Pain and quality of life in human t-cell lymphotropic virus type 1-associated myelopathy or tropical spastic paraparesis after home-based exercise protocol: a randomized clinical trial

Abstract INTRODUCTION: Human T-cell lymphotropic virus type 1-associated myelopathy or tropical spastic paraparesis (HAM/TSP) causes, among other abnormalities, chronic pain that may impair quality of life (QOL). Home protocols can help those who have difficulty attending rehabilitation centers. This study aimed to evaluate the impact of a home-based exercise protocol on pain and QOL in people with HAM/TSP. METHODS: A randomized clinical trial of people with HAM/TSP (World Health Organization criteria) classified as probable or definite. The supervised group (SG) underwent training for 12 weeks and continued the protocol at home for another 12 weeks; the unsupervised group (UG) performed the same protocol at home without physical therapist supervision for 24 weeks; and the control group (CG) maintained the usual care. QOL was assessed by the Short Form-36 health survey and the pain condition by the Brief Pain Inventory (BPI). The Chi-square, analysis of variance, Kruskal-Wallis, and Friedman tests (5% alpha) were used for the analyses. The intention-to-treat method was adopted in case of follow-up losses. Record number RBR-849jyv/UTN: U1111-1176-2858. RESULTS: Of 56 participants, 49 completed the protocol. Mean pain was moderately reduced (>30%) in the UG and CG and mildly reduced (20%) in the SG. Loss in the vitality score of QOL in the CG was noted. CONCLUSIONS: The protocol generated mild and moderate pain relief and reduced losses in the functional QOL in the treatment groups.

Influence of proprioceptive neuromuscular facilitation on the muscle tonus and amplitude of movement in HTLV-1-infected patients with HAM/TSP

Abstract An HTLV-1-infected patient can develop paraparesis that limits their movements. Rehabilitation techniques could improve the motor abilities of these patients. The present study investigates five cases of physical therapy intervention in HTLV-1 patients to evaluate the influence of functional rehabilitation on the tonus and range of motion (ROM) of HTLV-1 patients with spasticity. The patients had a gain of ROM, especially in the lower limb, and reduction in hypertonia/spasticity after functional treatment. The reduction in hypertonia increased the ROM. Thus, functional methods may be valuable for the rehabilitation of HTLV-1 patients with neurological damage.

The relationship between atopy and neurological manifestations in HTLV-1 infection

Abstract INTRODUCTION: Human T-cell lymphotropic virus type 1 (HTLV-1)induces exaggerated Th1 responses, whereas atopy is associated with exacerbated Th2 responses. METHODS: Here, a cross-sectional study compared the prevalence of atopy in HTLV-1 carriers and HAM/TSP patients. It also compared the spontaneous cytokine production in HTLV-1-infected individuals. A retrospective cohort study evaluated the development of neurological manifestations in atopic and non-atopic carriers. RESULTS: Atopic HAM/TSP patients with high IFN-γ production exhibited higher IL-5 levels than non-atopic patients. Allergic rhinitis accelerated the development of Babinski signals and overactive bladders. CONCLUSIONS: Abnormal Th1 and Th2 responses coexist in HTLV-1-infected individuals and allergic diseases may worsen the clinical course of HTLV-1 infections.

Balance, functional mobility, and fall occurrence in patients with human T-cell lymphotropic virus type-1-associated myelopathy/tropical spastic paraparesis: a cross-sectional study

Abstract INTRODUCTION: Human T-cell lymphotropic virus type-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP) may lead to reduced functional mobility and balance. It is important to establish specific parameters that identify these changes and predict the risk of falls in these patients. The aim was to compare balance, functional mobility, and occurrence of falls among patients with and without HAM/TSP and to suggest values to predict the risk of falls in these patients. METHODS: A cross-sectional study in patients with and without HAM/TSP involved balance assessments based on the berg balance scale (BBS) and functional mobility evaluation based on the timed up and go (TUG) test. From reports of falls, the sensitivity, specificity, and best cutoff points for the risk of falls assessed by these instruments were established using the receiver-operating characteristic (ROC) curve; 5% alpha was considered. RESULTS: We selected 42 participants: 29 with HAM/TSP and 13 without HAM/TSP. There was a statistically significant difference in the occurrence of falls, balance, and functional mobility between the groups (p<0.05). Good accuracy was determined for the BBS (77%) and TUG test (70%) and the cutoff points for the risk of falls were defined as 50 points for the BBS and 12.28 seconds for the TUG test. CONCLUSIONS: Patients with HAM/TSP present reduced functional mobility and balance in relation to those without HAM/TSP. The risk of falls increased for these patients can be evaluated by the values ​​of 50 points using the BBS and 12.28 seconds using the TUG test.

