Autonomic Neuropathy in HIV: A Case Report and Review of Potential Symptoms in an Advanced-Stage, HIV Cohort

A woman with a seventeen-year history of HIV infection on effective antiretroviral therapy presented with signs and symptoms of distal symmetric polyneuropathy (DSP). She developed significant side effects (dizziness, nausea, edema) with medications for pain management. Chart review revealed a history of similar intolerance to multiple antiretrovirals, which was not explained by known cardiac or gastrointestinal disease or psychological factors. Specialized testing revealed the presence of an autonomic neuropathy, which provided an explanation for her medication intolerance. The patient was educated on the symptoms of autonomic neuropathy and its relationship to DSP and subsequent symptommatic medications were initiated at the lowest possible doses. Although symptom management remained challenging, the patient exhibited lower frustration and greater acceptance of medication trials. Review of 168 advanced stage HIV infected individuals demonstrated that 81% experienced at least one, and 33% three or more, symptoms potentially attributable to autonomic neuropathy. Potentially autonomic symptoms were significantly associated with the presence of symptomatic DSP. Autonomic neuropathy is difficult to diagnose without specialized testing, as its symptoms are non-specific and overlap with a large number of somatic disorders. The high prevalence of autonomic-type symptoms in chronic HIV, and their association with peripheral neuropathy, may warrant further investigation of the potential for autonomic dysfunction in individuals with HIV-related symptomatic DSP.