Genitourin Med 1992;68:192-198

192

LETTERS TO THE EDITOR

CMV polyradiculopathy in AIDS-sug- foscarnet, ganciclovir at a reduced maintenance dose of 3 mg/kg/day (5 out of 7 days) gestions for new strategies in treatment was reinstituted. This has continued to be self Cytomegalovirus (CMV) polyradiculopathy administered at home via a Hickman line. presenting as a cauda equina syndrome is now Zidovudine had been discontinued 4 weeks a well described disorder in AIDS and is after it was restarted because of anaemia. Five months after the initial presentation, estimated to occur in 2% ofAIDS patients with neurological problems.' Although dihydrox- the patient is mobile around his home using ypropoxymethylguanine (DHPG, ganciclovir) crutches but still requires an indwelling urinary has been shown to be effective, the optimum catheter. The most prominent deficit is a left dose and duration of induction therapy have foot drop and absent ankle reflexes. We report this case to highlight four issues not been determined. Trisodium phosphonoformate guanine (foscarnet) has been shown to regarding treatment of CMV polyradiculopbe efficacious in the treatment of some of the athy in AIDS patients: firstly, substantial other complications of CMV, such as retinitis, improvement is possible in this condition. Our but there have been no reports of its use in the patient improved from having a complete flaccid paralysis to being mobile with crutches. polyradiculopathy syndrome. A 41 year old bisexual man, HIV ser- Secondly, unless the patient's general condiopositive since 1984, progressed to AIDS in tion dictates otherwise, a deterioration in spite August 1988 when he developed Pneumocystis of treatment should not be a deterrent to the carinii pneumonia. In April 1990 he was continuation of anti CMV therapy. With admitted with a two week history of increasing regards to drug dosages and the necessity for weakness and paraesthesia in the legs, urinary maintenance treatment, much of the experifrequency and two episodes of faecal incon- ence from CMV retinitis has been extrapolated tinence. On examination the lower limbs were to CMV polyradiculopathy. A review of the hypotonic and weak: MRC grade 4 proximally literature shows that induction therapies of and grade 3 on the right, grade 1 on the left ganciclovir 5-10 mg/kg/day for between 10 to distally. The knee and ankle jerks were absent 21 days are being used. This case suggests that and the plantar responses equivocal. There was high dose induction therapy of anti-CMV a mild sensory deficit with reduction to pin- treatment should be continued at least until prick sensation over the Sl dermatome on the there is no further neurological improvement. left. Anal tone was reduced and the bladder Finally, although it is difficult to attribute was palpable to the umbilicus. Examination of improvement in our patient specifically to the upper limbs and cranial nerves was normal. foscarnet, this may be an effective alternative There was no evidence of cytomegalovirus to ganciclovir in CMV polyradiculopathy as in, for example, CMV retinitis. Furthermore, as retinitis. A thoracolumbar myelogram was normal. foscarent is less myelotoxic than ganciclovir, Cerebrospinal fluid examination showed 44 zidovudine therapy may be continued. FoscarWBC, predominantly neutrophils, and the ent should be considered as alternative therapy protein was 1.7 g/l. No organisms were in cases where no improvement has occurred cultured. Cytological examination and syphilis after two to three weeks of treatment with serological tests were negative. Nerve conduc- ganciclovir or in cases intolerant of ganciclovir. tion tests on the lower limbs were consistent Clearly, further studies comparing the efficacy with a lumbar radiculopathy. of these two therapies are required. HADI MANJI* A presumptive diagnosis of CMV polyADAM MALINt SEAN CONNOLLY* radiculopathy was made and treatment was *Department of Neurology started with ganciclovir 10 mg/kg/day, 72 tDepartment of Medicine hours after admission. Zidovudine was The Middlesex Hospital, London, WIN 8AA, UK stopped. Despite three weeks of treatment he continued to deteriorate and developed com- 1 De Gans J, Portegies P. Neurological complications of infection with the Human Immunodeficiency Virus type plete flaccid paralysis of his legs and required a 1. A review. Clin Neurol Neurosurg 1989;91:197-217. suprapubic urinary catheter in situ. Empirically, foscarnet (57 mg/kgTID) was substituted for the ganciclovir. Zidovudine was reinstituted initially at a dose of 300 mg gradually National STD trends in Zambia: 1987-89 increasing to 1000 mg daily. The first signs of improvement were noted We have previously reported a rise in the after two weeks of treatment with foscarnet. number of cases of sexually transmitted disOver the next five weeks clinical improvement eases (STDs) in Zambia from 1983 to 1987 and continued. However, owing to deteriorating expressed concern over the exponential renal function after 7 weeks of treatment with increase in cases of chancroid and syphilis in

CMV polyradiculopathy in AIDS--suggestions for new strategies in treatment.

Genitourin Med 1992;68:192-198 192 LETTERS TO THE EDITOR CMV polyradiculopathy in AIDS-sug- foscarnet, ganciclovir at a reduced maintenance dose of...
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