Cardiovascular risk profile in patients with myelopathy associated with HTLV-1

ABSTRACT HAM/TSP (HTLV-1-associated myelopathy/tropical spastic paraparesis) is a slowly progressive disease, characterized by a chronic spastic paraparesis. It is not known if the disease carries an independent risk for cardiovascular disease. The objective of this study was to evaluate the cardiovascular risk profile related to HAM/TSP and compare it with the general population. Methods: This was a cross-sectional study, with a control group. HAM/TSP patients were evaluated using cardiovascular risk scores (ASCVD RISK, SCORE and Framingham) and inflammatory markers (ultrasensitive CRP and IL-6), and compared with a control group of healthy individuals. We also evaluated the correlation between cardiovascular risk and the functional status of patients with HAM/TSP evaluated by the FIM scale. Results: Eighty percent of patients in this study were females, mean age of 51 years (11.3). The control group showed an increased cardiovascular event risk in 10 years when ASCVD was analyzed (cardiovascular risk ≥7.5% in 10 years seen in 43% of patients in the control group vs. 23% of patients with HAM/TSP; p = 0.037). There was no difference in ultrasensitive CRP or IL-6 values between the groups, even when groups were stratified into low and high risk. There was no correlation between the functional status of HAM/TSP patients and the cardiovascular risk. Conclusions: In this study, the cardiovascular risk profile of patients with HAM/TSP was better than the risk of the control group.

The use of botulinum toxin type A in the treatment of HTLV-1-associated overactive bladder refractory to conventional therapy

Urinary symptoms occur in 19% of human T-cell lymphotropic virus type 1 (HTLV-1)-infected patients who do not fulfill criteria for HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP) and in almost 100% of HAM/TSP patients. Few studies have evaluated therapies for overactive bladder (OAB) caused by HTLV-1 infection. This case report describes the effect of onabotulinum toxin A on the urinary manifestations of three patients with HAM/TSP and OAB symptoms. The patients were intravesically administered 200 units of Botox®. Their incontinence episodes improved, and their OAB symptoms scores (OABSS) reduced significantly. These data indicate that Botox® should be a treatment option for OAB associated with HTLV-1 infection.

Immunopathogenesis and neurological manifestations associated to HTLV-1 infection / Imunopatogênese e manifestações neurológicas associadas à infecção pelo HTLV-1

The human T lymphotropic virus type-1 (HTLV-1) was the first human retrovirus identified. The virus is transmitted through sexual intercourse, blood transfusion, sharing of contaminated needles or syringes and from mother to child, mainly through breastfeeding. In addition to the well-known association between HTLV-1 and HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP), several diseases and neurologic manifestations have been associated with the virus. This review was conducted through a PubMed search of the terms HTLV-1, immune response and neurological diseases. Emphasis was given to the most recent data regarding pathogenesis and clinical manifestations of HTLV-1 infection. The aim of the review is to analyze the immune response and the variety of neurological manifestations associated to HTLV-1 infection. A total of 102 articles were reviewed. The literature shows that a large percentage of HTLV-1 infected individuals have others neurological symptoms than HAM/TSP. Increased understanding of these numerous others clinical manifestations associated to the virus than adult T cell leukemia/lymphoma (ATLL) and HAM/TSP has challenged the view that HTLV-1 is a low morbidity infection.

O vírus linfotrópico de células T humanas do tipo 1 (HTLV-1) foi o primeiro retrovírus humano identificado. O vírus é transmitido via relação sexual, transfusão de sangue, compartilhamento de agulhas ou seringas contaminadas ou da mãe para o filho, principalmente através da amamentação. Além da conhecida associação entre o HTLV-1 e a mielopatia associada ao HTLV-1 (HAM/TSP), várias doenças e manifestações neurológicas tem sido associadas com o vírus. Esta revisão de literatura foi conduzida através de pesquisa ao banco de dados do PubMed, com os termos HTLV-1, resposta imune e doenças neurológicas. Foram enfatizados os dados mais recentes sobre a patogênese e às manifestações clínicas na infecção pelo HTLV-1. O objetivo dessa revisão é analisar a resposta imune e a variedade de manifestações neurológicas associadas com a infecção pelo HTLV-1. Um total de 102 artigos foi analisado. A literatura mostra que grande porcentagem de indivíduos infectados pelo HTLV-1 apresenta sintomas neurológicos mesmo na ausência de HAM/TSP. Uma maior compreensão das várias manifestações clínicas associadas ao vírus, além da leucemia/linfoma de células T do adulto (ATLL) e HAM/TSP, auxilia a estabelecer que, na realidade, a infecção pelo vírus possui uma morbidade maior do que se pensava.

