Autonomic Neuropathy in HIV: A Case Report and Review of Potential Symptoms in an Advanced-Stage, HIV Cohort
268
were relatively mild until exacerbated by medication. In
her case, the development of painful HIV-DSP finally led
to the diagnosis of her autonomic neuropathy.
It is unknown what proportion of patients with HIV-
DSP have autonomic neuropathy, although recent studies
have documented an association between autonomic
neuropathy and HIV [8-10] and studies from early in the
HIV epidemic suggested that autonomic neuropathy was
in fact quite common [11,12]. In our review of partici-
pants in the MHBB, potentially autonomic symptoms
were found far more frequently in participants with
symptomatic HIV-DSP than those without. Without for-
mal autonomic testing it is impossible to say whether or
not these symptoms were truly due to autonomic neu-
ropathy. However the symptoms were not associated
with current disease severity as measured by CD4+ count
and HIV-1 viral load, suggesting that they were not read-
ily explained by HIV alone. Similarly, the lack of asso-
ciation with antiretrovirals suggests that these symptoms
cannot be explained by toxicity alone.
Raising awareness about the symptoms of autonomic
neuropathy is complicated by the diverse and non-spe-
cific nature of autonomic symptoms, and the difficulty in
proving that any g iven symptom is autonomic. The com-
plexity of assessing autonomic symptoms is illustrated by
the Autonomic Symptom Profile (ASP), the most exten-
sively used measure of autonomic symptoms [6]. The
ASP contains 169 items which query a wide variety of
symptoms including: positional and situational dizziness
and syncope; skin changes including color changes (due
to vasomotor instability) and changes in sweat output;
dry eyes and mouth; gastrointestinal symptoms such as
nausea, vomiting or bloating (particularly after eating),
diarrhea or constipation; urinary incontinence or hesi-
tancy; sexual dysfunction; sensitivity to light or blurry
vision (due to dysfunction of pupillary constriction); and
sleep disturbance. Even patients with florid autonomic
failure do not typically experience all of these sympto ms
and patients with milder disease may have only one or
two, which may make appreciation of an underlying
autonomic disorder particularly challenging.
In the case of our patient, autonomic neuropathy likely
predated her HIV-DSP symptoms and could have ac-
counted for the numerous side effects she experienced
from antiretrovirals. This would have been important
information for her care providers that might have altered
their prescribing strategy and led to exposure to fewer
antiretrovirals and greater attention to providing symp-
tomatic relief. Further research is needed to determine
the prevalence of autonomic neuropathy in HIV and its
relationship to HIV-DSP.
5. Acknowledgements
The authors thank the staff and participants of the Man-
hattan HIV Brain Bank. Dr. Robinson-Papp receives
funding from NINDS (K23NS066789) and Dr. Morgello
receives funding from NIMH and NINDS (U01MH-
083501, R24MH59724).
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