Volume 2 Supplement 1

Infectious diseases of the nervous system: pathogenesis and worldwide impact

Open Access

Subacute progression of HTLV-1 associated myelopathy/tropical spastic paraparesis in Peru: a report of 20 cases

  • Martin Tipismana1, 2Email author,
  • Kristine Verdonck1, 3,
  • Elsa González1, 4,
  • Giovanni López1,
  • Daniel Clark1, 5 and
  • Eduardo Gotuzzo1, 2
BMC Proceedings20082(Suppl 1):P70

DOI: 10.1186/1753-6561-2-s1-p70

Published: 23 September 2008

Background

The course of HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP) is most frequently insidious. However, the disease evolves rapidly in a subgroup of patients. The purpose of this study is to better characterize subacute HAM/TSP.

Methods

We describe a series of cases with subacute progression of HAM/TSP from the HTLV-1 cohort at the Institute of Tropical Medicine Alexander von Humboldt in Lima. The diagnosis of HAM/TSP was based on WHO criteria. We used the IPEC (Insituto de Pesquisa Clinica Evandro Chagas) disability scale and the EDSS (Expanded Disability Status Scale) to evaluate HAM/TSP progression. Subacute progression was defined as the inability to walk unaided within two years after onset of lower limb symptoms. The HTLV-1 provirus load (PVL) was determined by SYBR-Green-based real-time quantitative PCR, using human endogenous retrovirus-3 as an internal reference. The PVL was expressed as the number of HTLV-1 copies per 10,000 peripheral blood mononuclear cells.

Results

In 2005–2008, 164 patients with HAM/TSP underwent neurological evaluation. Twenty subjects (12%) presented subacute progression of HAM/TSP. The mean age at disease onset was 45 years (standard deviation (SD) 16; range 12–67); 9/20 (45%) were men. Among 144 subjects with slow progression, the mean age at disease onset was 42 (SD: 15; T-test P = 0.4); and 27 were men (19%; fisher's exact test: P = 0.02). Among those with subacute progression, the time to maximum disability ranged from 1 week to 24 months (mean: 10 months). Symptoms at disease onset were lumbar pain and weakness (15/20), sensory (3/20) and urinary symptoms (2/20). The mean EDSS score was 6.7 (range: 5–8.5) and the mean IPEC score was 20.25 (range: 15–29). After the initial, rapidly progressive phase, 9/20 patients were wheelchair-bound, 7/20 needed two walking-sticks, and 4/20 presented variable remission. Thoracic spinal cord magnetic resonance imaging (MRI) was performed in 14/20. In four subjects, there was hyperintensity in T2 with gadolinium enhancement; in one subject there was atrophy. The remaining MRIs were normal. Cyto-biochemical evaluation of cerebrospinal fluid was done in five subjects, no abnormalities were found. PVL results were available in 7 subjects with subacute progression (mean: 3135; SD: 1482), and 54 subjects with slow progression (mean: 3337; SD: 1896; T-test: P = 0.8).

Conclusion

By contrast with other reports, subacute HAM/TSP progression was associated with male sex, but not with provirus load in this setting. The outcome of subacute HAM/TSP is variable, and remission occurs occasionally.

Authors’ Affiliations

(1)
Instituto de Medicina Tropical "Alexander von Humboldt", Universidad Peruana Cayetano Heredia
(2)
Hospital Nacional Cayetano Heredia
(3)
Virology Unit, Department of Microbiology, Institute of Tropical Medicine
(4)
Facultad de Medicina, Universidad Peruana Cayetano Heredia
(5)
Facultad de Ciencias y Fiolosofía, Universidad Peruana Cayetano Heredia

Copyright

© Tipismana et al; licensee BioMed Central Ltd. 2008

This article is published under license to BioMed Central Ltd.

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