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AIDP/CIDP Anal Pap Smear. Jeffrey A. Beal, M.D. Faculty, Florida/Caribbean AIDS Education Training Center . III.35 AIDP/CIDP. Discuss the clinical presentation, differential diagnosis, and management of acute and chronic inflammatory demyelinating polyneuropathy in HIV+ patients .

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aidp cidp anal pap smear

AIDP/CIDPAnal Pap Smear

Jeffrey A. Beal, M.D.

Faculty, Florida/Caribbean AIDS Education Training Center

iii 35 aidp cidp

III.35 AIDP/CIDP

Discuss the clinical presentation, differential diagnosis, and management of acute and chronic inflammatory demyelinating polyneuropathy in HIV+ patients

iii 16 anal pap smears
III.16 Anal Pap Smears
  • Describe an anal Pap smear, how it is performed, and its potential use for screening for anal intraepithelial neoplasia in men and women, and discuss indications for referral to a specialist for patients with abnormal Pap smears
acute or chronic inflammatory demyelinating polyneuropathy aidp or cidp
Acute or Chronic Inflammatory Demyelinating Polyneuropathy (AIDP or CIDP)
  • Demyelinating Polyneuropathies are diagnosed in 1/3 of HIV+ Patients referred for peripheral nerve disease
  • Cause: autoimmune-induced inflammatory response and breakdown of peripheral nerve myelin
acute or chronic demyelinating polyneuropathy aidp or cidp
Acute or Chronic Demyelinating Polyneuropathy (AIDP or CIDP)
  • AIDP
    • Rapid onset and progression
    • Often develops during HIV seroconversion or during early HIV infection
  • CIDP
    • More common in middle to late stages of HIV disease
    • Slower onset and progression over several weeks or months
acute or chronic demyelinating polyneuropathy aidp or cidp6
Acute or Chronic Demyelinating Polyneuropathy (AIDP or CIDP)
  • Characteristic features:
    • AIDP: Progressive ascending lower and upper extremity weakness, more distal than proximal
    • CIDP: Patchy (can be both distal and proximal) lower and upper extremity weakness
    • Respiratory paralysis in AIDP
    • Cranial neuropathy (VII, X, XII) in both
acute or chronic demyelinating polyneuropathy aidp or cidp7
Acute or Chronic Demyelinating Polyneuropathy (AIDP or CIDP)
  • AIDP & CIDP:
    • Mildly impaired sensation, mild pain
    • Autonomic dysfunction with cardiac arrhythmia, urinary retention, and blood pressure instability
    • Hyporeflexia or areflexia
  • Thomas, et. al.; eMedicine Journal, January 18, 2002, Vol. 3, No. 1
acute or chronic demyelinating polyneuropathy aidp or cidp8
Acute or Chronic Demyelinating Polyneuropathy (AIDP or CIDP)
  • CSF  increased protein with lymphocytic pleocytosis
  • EMG and nerve conduction velocity studies show marked slowing of nerve conduction velocities and conduction block
  • Nerve Biopsy macrophage-mediated segmental demyelination
acute or chronic demyelinating polyneuropathy aidp or cidp9
Acute or Chronic Demyelinating Polyneuropathy (AIDP or CIDP)
  • Treatment of AIDP:
    • Plasmapheresis or IVIG, not corticosteroids
    • Concomitant GCV, FOS, or, Cidofovir if CD4 < 50
  • Treatment of CIDP
    • Prednisone
    • Intravenous immunoglobulin as effective as plasma exchange
iii 16 anal pap smears10
III.16 Anal Pap Smears
  • Describe an anal Pap smear, how it is performed, and its potential use for screening for anal intraepithelial neoplasia in men and women, and discuss indications for referral to a specialist for patients with abnormal Pap smears
anal pap smear
Anal Pap Smear
  • The incidence of anal cancer among HIV infected MSM is higher than that among HIV-negative MSM
  • Goedert JJ, Cote TR, Virgo P, et al. Spectrum of AIDS-associated malignant disorders. Lancet. 1998;351:1833-1839