Neurological symptoms and signs in HTLV-1 patients with overactive bladder syndrome / Sinais e sintomas neurológicos em pacientes com HTLV-1 e síndrome de bexiga hiperativa

OBJECTIVE: To compare neurological symptoms and signs in HTLV-1 asymptomatic carriers and HTLV-1 patients with overactive bladder (OB) syndrome. METHODS: We studied 102 HTLV-1 positive individuals without HAM/TSP (HTLV-1 associated myelopathy/tropical spastic paraparesis) divided into two groups according to the presence or absence of OB syndrome. Clinical interview, neurological exam and proviral load was performed in all patients. RESULTS AND CONCLUSIONS: Individuals with OB were more commonly female (84.3 vs. 60.8% of asymptomatics, p=0.01). The prevalence of neurological complaints was higher in OB group, especially hand or foot numbness and arm or leg weakness. There was no difference between the groups in neurological strength and reflexes. Weakness complaint remained strongly associated with OB in multivariate logistic regression analysis adjusting for sex and age [adjusted odds ratio and 95%CI 3.59 (1.45-8.88) in arms and 6.68 (2.63-16.93) in legs]. Proviral load was also different between the two groups with higher level on OB individuals.

OBJETIVO: Comparar sintomas e sinais neurológicos em pacientes portadores do HTLV-1 assintomáticos e com síndrome de bexiga hiperativa (BH). MÉTODOS: Foram estudados 102 indivíduos com HTLV-1 sem HAM/TSP (mielopatia associada ao HTLV-I/paraparesia espástica tropical), divididos em dois grupos segundo a presença ou ausência de BH. Foram realizados em todos os pacientes entrevista clínica, exame neurológico e carga proviral. RESULTADOS E CONCLUSÕES: Indivíduos com BH foram na maioria do sexo feminino (84,3 vs. 60,8% dos assintomáticos, p=0,01). A prevalência de queixas neurológicas foi maior no grupo BH, especialmente dormências e fraqueza em extremidades. Não houve diferença entre os grupos em relação a achados do exame neurológico. Fraqueza subjetiva permaneceu fortemente associada com BH na regressão logística multivariada ajustada para sexo e idade [OR e IC95% 3,59 (1,45-8,88) nos braços e 6,68 (2,63-16,93) nas pernas]. A carga proviral foi também diferente entre os dois grupos com nível maior em indivíduos com BH.

Quality of life in patients with HTLV-I associated myelopathy/tropical spastic paraparesis / Qualidade de vida em pacientes com mielopatia associada ao HTLV-I/paraparesia espástica tropical

OBJECTIVE: To assess the quality of life (QoL) of patients with HTLV-I-associate myelopathy/tropical spastic paraparesis (HAM/TSP) and to correlate it with specific aspects of the disease. METHODS: Fifty-seven HAM/TSP patients completed the SF-36 QoL questionnaire. They were also asked about common complaints related to the disease, and we looked for associations between QoL and these complaints. RESULTS: Patients with HAM/TSP showed a strong negative association to QoL. Pain was the condition which most affected their QoL. The practice of physical activity is associated with better QoL in five out of eight domains of the scale. CONCLUSION: HAM/TSP leads to a poor QoL, mostly influenced by pain. Physical activity may have a positive association to QoL of these patients.

OBJETIVO: Avaliar a qualidade de vida (QV) em pacientes com mielopatia associada ao HTLV-I/paraparesia espástica tropical (MAH/PET) e correlacioná-la com aspectos específicos da doença. MÉTODOS: Cinquenta e sete pacientes com MAH/PET completaram o questionário de qualidade de vida SF-36. Também foram feitas perguntas sobre queixas comuns relacionadas à doença e investigadas posteriormente associações entre QV e essas queixas. RESULTADOS: Pacientes com MAH/PET apresentaram uma associação negativa com a QV. A dor foi a condição que mais afetou a QV. A prática de atividade física foi associada a uma melhor QV em cinco dos oito domínios da escala. CONCLUSÃO: MAH/PET leva a uma pior QV, principalmente influenciada pela dor. A atividade física pode estar positivamente associada à QV destes pacientes.

