What is progressive polyradiculopathy in HIV infection?

Updated: Nov 05, 2019
  • Author: Emad R Noor, MBChB; Chief Editor: Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM  more...
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Answer

Progressive polyradiculopathy typically occurs late in the course of HIV infection, unlike inflammatory demyelinating polyradiculoneuropathies in HIV, which usually occur earlier in the course of disease. [2, 3, 4] Progressive polyradiculopathy in HIV is extremely uncommon, however, is more prevalent in untreated patients with severe immunosuppression. Given its rare occurrence, incidence rate is unknown. HIV-infected patients become susceptible to progressive polyradiculopathy in advanced immunosuppression when the CD4 T-cell count is less than 50/µL. [5]  However, cases of progressive polyradiculopathy have been seen in varying degrees of immunosuppression. [6]  The lumbrosacral region is most often the affected site.

Polyradiculopathy typically results from cytomegalovirus (CMV) infection. The most common manifestation of neurological CMV disease in HIV infection is retinitis followed by encephalitis, myelitis, multifocal polyneuropathy, and polyradiculopathy. [8, 9] CMV co-infection of the retina and other sites is common. An idiopathic form of polyradiculopathy exists, which has a better prognosis than the CMV-related form.

Histologically, polyradiculopathy typically features necrosis of nerve roots and endoneurial and epineurial blood vessels, along with marked inflammation (most pronounced in the lumbar region). In CMV-associated cases, cytoplasmic and nuclear CMV inclusions may be apparent in Schwann cells and fibroblasts. 

CMV polyradiculopathy is rapidly fatal without treatment. Treatment with foscarnet or ganciclovir may improve or stabilize the condition. Clinical stabilization often occurs after initial worsening during the first 2 weeks of treatment. [3]  Even with treatment, mortality is 22%. In idiopathic polyradiculopathy, spontaneous improvement without treatment is common. [10]

Less common causes of polyradiculopathy in HIV infection include spinal lymphomas, diffuse infiltrative lymphocytosis syndrome, and CNS (central nervous system) opportunistic infections such as tuberculosis meningitis, syphilis, cryptococcosis, herpes simplex virus type 2, varicella-zoster virus, and toxoplasmosis. [6]  

Reactivation of HSV-2 after genital herpes with HIV infection can cause lumbosacral radiculitis. [11] Lumbosacral radiculopathy caused by tuberculous meningitis is due to infection of spinal leptomeninges characterized by granulomatous inflammation. This can compress nerve roots or the cord resulting in radiculopathy. [12] A single case of syphilitic lumbosacral radiculopathy has also been reported. [13]

Idanivir-induced epidural lipomatosis in the lumbar canal causing polyradiculopathy has been described, but resolved with discontinuation of the drug. [14]


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