Case: 35-year-old with Difficulty Walking

00:02 Let's start with a case.

00:04 This is a 35-year-old person who presents with difficulty walking and a weakness in his legs and hands.

00:11 He was recently diagnosed with HIV and has not yet started treatment.

00:16 Work up reveals a CD4 count of 300 and elevated HIV viral load.

00:23 Lumbar puncture is performed revealing no white blood cells and elevated CSF protein of 80.

00:30 CSF culture and viral studies including CMV-PCR are negative for an infectious process.

00:38 So there are a couple of features of this case.

00:41 This patient is presenting with difficulty walking and weakness prominent motor symptoms.

00:48 The evaluation is concerning for a diagnosis of AIDS which is defined as a CD4 count less than 200 or other AIDS-defining illness that we're not quite there and may be at that process of seroconversion.

01:02 And spinal fluid is negative for an infectious work up with elevated CSF protein suggesting some type of underlying inflammation.

01:11 So what's your diagnosis? Is this Acute inflammatory demyelinating polyneuropathy (AIDP) or Guillain Barré? Is it inflammatory demyelinating polyneuropathy, associated with HIV? CMV-polyradiculopathy or HIV-associated distal symmetric polyneuropathy? Well, let's start with CMV-polyradiculopathy.

01:34 That's not the right diagnosis for this patient.

01:37 CMV-polyradiculopathy is seen in patients with HIV, but our patient is negative for CMV PCR and this argues against that diagnosis.

01:48 This presentation is not consistent with HIV-associated distal symmetric polyneuropathy.

01:53 That's the most common form of neuropathy in patients with HIV, but typically occurs late in the disease course which is not where this patient is in his disease course.

02:05 The presentation is not consistent with standard garden-variety AIDP, while the presentation, the signs, symptoms and exam is similar to AIDP.

02:17 The presentation at seroconversion of HIV is suggestive of inflammatory demyelinating polyneuropathy associated with HIV.

02:26 And so that is the correct diagnosis in this patient.

02:29 This is a common neuropathic complication of patients with HIV at seroconversion.