Implications of HAM/TSP functional incapacity in the quality of life / Implicações da incapacidade funcional na qualidade de vida de pacientes com HAM/TSP

OBJECTIVE: To identify the functional status and quality of life of HAM/TSP patients. METHOD: We evaluated prospectively 30 HAM/TSP patients (20 females) seen in the Neuroinfection Clinic of the HUGG. The functional capacity was analyzed by the functional independence measure (FIM), the expanded disability status (EDSS) scale and the Osame's motor disability score (OMDS). The quality of life was assed by the Short-Form Health Survey 36 (SF-36)TM. RESULTS: All patients need assistance device. The FIM, OMDS and EDSS scores classified 70 percent, 67 percent and 67 percent of the patients as dependent, respectively. The lowest scores of the SF-36 survey were found in the domains related to the physical health (D1, D2), role-emotional functioning (D7) and social functioning (D6). CONCLUSION: Our data suggest that the HAM/TSP physical impairment has an impact in the emotional and social issues, considering the limitation in the daily activities.

OBJETIVO: Avaliar a capacidade funcional e sua interferência na qualidade de vida de pacientes com HAM/TSP. MÉTODO: Foram analisados prospectivamente 30 casos (20 mulheres) de HAM/TSP, atendidos no Ambulatório de Neuroinfecção do HUGG. As escalas para avaliação da capacidade funcional consistiram em: medida de independência funcional (FIM), escala de incapacidade expandida (EDSS) e pontuação da incapacidade motora de Osame (OMDS). A qualidade de vida foi analisada pelo Short-Form 36 Health Survey (SF-36)TM. RESULTADOS: Todos os pacientes necessitavam de assistência para deambular. As escalas FIM, OMDS e EDDS classificaram 70 por cento, 67 por cento e 67 por cento dos pacientes como dependentes, respectivamente. A avaliação pelo SF-36 demonstrou menores escores nos domínios físico (D1, D2), emocional (D7) e social (D6). CONCLUSÃO: Os achados sugerem que a limitação nas atividades diárias decorrentes do envolvimento físico comprometem aspectos emocionais e sociais na HAM/TSP.

The motor evoked potential in aids and HAM/TSP State of the evidence / El potencial evocado motor en SIDA y HAM/PET

OBJECTIVE: We aimed to better understand the involvement of the corticospinal tract, assessed by non-invasive transcranial stimulation, in order to determine the actual involvement of the motor system in patients with HAM/TSP and AIDS. METHOD: An exhaustive MEDLINE search for the period of 1985 to 2008 for all articles cross-referenced for "HTLV-I, HTLV-II, HTLV-III and HIV, HIV1, HIV2, evoked potential, motor evoked potential, high voltage electrical stimulation, transcranial magnetic stimulation, magnetic stimulation, corticomotor physiology, motor pathways, acquired immunodeficiency syndrome, AIDS, SIDA, tropical spastic paraparesis, HTLV-I-associated myelopathy, HAM, TSP, and HAM/TSP" were selected and analysed. RESULTS: Eighteen papers published in English, Spanish, Portuguese, French and Japanese were identified. Only the central motor conduction time has been analyzed in seropositive patients to human retroviruses. The investigations done on HAM/TSP support the involvement of the pyramidal tract mainly at lower levels, following a centripetal pattern; in AIDS, such an involvement seems to be more prominent at brain levels following a centrifugal pattern. CONCLUSION: The central motor conduction time abnormalities and involvement differences of the corticospinal tract of patients with AIDS and HAM/TSP dissected here would allow to re-orient early neurorehabilitation measures in these retroviruses-associated neurodegenerative disorders. Besides this, more sophisticated and sensitive non-invasive corticospinal stimulation measures that detect early changes in thalamocortical-basal ganglia circuitry will be needed in both clinically established as well as asymptomatic patients at times when the fastest corticospinal fibers remain uninvolved.