anal pap smear12
Anal Pap Smear
  • The incidence of anal cancer is also elevated among HIV-positive women compared to the general population.
  • Frisch M, et.al, Human papillomavirus-associated cancers in patients with human immunodeficiency virus infection and acquired immunodeficiency syndrome. J Natl Cancer Inst. 2000; 92:1500-1510
anal intraepithelial neoplasia
Anal Intraepithelial Neoplasia
  • “Left untreated, anal cancer is fatal. If detected at an early stage, however, survival is excellent among both HIV + and HIV – MSM. Like cervical cancer, anal cancer is probably preventable.”
  • Screening for and Treatment of Anal Intraepithelial Neoplasia Joel Palefsky, MD HIV/AIDS Update 2002 MEDSCAPE 2002
anal pap smear14
Anal Pap Smear
  • Palefsky XIV AIDS Conf reported
    • Prior to HIV, anal cancer incidence in MSM was 35 in 100,000
    • Since 1998 the risk has more than doubled and now exceeds the risk of cervical cancer in women
    • Survey of >350 men in SF, anal swabs and anoscopy found early neoplasia in 52%
    • Risk independent of CD4 and is not decreased with HAART
anal pap who to screen
Anal Pap, Who to screen?
  • MSM
  • HIV infected women
  • HIV infected Men with history of IDU
  • Women with a history of high-grade CIN/cervical cancer or vulvar intraepithelial neoplasia/vulvar cancer
  • Men and Women with history of perianal condlyoma
  • Screening for and Treatment of Anal Intraepithelial Neoplasia Joel Palefsky, MD HIV/AIDS Update 2002 MEDSCAPE 2002
anal pap smear16
Anal Pap Smear
  • Anal cytology sensitivity appears similar to cervical Pap smears, although the grade of dysplasia may not correlate as well with the histology
anal pap smear17
Anal Pap Smear
  • Procedure:
    • Moistened Dacron swab inserted 1-1.5” into anal canal
    • Rotate swab and withdraw in a tight spiral motion. Sampling process of 15-20 seconds.
    • Smear on glass slide and fix immediately or use Thin Prep liquid based media
anal pap smear18
Anal Pap Smear
  • No universally accepted guidelines
  • Not yet considered Standard of Care
  • Recommendations:
    • Perform at initial exam and if normal, repeat in 6 months
    • If initial 2 Pap smears are Normal, repeat annually. Consider more frequent when CD4 < 500 cells/mm3
    • Abnormal results refer for high-resolution anoscopy and biopsy
anal pap smear19
Anal Pap Smear
  • Cost/Benefit Analysis:
    • Screening q 2 years beginning during acute HIV infection hypothetical cohort HIV + MSM
      • Cost of $13,000 per quality-adjusted life year
      • Annual screening augmented this benefit at a cost of $16,000 per QALY saved
    • TMP-SMX for PCP prophylaxis results in cost of $13,000 per year of life saved.

Goldie, et.al.; May 19, 1999; JAMA

anal intraepithelial neoplasia20
Anal Intraepithelial Neoplasia
  • “Treatment of AIN has not been shown to prevent anal cancer. This is a serious impediment. Unfortunately, it becomes a self-fulfilling prophecy: we will not know until we try it. Cervical cytology screening was practiced for many years before it became clear that it was contributing to the reduction in cervical cancer incidence.”
  • Screening for and Treatment of Anal Intraepithelial Neoplasia Joel Palefsky, MD HIV/AIDS Update 2002 MEDSCAPE 2002
iii 35 aidp cidp21

III.35 AIDP/CIDP

Discuss the clinical presentation, differential diagnosis, and management of acute and chronic inflammatory demyelinating polyneuropathy in HIV+ patients

iii 16 anal pap smears22
III.16 Anal Pap Smears
  • Describe an anal Pap smear, how it is performed, and its potential use for screening for anal intraepithelial neoplasia in men and women, and discuss indications for referral to a specialist for patients with abnormal Pap smears