Advanced AIDS: Alert for CMV Polyradiculopathy. Interview with Lawrence Drew, M.D., Ph.D.

Persons with T-helper counts under 50 who have a sudden
weakness in the legs -- especially if there is any loss of
bladder control -- should get medical attention immediately
to see if they have a neurological CMV infection called CMV
polyradiculopathy. If so, they need to start treatment
immediately with ganciclovir (or possibly foscarnet). The
treatment is the same as for CMV retinitis.

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.