OBJETIVO: Investigar el compromiso del tracto piramidal, evaluado por estimulación trascranial no invasiva, en pacientes afectados por SIDA y HAM/TSP. MÉTODO: Se realizó una búsqueda en la base de datos MEDLINE, que abarcó el período de 1985 a 2008; se incluyeron los términos "HTLV-I, HTLV-II, HTLV-III and HIV, HIV1, HIV2, evoked potential, motor evoked potential, high voltage electrical stimulation, transcranial magnetic stimulation, magnetic stimulation, corticomotor physiology, motor pathways, acquired immunodeficiency syndrome, AIDS, SIDA, tropical spastic paraparesis, HTLV-I-associated myelopathy, HAM, TSP, and HAM/TSP". RESULTADOS: Se obtuvieron 18 artículos publicados en inglés, español, portugués, francés y japonés. El tiempo de conducción central es el único parámetro que se ha estudiado en individuos seropositivos a retrovirus humanos. Las investigaciones hechas en HAM/PET apoyan el compromiso del tracto piramidal, principalmente a nivel dorso-lumbar, de manera centrípeta. En SIDA, el compromiso parece ser mas prominente a nivel cortical, siguiendo un patrón centrifugo. CONCLUSION: El conocer las diferencias en el compromiso y anormalidades del tracto corticoespinal de los pacientes con SIDA y HAM/TSP podrán ser útiles para reorientar la neurorehabilitación temprana en estos desórdenes neurodegenerativos asociados a retrovirus. De otro lado, evaluaciones mas sensibles y sofisticadas del sistema piramidal, que permitan detectar cambios tempranos en los circuitos talamocorticoganglionicos serán mandatarios de realizar a partir de la fecha, bien sea que los individuos estén asintomáticos o no, en estadios clínicos donde las fibras corticoespinales rápidas no estén aun comprometidas.

Pain in tropical spastic paraparesis/HTLV-I associated myelopathy patients / Dor em pacientes com paraparesia espástica tropical/mielopatia associada ao HTLV-I

OBJECTIVE: Tropical Spastic Paraparesis/HTLV-I Associated Myelopathy (TSP/HAM) is a chronic myelopathy, and pain has been mentioned as a frequent sensory symptom in this condition. The authors aimed at analyzing this symptom in a TSP/HAM patients series. METHOD: For this, 46 patients were analyzed considering demographic and clinical characteristics and complaint of pain as to verbal description, time of onset and classification, correlated with the degree of motor disability and type of pain. RESULTS: Among the 46 TSP/HAM patients, 28 (60.8 percent) complained of pain, predominant in the early phase of the disease. Most of the patients exhibited neuropathic characteristics of pain, correlated with increased motor disability. CONCLUSION: Pain in TSP/HAM patients is a frequent and early symptom, and the neuropathic type is predominant (57.1 percent) and paralleled with increased incapacitation. The pathogenic involvement of cytokines may possibly be involved in the meaning of this symptom in this condition.

OBJETIVO: A Paraparesia Espástica Tropical/Mielopatia Associada ao HTLV-I (PET/MAH) é uma mielopatia crônica, e a dor tem sido mencionada como um sintoma sensitivo freqüente nessa condição. Os autores objetivam analisar esse sintoma numa série de pacientes com PET/MAH. MÉTODO: Para isso, 46 pacientes foram analisados considerando características demográficas e clínicas, e queixa de dor do ponto de vista da descrição verbal, tempo de início e classificação, correlacionados com o grau de incapacitação motora e o tipo de dor. RESULTADOS: Dentre os 46 pacientes com PET/MAH, 28 (60,8 por cento) se queixavam de dor, predominando na fase inicial da doença. A maioria dos pacientes evidenciou características de dor neuropática, correlacionada com aumento da incapacitação motora. CONCLUSÃO: A dor em pacientes com PET/MAH é um sintoma freqüente e inicial, sendo o tipo neuropático predominante (57,1 por cento) e em paralelo com maior incapacitação. O envolvimento patogênico das citocinas poderá possivelmente estar relacionado com o significado desse sintoma nessa condição clínica.

Myelopathy and adult T-cell leukemia associated with HTLV-1 in a young patient with hearing loss as the initial manifestation of disease / Mielopatia e leucemia de células T do adulto associada ao HTLV-1 em um paciente jovem com perda auditiva como manifestação inicial da doença

A young male developed hearing loss, vertigo, headache and facial palsy. Neurological examination did not show any abnormalities. Two years later, cervical lymphadenopathy, hepatosplenomegaly and atypical lymphocytes in peripheral blood revealed leukemia. At the same time, acquired ichthyosis was observed. Subsequently, neurological abnormalities revealed myelopathy associated with HTLV-1, due to vertical transmission.

