Patel, K., Janora, D., Jermyn, R. “Multifocal Motor Neuropathy in a Long-Term HIV Survivor with Azidothymidine Exposure and Intravenous Immunoglobulin Therapy.” Association of Academic Physiatrists, Orlando, FL. March 6 2020.
Patel, K., Janora, D., Jermyn, R. Multifocal Motor Neuropathy in a Long-Term HIV Survivor with Azidothymidine Exposure and Intravenous Immunoglobulin Therapy. American Journal of Physical Medicine & Rehabilitation. March 2020. 99(3S):a81.
Case Diagnosis:
Multifocal motor neuropathy (MMN) is a rare, purely motor neuropathy, characterized by progressive, asymmetric, distal limb weakness with minimal sensory impairment. The etiology is deemed immune mediated and treatable with intravenous immunoglobulin (IVIg) therapy.
Case Description:
A 67-year-old woman presented HIV positive since 1994 with a history of intermittent limb paresthesias and sensory polyneuropathy from 2002-2009. In 2010, she experienced progressive left hand and bilateral leg weakness. Nerve conduction studies (NCS) showed axonal peripheral polyneuropathy affecting motor nerve fibers preferentially. She was started on IVIg with slight improvement in five months. However, due to insurance denial, she was soon taken off IVIg. August 2011 NCS showed worsening left motor peroneal and tibial nerve amplitudes. In 2012, she was back on IVIg and reported less fatigue and fewer cramps. In 2016, she complained of headaches with IVIg and skipped her treatments. Subsequently, she had a fall and injured her face and right knee. In 2018, due to insurance and surgeries, she again declined treatments and experienced frequent falls. This year, motor NCS amplitudes and conduction velocities have further worsened in both upper and lower extremities.
Discussion:
Overall, this patient had a progressive decline in the amplitudes and conduction velocities of her median, tibial and peroneal motor fibers. Left side showed more prominent weakness compared to her right. The support for IVIg is heightened after her relapses following multiple discontinuations. Laboratory results demonstrated CD4 counts > 300 and viral load < 50 copies to indicate she was virally suppressed.
Conclusions:
This case illustrates the potential for MMN following initial use of azidothymidine in long-term HIV survivors. Although the motor neuropathy seen in this patient is rare, it is a predictable side effect of azidothymidine use. Recognition of this condition is critical to implement early NCS screenings for patients and apply appropriate IVIg therapy to prevent deterioration.
Kishan Patel, OMSIII, Rowan University School of Osteopathic Medicine