44 y/o bf viral load now non detectable on current regimine of Norvir, Epivie, and Zerit. Now deveoloped severe ascending radiculoapthy with 3-5/5 muscle strength in legs and forearms. Now in hospital on low dose norvir and regular dose saquinivir. All "nukes" stopped and on IV Gangciclovir. CSF cultures pending/negative. ? improvement.?? If no CMV isolated and /or no improvement ? Foscarnet vs. ? Thanks WBH MD

I can't make a diagnosis in this particular case, but CMV radiculopathy (or polyradiculomyelitis) is clearly in the differential diagnosis.

CMV radiculopathy usually presents with pain, weakness, and numbness in the lower extremities. Back or buttock pain or saddle anesthesia can also occur, and bowel and bladder function are commonly affected. Lower extremity reflexes are depressed or absent, and weakness can progress to flaccid paralysis. Upper extremity strength and reflexes are usually normal (I wasn't clear on whether this patient's upper extremity strength was impaired).

MRI of the spine is helpful because it will show diffuse enhancement of the cauda equina and conus medularis. The MRI would be normal in Guillain-Barre or HIV-associated myelitis. CSF will show a large neutrophilic pleocystosis, a positive PCR for CMV, and/or a positive viral culture for CMV.

The treatment of CMV radiculopathy is with IV ganciclovir, IV foscarnet; we don't know whether either is better. Studies are underway evaluating the use of combination ganciclovir/foscarnet.

These are just general comments, but I hope they help ou with your patient.

Oh, I wasn't sure what you meant by "low dose Norvir" and "regular dose saquinavir"--usually it's the other way around. The doses used when you combine those two protease inhibitors are generally 400 mg of saquinavir twice daily and 400 to 600 mg of ritonavir twice daily.