Um jovem do sexo masculino desenvolveu perda auditiva, vertigem, cefaléia e paralisia facial. Exame neurológico sem alterações. Dois anos mais tarde, linfadenopatia cervical, hepatoesplenomegalia e linfócitos atípicos no sangue periférico divulgado leucemia. Concomitante, observou-se ictiose adquirida e, posteriormente, anormalidades neurológicas revelaram mielopatia associada ao HTLV-1, transmitido verticalmente.

HTLV-1 and neurological conditions: when to suspect and when to order a diagnostic test for HTLV-1 infection? / Doenças neurológicas e infecção pelo HTLV-1: quando suspeitar e quando solicitar testes diagnósticos para a infecção pelo HTLV-1

HTLV-1 is a retrovirus associated with a myriad of clinical conditions, especially hematological and neurological ones. Regarding nervous system diseases, it is of utmost importance to select those cases in which HTLV-1 infection could really be associated. This is particularly true for patients from endemic areas and for HIV-infected patients and drug users, since that these groups are at a higher risk for HTLV infection. This caution in selecting neurological patients for HTLV diagnostic tests is justified by the fact that in some circumstances the seropositivity may merely represent an epiphenomenon. In this paper we enroll some neurological conditions that have been associated with HTLV-1/2 infection in the literature and discuss the real need for HTLV-1/2 diagnostic tests in each one. Because HIV/HTLV-co-infected patients seem to be at an increased risk for neurological diseases development, a special consideration about this matter is also made.

O HTLV-1 é um retrovírus associado tanto a doenças hematológicas quanto a doenças neurológicas. Em relação às doenças neurológicas, é fundamental que selecionemos aquelas em que de fato a infecção pelo HTLV-1 possa ser a causa. Isto é particularmente verdadeiro nos pacientes oriundos de áreas endêmicas e nos pacientes infectados pelo HIV e usuários de drogas, haja vista que estes grupos são de risco para infecção pelo HTLV. Este cuidado ao selecionarmos aquelas condições neurológicas que merecem ser investigadas com sorologia para o HTLV se justifica pelo fato de que nem sempre podemos afastar uma associação fortuita entre a infecção e a referida doença. Neste artigo, comentaremos sobre algumas condições neurológicas que podem estar associadas com a infecção pelo HTLV-1/2, discutindo a real necessidade de solicitar testes para o diagnóstico da infecção pelo HTLV-1/2 frente a elas. Uma breve consideração sobre a co-infecção HIV/HTLV será feita no final deste artigo tendo em vista que estes pacientes apresentam um risco aumentado para o desenvolvimento de doenças neurológicas.

Two Babinski signs in seropositive (HAM) and seronegative tropical spastic paraparesis / Dos signos de Babinski en pacientes con paraparesia espástica tropical seropositiva (HAM) y seronegativa

Tropical spastic paraparesis (TSP) may or may not be associated to HTLV-I antibodies and is usually characterized by clinical and pathological spinal cord abnormalities at thoracic levels. We present here five Brazilian patients who had typical chronic idiopatic spastic paraparesis; two of them were HTLV-I seropositive (HAM) and three HTLV-I seronegative (TSP) - associated-myelopathy. Three out of these five patients also displayed clinical supraspinal involvement, indeed, platysma muscle hypotrophy or atrophy (the Babinski plus sign). These findings support the view that clinical involvement in HAM and TSP is wider than the spinal cord abnormalities usually considered. Possible non-infectious co-factors (e.g., mycotoxins) may be involved in disease pathogenesis in a multistep process of viruses, toxins and environment which may account for serological differences found in this group of patients.

La paraparesia espástica tropical (PET), puede o no estar asociada con anticuerpos contra el HTLV-I y se caracteriza, usualmente, por alteraciones clínicas y patológicas a nivel de region dorso-lumbar de la medula espinal. Presentamos cinco pacientes brasileros, quienes tuvieron hallazgos típicos de paraparesia espástica crónica idiopática; dos de ellos tuvieron (HAM) y tres no tuvieron (TSP) anticuerpos, en el suero, contra el HTLV-I. En tres pacientes se encontró hipotrofia o atrofia del músculo platisma (signo de Babinski plus), demostrando que el compromiso clínico en pacientes con HAM y TSP se extiende más allá de la médula espinal torácica. Cofactores (por ejemplo, micotoxinas) podrían estar involucrados en la patogénesis de esta enfermedad, en una interacción compleja de virus, toxinas y medio ambiente, lo cual explicaría las diferencias serológicas encontradas en este grupo de pacientes.

