AIDS TREATMENT NEWS Issue #189, December 17, 1993
John S. James

This condition is rare, occurring in perhaps only one percent of people with AIDS. But doctors are seeing more of it today, since AIDS patients are living longer.

Many physicians are not familiar with this condition. So we interviewed Lawrence Drew, M.D., Ph.D., a CMV expert at Mt. Zion Hospital in San Francisco, who brought the matter to our attention. There is also a literature review and report of two cases which was published last July.(3)

JJ: Who should be on the alert? Only people with a CD4 count (T-helper count) under 50?

LD: I think so. This is a late manifestation of AIDS, and even late for CMV. We haven't had anybody with a CD4 count above 50. They may well have already had CMV retinitis, but not necessarily.

Neurological abnormalities in the legs can be caused by many different problems -- either HIV itself, or the drugs used to treat it. When you have tingling, that's likely to be peripheral neuropathy, caused by either HIV or the drugs. But if you get true weakness of the legs, especially with a loss of bladder control, in a patient with CD4 count under 50, those would represent a warning sign about this syndrome. Maybe two thirds of patients with this condition have a bladder problem. Pain can also occur, but that can happen with peripheral neuropathy also.

The doctor examining the patient also finds an absence of reflexes in the knee and/or the ankle; that can happen with the neuropathy too.

People with a change, especially if reflected by weakness in the lower legs, and maybe an intensification of pain, should at least see the doctor, especially if they're not on ddC or ddI [which can cause symptoms which may be confused with CMV polyradiculopathy].

JJ: What should the doctor look for?

LD: The examination will show absent reflexes, or highly diminished reflexes, as well as muscle weakness. If there is not an evident explanation, like ddC or perhaps ddI, and if there is any suggestion of a bladder problem, that might help the doctor suspect this condition.

What has to be done to make the diagnosis is a spinal tap -- something that many patients are reluctant to have, although it's not that difficult or invasive. The findings in the spinal fluid are very characteristic, very unique. JJ: Will most medical labs be able to diagnose this properly?

LD: They have to be on the lookout, and be aware of this condition. The pattern in the spinal fluid -- the cell response, the glucose, and the protein -- are very typical, and very unusual for a virus. It looks like the pattern of a bacterial meningitis -- low sugar, and high white count, polymorphonuclear cells. These two together -- spinal fluid test results that look like bacterial infection, but the fluid does not grow bacteria -- should be a major alert to the doctor and the laboratory.

Together with the clinical picture, you should begin treatment for CMV on that basis. We do know that you get a reduction in viral signal in the spinal fluid, when you treat with ganciclovir. We have shown that in two patients now, using the new Chiron bDNA assay. [For background on the bDNA (branched DNA) viral test, see AIDS TREATMENT NEWS #186, November 5, 1993. In this case, the test has been adapted to test for CMV, instead of for HIV.] This is important because there have been questions about how well either ganciclovir or foscarnet get into the spinal fluid.

JJ: Can foscarnet be used for treating this condition?

LD: We have not yet had the opportunity to test with foscarnet [to see if it lowers viral activity in the spinal fluid, as ganciclovir apparently does]. And there are not enough cases in the literature at this time to know which of these two drugs would be better. If you had a patient already being treated with ganciclovir and this problem appeared while they were on it, my instinct would be to use foscarnet. [Note: a recently published report of a case where this happened found that the virus was resistant to ganciclovir -- supporting the decision to use foscarnet instead.]

JJ: Any other information we should include?

LD: The main point I would emphasize is that late treatment has been disappointing -- usually either no response, or a minimal arresting of the disease. Since the drugs evidently do get in, and are active against the virus, too extensive disease may have occurred by the time the diagnosis has been made. So the hope is to identify this condition earlier, and treat immediately. This should be viewed as an emergency, because it is very disabling if not arrested early. There are also cases where patients respond only after weeks or months of treatment.

Although this is a rare condition, patients and physicians should keep in mind these red flags, the clinical symptoms and what the physician needs to know. Patients may need to bring the information to their physician's attention, if that individual has not had any experience with this problem.

References

1. Kim YS and Hollander H. Polyradiculopathy due to cytomegalovirus: Report of two cases in which improvement occurred after prolonged therapy and review of the literature. CLINICAL INFECTIOUS DISEASES. July 1993; volume 17, pages 32-37.

Note: At this time there are at least six references to CMV polyradiculopathy in the AIDSLINE computer database of AIDS medical articles.

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