Pilot Study of Intravenous Immunoglobulin in HIV-Associated Myelopathy

Abstract

There is no effective treatment for HIV-associated myelopathy (HIVM). The introduction of highly active antiretroviral therapy (HAART) has made little difference to its natural history. Spinal cord pathology reveals vacuolization and inflammation. Intravenous immunoglobulin (IVIg) is used successfully in a number of inflammatory conditions associated with HIV. In view of the potential for reversibility of the inflammatory response in HIVM, we treated 17 patients with IVIg twice over a 56-day study period. There was improvement in composite Medical Research Council (MRC) strength scores 28 days following the first infusion (increase in score: 3.94; p = 0.021). The second infusion did not produce further improvement, however there was little reduction from peak strength. These pilot data suggest that further investigation of the use of IVIg in HIVM is warranted.

HIV-associated vacuolar myelopathy: A rare initial presentation of HIV

“…A few studies have shown that patients with HIVM may benefit from immunoglobulin therapy, but further research is warranted. 16 Supportive measures are aimed towards improving the complications of HIVM including weakness, bowel, bladder and erectile dysfunction, as well as paresthesia and neuropathic pain.…”

Atypical HIV-Vacuolar Myelopathy. Case Report and Literature Review.

“…The same author highlighted IVIg treatment's viability in cases presenting HIV-VM, mainly when autoimmune reactions are under suspicion. We like to highlight the study done by Cikurel et al because it is the only report delivering a number of cases of HIV-VM treated and an important number of improvements (n = 17) after being treated with Ig at the dosage of 2 g/kg for two days of IV infusion but they did not report any improvement of spastic paraparesis and urinary incontinence [10] and they did not report the method to measure the improved symptoms and signs. Other authors also report a complete recovering of symptoms and signs from HIV-VM after being treated with highly active antiretroviral therapy [18,19] but the procedure to measure the improvements are also questionable.…”

“…At the same time, Cikurel et al studied a series of patients with VM to evaluate IVIg's e cacy. They demonstrated that all patients reported reduced palsy in the lower limbs, due to the anti-in ammatory effect of IVIg, causing suppression of the complement cascade, inhibition of production of pro-in ammatory cytokines mainly by monocytes, and reinforcing the antiidiotypic response, leading to neutralization of growth factors (B-cell), and inhibition of the T-cell proliferations with clonal expansion and activation of T-reg cells and downregulation of the Th17 [10].…”

“…Lesions may be con ned to the posterior column, especially the gracile tracts, or be diffuse [3,7]. Currently, there is no de nitive treatment; however, most modalities focus on symptomatic therapies, combined Anti-retroviral treatment (cART) [9], and some authors have found some good outcomes prescribing IV-immunoglobulins [3,10].…”

Indications and safety of intravenous and subcutaneous immunoglobulin therapy

“…IVIg at a dose of 1000 mg/kg/day for 2 days has been successfully used to treat HIV-associated thrombocyto penia. Although adults with HIV are susceptible to opportunistic infections, evidence for effectiveness of Ig replacement therapy in adult HIV patients has not been demonstrated [75][76][77][78][79]. There are some cohort studies demonstrating that the administration of IVIg during the acute phase of HIV does not reduce the length of hospital admission or mortality in HIV-infected children [78].…”