1 / 25

“Pins and needles”

“Pins and needles”. ECHO / WITS PAEDIATRIC HIV CLINICS. Patient TM. 14 years and 11 months on presentation at HIV Clinic on 14/7/2009 Referred from Dermatology clinic where treated for hypertrophic shingles X 4 episodes Mother HIV negative in second pregnancy. Complaints. Weakness

andralyn
Download Presentation

“Pins and needles”

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. “Pins and needles” ECHO / WITS PAEDIATRIC HIV CLINICS

  2. PatientTM • 14 years and 11 months on presentation at HIV Clinic on 14/7/2009 • Referred from Dermatology clinic where treated for hypertrophic shingles X 4 episodes • Mother HIV negative in second pregnancy

  3. Complaints • Weakness • Short of breath • Cough • Dysphagia • No TB contacts/previous TB • Missed 3mths school due to illness

  4. On Examination • 32.25kg (59% EWFA) • Extensive hyperpigmented nodules right arm, lesions resolving • Oro-oesophageal thrush • No clubbing • Shotty lymphadenopthy axillae • Rest of examination findings non-contributary • Chest Xray- Bilateral infiltrates, some breakdown

  5. Assessment • Almost 15 year old girl • WHO IV – 59% EWFA - Oesophageal candidiasis - Pulmonary TB - Resolving hypertrophic Zoster

  6. Blood tests • Severe immunocompromise: • CD4 7 (1.08%) • HIV RNA (Viral load) 140 000 • ALT 20 • FBC essentially normal, normocytic anemia

  7. Treatment • Started on Rifafour at 1st visit after sputum and Bactec ® taken • Oral fluconazole • Preparation for ART

  8. 2 weeks later…. • Still very ill • Weight loss • Started ART (3TC/D4T/EFV) at appropriate doses

  9. Progress….. • Seemed to be doing well on TB treatment and ART • Gained weight • Beginning of October started complaining of painful lower legs- burning, pins and needles type pain • Hyperaesthesia to touch, level to just below knee… “stocking” distribution • Absent ankle reflexes

  10. Assessment-Peripheralneuropathy • What could be causing this? • HIV • INH • D4T

  11. Onfurtherenquiry……. • Seemed as if “pins and needles” present prior to starting TB treatment or ART • Further management • D4T changed to ABC • Pyridoxine added • Unfortunately missed follow up

  12. Sensory Neuropathies associated with HIV

  13. Two main types of HIV associated sensory neuropathy • Distal sensory polyneuropathy • Antiretroviral toxic neuropathy • Clinically indistinguishable • Usually discussed in combination as many think that antiretroviral toxcity may “unmask” an existing silent distal sensory polyneuropathy

  14. Prevalence • In USA around 30% in hospitalised (advanced) patients • Much lower if CD4 count > 200 cells/µl (3%) • Malawi, Beadles et al 35% of patients • Thailand, Sthininamsuwan et al 6-20% • Nigeria, Isezuo et al Nil recorded • Paucity of Paediatric data….up to 35% of children in 2000

  15. Risk factors • Age • Nutritional deficiencies • Alcohol • High HIV viral set point • Low CD4 count

  16. Clinical features • Pain or uncomfortable sensations • Timing of onset and ART may help with distinguishing between the two • Bilateral, symmetrical symptoms • Gradual onset- aching, burning, painful numbness • Mostly soles, worse at night or after walking • Hyperalgesia

  17. Clinical features cont…. • Weakness rare • Usually confined to intrinsic foot muscles • No fasciculations • Ankle reflexes often absent/reduced • Nerve conduction velocities axonal, length dependant sensory polyneuropathy • Quantitative sensory testing: impairment of thresholds for heat, pain and cooling (usually research tool)

  18. Distal sensory polyneuropathy- Pathophysiology • Sensory fibre degeneration with little regeneration • Large myelinated and unmyelinated • Same symptoms as diabetes, alchoholism and amyloidosis • Skin-punch biopsies show epidermal denervation

  19. Pathophysiology of antiretroviral toxicities • “Deadly D’s” –dideoxynucleosides;d4T;ddI;ddC • d4T currently part of 1st line regimen in SA • Alternatives eg Abacavir far more expensive (about 10X) • Mitochondrial toxicity underlies pathogenesis • Often increased serum lactate and reduced acetyl carnitine

  20. Pathophysiology continued • Inhibition of gamma DNA polymerase • Reduction in copy numbers of mtDNA • Resulting metabolic abnormalities • Usually takes a few months to develop • Mitochondrial toxicity may also cause pancreatitis, lactic acidosis, hepatic steatosis, lipodystrophy • May be dose dependant

  21. Treatment • In ART-toxic neuropathy change offending agent eg. d4t to ABC/ TDF in older children • d4T dose in adults reduced to a max of 30mg • Usually improve within 3 months • Add pyridoxine to all TB treatment in HIV infected children • Dose: < 5 years 12.5 mg/day • > 5 years 25 mg

  22. Treatment continued… • Tricyclic antidepressants (placebo controlled trials show modest benefit) • Anticonvulsants- lamotrigine showed large benefit in 2 trials • High dose capsaicum or lidocaine have yielded positive results • HD Co-enzymeQ worsened pain • Acupuncture not effective

  23. Treatment….. • Narcotics- transdermal fentanyl, morphine, oxycodone preparations for severe neuropathies • Regenerative strategies with recombinant human nerve growth factor- trials showed moderate effect • Further research needed

  24. Patient TM • All risk factors for HIV sensory neuropathy • Likely distal sensory neuropathy • BUT complicated by INH and d4T • Late detection of problem • Need increased awareness • Likely often missed in children

  25. References • McArthur J et al. Neurological complications of HIV Infection. Lancet Neurol 2005;4 • Beadles W et al. Neuropathy In HIV-positive patients at an ART clinic in Lilongwe, Malawi. Tropical Doctor 2009;39 • Isezuo SA et al. Clinical neuropathy in HIV/AIDS:an eight year review of hospitalised patients in Sokoto, North Western Nigeria. Tropical Doctor. 2009;39 • Sithinamsuwan P et al. Frequency and Characteristics of HIV associated sensory neuropathy Among HIV patients in Bangkok, Thailand. JAIDS 2008; 49

More Related