Neurologic Abnormalities in Human Immunodeficiency Virus Infection

, Department of Psychiatry and Neurology, Tulane University School of Medicine, New Orleans, La 

South Med J. 2001;94(3) 

In This Article

Dyskinesias and Gait Impairment

Many different types of dyskinesia, including chorea, dystonia, akathisia, and tremor, have been reported in patients infected with HIV.[27] These dyskinesias may result from past or present use of dopamine-blocking agents, eg, neuroleptics or antiemetics, such as prochlorperazine (Compazine) and metoclopramide (Reglan). Patients infected with HIV are excessively sensitive to neuroleptic and antiemetic medications. Side effects may occur even at low doses or may be due to interactions with other medications, including antiretroviral agents. The neuroleptics may cause parkinsonism. Other medications, including lithium, divalproex, or pyrimethamine, may induce or exaggerate postural tremor. Focal mass lesions (eg, toxoplasmosis, abscess, lymphoma) may cause hemichorea or hemidystonia.[28] Infection of subcortical gray matter with HIV may cause bilateral dyskinesia.

Gait abnormalities in HIV-positive patients may result from disturbances at multiple levels of the neuraxis. These include (1) a waddling broad-based gait with difficulty rising from chairs and difficulty climbing stairs due to myopathy (HIV- or AZT-induced mitochondrial injury in muscle tissue); (2) a broad-based, unsteady gait with Romberg's sign due to sensorimotor neuropathy or radiculopathy; (3) a spastic, stiff, scissoring gait due to myelopathy associated with dementia or a spinal cord lesion; (4) unilateral weakness (hemiparesis) or gait ataxia due to a focal mass lesion; (5) a slow shuffling gait with difficulty initiating walking and difficulty turning due to parkinsonism.

Vitamin B12 deficiency should be considered if spastic paraparesis (myelopathy) and findings of peripheral neuropathy are present.[29] If the etiology of the gait disorder remains unexplained, a trial of B12 therapy is warranted even when hematologic findings are not supportive of this vitamin deficiency. Cytomegaloviral myelitis and radiculitis may cause gait impairment, but they are rarely seen unless the CD4 lymphocyte count is less than 50. In patients with evidence of spinal cord dysfunction (sensorimotor and bladder/bowel symptoms and signs) who report back pain, spinal cord compression should be considered and excluded.[30,31,32]

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