T CD4+ cells count among patients co-infected with human immunodeficiency virus type 1 (HIV-1) and human T-cell leukemia virus type 1 (HTLV-1): high prevalence of tropical spastic paraparesis/HTLV-1-associated myelopathy (TSP/HAM)

INTRODUCTION: HIV positive patients co-infected with HTLV-1 may have an increase in their T CD4+ cell counts, thus rendering this parameter useless as an AIDS-defining event. OBJECTIVE: To study the effects induced by the co-infection of HIV-1 and HTLV-1 upon CD4+ cells. MATERIAL AND METHODS: Since 1997, our group has been following a cohort of HTLV-1-infected patients, in order to study the interaction of HTLV-1 with HIV and/or with hepatitis C virus (HCV), as well as HTLV-1-only infected asymptomatic carriers and those with tropical spastic paraparesis/HTLV-1 associated myelopathy (TSP/HAM). One hundred and fifty HTLV-1-infected subjects have been referred to our clinic at the Institute of Infectious Diseases "Emílio Ribas", São Paulo. Twenty-seven of them were also infected with HIV-1 and HTLV-1-infection using two ELISAs and confirmed and typed by Western Blot (WB) or polymerase chain reaction (PCR). All subjects were evaluated by two neurologists, blinded to the patient's HTLV status, and the TSP/HAM diagnostic was based on the World Health Organization (WHO) classification. AIDS-defining events were in accordance with the Centers for Disease Control (CDC) classification of 1988. The first T CD4+ cells count available before starting anti-retroviral therapy are shown compared to the HIV-1-infected subjects at the moment of AIDS defining event. RESULTS: A total of 27 HIV-1/HTLV-1 co-infected subjects were identified in this cohort; 15 already had AIDS and 12 remained free of AIDS. The median of T CD4+ cell counts was 189 (98-688) cells/mm³ and 89 (53-196) cells/mm³ for co-infected subjects who had an AIDS-defining event, and HIV-only infected individuals, respectively (p = 0.036). Eight of 27 co-infected subjects (30 percent) were diagnosed as having a TSP/HAM simile diagnosis, and three of them had opportunistic infections but high T CD4+ cell counts at the time of their AIDS- defining event. DISCUSSION: Our results indicate that...

INTRODUÇÃO: A possibilidade que a co-infecção pelo vírus da leucemia de células T humana do tipo 1 (HTLV-1) em indivíduos infectados pelo vírus da imunodeficiência humana do tipo 1 poderia falsamente elevar o número de linfócitos T CD4+ no momento do evento definidor de aids, inferindo que essa contagem poderia ser um marcador laboratorial incompleto nos pacientes com a co-infecção HIV-1/HTLV-1. OBJETIVO: Estudar a interação entre o HIV-1 e a co-infecção como o HTLV-1. MATERIAL E MÉTODO: Desde 1997, nosso grupo tem seguido uma coorte de pacientes para estudar a interação entre HIV e/ou vírus da hepatite C (HCV), como também pacientes assintomáticos ou com TSP/HAM. 150 pacientes infectados pelo HTLV-1, encaminhados à clínica de HTLV do Instituto de Infectologia Emilio Ribas, São Paulo, Brasil, foram estudados. Vinte e sete deles estavam co-infectados pelo HIV-1 e HTLV-1, usando dois ELISAs e confirmados tipados pelo WB ou PCR. Todos os pacientes foram avaliados por dois neurologistas, cegos para o status de HTLV e o diagnóstico de TSP/HAM foi baseado na classificação da Organização Mundial de Saúde, 1988. A primeira contagem de células T disponível antes da terapia anti-retroviral foi mostrada para comparar com os pacientes infectados pelo HIV no momento do evento definidor de aids de acordo com Classificação do Centro de controle de Doenças, 1988. RESULTADOS: Um total de 27 HIV-1/HTLV-1 co-infectados foram identificados na coorte, 15 já apresentavam aids e 12 permaneceram sem evento de aids. A mediana de células T CD4 foi de 189 (98-688) células/mm³ e 89 (53-196) células/mm³ nos co-infectados que tinham evento definidor de aids e naqueles com a infecção somente pelo HIV, respectivamente (p = 0,036). Oito dos 27 co-infectados (30 por cento) foram diagnosticados tendo TSP/HAM símile, e três deles mostraram elevada contagem de células T CD4 e apresentaram infecções oportunistas no momento do evento definidor de aids. DISCUSSÃO: Nossos resultados...

