:

• Facial nerve palsy (Bell's palsy): Usually occurs during the early, asymptomatic stages of HIV
• Herpes zoster reactivation: One of the earliest signs of HIV, and affects the thoracic and trigeminal nerve

Management / Interventions

• HIV infection control - early diagnosis and treatment with ARVs
• Drug regime alteration if associated with ARVs - Avoiding dideoxynucleoside reverse transcriptase inhibitors
• Pain control - With neuropathic medication (amitriptyline, gabapentin, pregabalin)
• Education - On possible other causes of neuropathy (alcohol, diabetes and Vit B6 deficiency secondary to isoniazid)
  

Differential Diagnosis

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Resources

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