Volume 4 • Issue 12 • 1000262 Open Access Case Report J AIDS Clin Res ISSN:2155-6113 JAR an open access journal Lindholm et al., J AIDS Clin Res 2013, 4:12 DOI: 10.4172/2155-6113.1000262 Treatment Challenges for Inflammatory Demyelinating Polyneuropathy in the Setting of Acute Retroviral Syndrome: Case Report and Review of the Literature David A Lindholm, Tatjana P Calvano, Natascha M Minidis, Thomas J Bayuk, Heather C Yun and Jason F Okulicz* San Antonio Military Medical Center, Fort Sam Houston, Texas, USA *Corresponding author: Jason F Okulicz, Infectious Disease (MCHE-MDI), San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, Texas 78234, USA, Tel: 210-916-5554; Fax: 210-916-0388; E-mail: jason.f.okulicz.mil@mail.mil Received August 30, 2013; Accepted November 12, 2013; Published November 17, 2013 Citation: Lindholm DA, Calvano TP, Minidis NM, Bayuk TJ, Yun HC, et al. (2013) Treatment Challenges for Infammatory Demyelinating Polyneuropathy in the Setting of Acute Retroviral Syndrome: Case Report and Review of the Literature. J AIDS Clin Res 4: 262. doi: 10.4172/2155-6113.1000262 Copyright: © 2013 Lindholm DA, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Keywords: HIV; AIDP; CIDP; Acute retroviral infection; HIV seroconversion Introduction Te frst case of Guillain-Barré Syndrome (GBS) in the setting of acute retroviral syndrome was reported in 1982 [1]. Since that time, multiple case series of acute and chronic infammatory demyelinating polyneuropathy (IDP) associated with human immunodefciency virus (HIV) have been reported. Although the true incidence and prevalence of infammatory demyelinating polyneuropathies in the setting of HIV are unknown, they are believed to be rare [2]. Nevertheless, acute and chronic IDP result in signifcant morbidity and mortality in up to 45% of cases in resource-limited settings [1-4]. Treatment of HIV-associated IDP is derived from experience in HIV-negative patients due to the paucity of data in HIV- infected individuals. For this reason, the beneft of early initiation of antiretroviral therapy (ART) is unknown, and there is a potential risk of immune reconstitution infammatory syndrome (IRIS) afer initiation of ART [5,6]. Autonomic dysfunction is common in IDP and can lead to gastric dysmotility, which presents an additional challenge for treatment with ART. Tis case presents several challenges for the treatment of demyelinating polyneuropathy in the setting of acute HIV, to include considerations for ART initiation, the potential risk for IRIS, balancing the risks and benefts of ART initiation in the setting of severe gastroparesis and jejunostomy placement, and the efect of plasmapheresis on the levels of antiretroviral therapy. Tese issues will be addressed herein, with signifcant focus on treatment challenges. Case Presentation A 20-year-old male initially diagnosed with mononucleosis syndrome in the setting of a positive heterophile antibody, cervical lymphadenopathy, pharyngitis, and fevers, was admitted to the hospital two months afer initial presentation with progressive ascending bilateral lower extremity weakness, signifcant upper extremity weakness, and arefexia in all four extremities. Te patient had associated paresthesias of his feet and hands as well as some progressive numbness on admission. Nerve conduction studies confrmed acute IDP. HIV was suspected and confrmed during his hospitalization. His initial CD4 count was 213 cells/mm 3 (CD4% of 11%), and his plasma viral load (VL) was 389,000 copies/mL. Tis was believed to represent acute retroviral syndrome since he was HIV-negative on screening two months prior to the onset of his mononucleosis syndrome. Initial cerebrospinal fuid (CSF) studies revealed mild lymphocytic pleocytosis (12 leukocytes/ mm 3 , 86% lymphocytes) and elevated protein (119 mg/dL). Qualitative cytomegalovirus (CMV) IgG and IgM titers were positive, though concurrent CSF viral culture was negative for CMV. Antivirals for CMV were not initiated, and CMV DNA was undetectable in both the serum and CSF seven weeks later. His polyneuropathy followed a relapsing and remitting course of weakness. He was treated initially with intravenous immunoglobulin (IVIG) and systemic corticosteroids, with sufcient improvement for transfer to an inpatient rehabilitation facility. On his frst relapse two weeks afer presentation, he was treated with plasmapheresis, again with minor improvement and transfer to inpatient rehabilitation. One month later, he presented with respiratory failure requiring intubation and transfer to our facility. Eventually, the patient required tracheostomy due to persistent weakness of his respiratory muscles resulting in frequent intubations and difculty liberating from the ventilator. Te patient also required placement of a jejunostomy tube due to severe gastroparesis and intractable nausea and vomiting as a part of his autonomic neuropathy. He received fve cycles of plasmapheresis with minimal improvement, prompting transition to IVIG, to which he responded well. Based on the duration of symptoms and relapsing nature of his IDP, the patient transitioned from acute to chronic IDP. ART with raltegravir and tenofovir/emtricitabine was initiated two months afer onset of symptoms. Initiation of ART was delayed Abstract This is a case of a 20-year-old male with acute retroviral syndrome and concurrent acute infammatory demyelinating polyneuropathy (IDP) progressing to chronic IDP. Whereas the patient followed a relapsing and remitting course prior to the initiation of antiretroviral therapy (ART), he demonstrated gradual and sustained clinical improvement in the ten months of follow-up after ART was combined with chronic corticosteroids and intermittent plasmapheresis. This case presents and addresses multiple challenges for the treatment of IDP in the setting of acute HIV infection to include: timing of initiation and selection of appropriate ART, the potential risk for immune reconstitution infammatory syndrome, ART initiation in the setting of severe gastroparesis with jejunostomy placement, and the effect of plasmapheresis on the levels of antiretroviral therapy. J o u r n a l o f A I D S & C l i n i c a l R e s e a r c h ISSN: 2155-6113 Journal of AIDS & Clinical Research