Urodynamic features of the voiding dysfunction in HTLV-1 infected individuals

OBJECTIVE:To describe urodynamic abnormalities in HTLV-1 infected individuals presenting urinary symptoms and verify if these findings and quality of life (QOL) evaluation correlate with overall neurological impairment. MATERIALS AND METHODS: From January/2001 to May/2004, 324 HTLV-1 seropositive subjects were evaluated to determine the occurrence of urinary symptoms. Urodynamic testing was performed in those who complained of frequency, urgency, or incontinence. They went through a complete clinical, neurological, and urological examination to investigate symptoms and signs of myelopathy. Neurological disability was assessed by Expanded Disability Status Scale (EDSS). RESULTS: From the 324 patients evaluated, 78 underwent the urodynamic testing. Fifty-seven individuals were females (73.1 percent) and age ranged from 23 to 76 years (mean = 48.7 years; SD ± 11.6). Urodynamic testing was abnormal in 63 patients (80.8 percent). The major abnormality was detrusor overactivity (DO), observed in 33 individuals (33/63; 52.4 percent), followed by detrusor-external sphincter dyssynergia (DESD), diagnosed in 15 subjects (15/63; 25.4 percent). HAM/TSP patients had significantly more DESD than the HTLV-I carriers (p = 0.005; OR = 5.5; CI: 1.6 to 19.4). QOL was severely compromised in HAM/TSP patients. CONCLUSIONS: Prominent urodynamic abnormalities were identified in individuals genuinely considered as HTLV-I carriers, suggesting an early compromise of the urinary tract; whereas HAM/TSP patients presented urodynamic findings, which posed a potential risk to the upper urinary tract (dyssynergia). Urodynamic evaluation should be performed in all HTLV-I-infected individuals with voiding complaints.

Urinary and sexual manifestations of patients infected by HTLV-I

HTLV-I is considered to be a virus of low morbidity, since the principal diseases associated with this viral infection, HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP) and adult T-cell leukemia/lymphoma (ATLL), are observed in less than 5 percent of infected individuals. Urinary symptoms are frequent in patients with myelopathy and consist principally of nocturia, frequency, urgency, and urinary incontinence; however, the importance of these dysfunctions and their correlation with myelopathy is still to be fully clarified. This review gives particular emphasis to the high frequency of urinary and sexual complaints not only in patients with myelopathy but also in individuals considered to be HTLV-I carriers. Detrusor overactivity and bladder-sphincter dyssynergia are the most common urodynamic findings. The fact that urinary complaints and urodynamic parameters reported in individuals considered to be carriers are similar to those detected in patients with myelopathy supports the hypothesis that urinary disorders may represent an oligosymptomatic form of HAM/TSP. Erectile dysfunction is frequently observed in HTLV-I-infected patients with or without myelopathy. Urinary tract infections are also highly prevalent in these patients. Despite the lack of an effective treatment for myelopathy, the use of anticholinergic drugs and phosphodiesterase type 5 (PDE5) inhibitors may improve urinary complaints and erectile dysfunction in these patients.

O HTLV-1 é considerado um vírus de baixa morbidade sendo a mielopatia associada ao HTLV-1 (HAM/TSP) e a leucemia / linfoma de células T do adulto (ATL) as principais doenças associadas à infecção viral, observados em menos de 5 por cento dos indivíduos infectados. Manifestações urinárias são freqüentes em pacientes com mielopatia, e representadas principalmente por noctúria, polaciúria, urgência e incontinência urinária, embora a importância destas alterações, e a correlação com a patologia medular não tem sido devidamente estudada. Nesta revisão enfatizamos a elevada freqüência de queixas urinárias e sexuais em pacientes, não apenas os portadores de mielopatias, mas também em indivíduos considerados como portadores assintomáticos do HTLV-I. Hiperatividade detrusora e dissinergia vesico-esfincteriana são as manifestações urodinâmicas mais freqüentes. A documentação de queixas urinárias e os achados urodinâmicos observados em indivíduos considerados portadores assintomáticos são semelhantes aos detectados em pacientes com mielopatia dão suporte à hipótese que alterações urinárias possam representar uma forma oligossintomática da HAM/TSP. Disfunção eréctil é freqüentemente observada em pacientes infectados pelo HTLV-1, com ou sem mielopatia. Infecção do trato urinário também tem elevada prevalência nestes pacientes. A despeito da ausência de um tratamento efetivo da mielopatia, o uso de anticolinérgicos e de inibidores da fosfodiesterase tipo 5 podem melhorar as queixas urinárias e a disfunção eréctil destes pacientes.