aidp/cidp anal pap smear jeffrey a. beal, m.d. faculty, florida/caribbean aids education training...

AIDP/CIDPAnal Pap Smear

Jeffrey A. Beal, M.D.

Faculty, Florida/Caribbean AIDS Education Training Center

III.35 AIDP/CIDP

Discuss the clinical presentation, differential diagnosis, and management of acute and

chronic inflammatory demyelinating polyneuropathy in HIV+ patients

III.16 Anal Pap Smears

Describe an anal Pap smear, how it is performed, and its potential use for screening for anal intraepithelial neoplasia in men and women, and discuss indications for referral to a specialist for patients with abnormal Pap smears

Acute or Chronic Inflammatory Demyelinating Polyneuropathy

(AIDP or CIDP)

Demyelinating Polyneuropathies are diagnosed in 1/3 of HIV+ Patients referred for peripheral nerve disease

Cause: autoimmune-induced inflammatory response and breakdown of peripheral nerve myelin

Acute or Chronic Demyelinating Polyneuropathy (AIDP or CIDP)

AIDP• Rapid onset and progression• Often develops during HIV seroconversion or

during early HIV infection

CIDP• More common in middle to late stages of HIV

disease• Slower onset and progression over several

weeks or months


Characteristic features:• AIDP: Progressive ascending lower and upper

extremity weakness, more distal than proximal• CIDP: Patchy (can be both distal and

proximal) lower and upper extremity weakness

• Respiratory paralysis in AIDP• Cranial neuropathy (VII, X, XII) in both


AIDP & CIDP:• Mildly impaired sensation, mild pain• Autonomic dysfunction with cardiac

arrhythmia, urinary retention, and blood pressure instability

• Hyporeflexia or areflexia

Thomas, et. al.; eMedicine Journal, January 18, 2002, Vol. 3, No. 1


CSF increased protein with lymphocytic pleocytosis

EMG and nerve conduction velocity studies show marked slowing of nerve conduction velocities and conduction block

Nerve Biopsy macrophage-mediated segmental demyelination


Treatment of AIDP:• Plasmapheresis or IVIG, not corticosteroids• Concomitant GCV, FOS, or, Cidofovir if CD4 <

50

Treatment of CIDP• Prednisone• Intravenous immunoglobulin as effective as

plasma exchange

Anal Pap Smear

The incidence of anal cancer among HIV infected MSM is higher than that among HIV-negative MSM

Goedert JJ, Cote TR, Virgo P, et al. Spectrum of AIDS-associated malignant

disorders. Lancet. 1998;351:1833-1839

Anal Pap Smear

The incidence of anal cancer is also elevated among HIV-positive women compared to the general population.

Frisch M, et.al, Human papillomavirus-associated cancers in patients with human immunodeficiency virus infection and acquired immunodeficiency syndrome. J Natl Cancer Inst. 2000; 92:1500-1510

Anal Intraepithelial Neoplasia

“Left untreated, anal cancer is fatal. If detected at an early stage, however, survival is excellent among both HIV + and HIV – MSM. Like cervical cancer, anal cancer is probably preventable.”

Screening for and Treatment of Anal Intraepithelial Neoplasia Joel Palefsky, MD HIV/AIDS Update 2002 MEDSCAPE 2002

Anal Pap SmearPalefsky XIV AIDS Conf reported

• Prior to HIV, anal cancer incidence in MSM was 35 in 100,000

• Since 1998 the risk has more than doubled and now exceeds the risk of cervical cancer in women

• Survey of >350 men in SF, anal swabs and anoscopy found early neoplasia in 52%

• Risk independent of CD4 and is not Risk independent of CD4 and is not decreased with HAARTdecreased with HAART

Anal Pap, Who to screen?

MSMHIV infected womenHIV infected Men with history of IDUWomen with a history of high-grade

CIN/cervical cancer or vulvar intraepithelial neoplasia/vulvar cancer

Men and Women with history of perianal condlyoma


Anal Pap Smear

Anal cytology sensitivity appears similar to cervical Pap smears, although the grade of dysplasia may not correlate as well with the histology

Anal Pap Smear

Procedure:• Moistened Dacron swab inserted 1-1.5” into

anal canal• Rotate swab and withdraw in a tight spiral

motion. Sampling process of 15-20 seconds.• Smear on glass slide and fix immediately or

use Thin Prep liquid based media

Anal Pap SmearNo universally accepted guidelines

Not yet considered Standard of Care

Recommendations:• Perform at initial exam and if normal, repeat in 6

months• If initial 2 Pap smears are Normal, repeat annually.

Consider more frequent when CD4 < 500 cells/mm3

• Abnormal results refer for high-resolution anoscopy and biopsy

Anal Pap Smear

Cost/Benefit Analysis:• Screening q 2 years beginning during acute

HIV infection hypothetical cohort HIV + MSM• Cost of $13,000 per quality-adjusted life year• Annual screening augmented this benefit at a cost

of $16,000 per QALY saved

• TMP-SMX for PCP prophylaxis results in cost of $13,000 per year of life saved.

Goldie, et.al.; May 19, 1999; JAMA

Anal Intraepithelial Neoplasia

“Treatment of AIN has not been shown to prevent anal cancer. This is a serious impediment. Unfortunately, it becomes a self-fulfilling prophecy: we will not know until we try it. Cervical cytology screening was practiced for many years before it became clear that it was contributing to the reduction in cervical cancer incidence.”


III.35 AIDP/CIDP

Discuss the clinical presentation, differential diagnosis, and management of acute and

chronic inflammatory demyelinating polyneuropathy in HIV+ patients

aidp/cidp anal pap smear jeffrey a. beal, m.d. faculty, florida/caribbean aids education training...

Documents