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Paper text:
bilateral diaphragmatic paralysis is a rare clinical condition due to different entities that can damage the phrenic nerves .
peripheral neuropathy is one of the most common neurological complications of human immunodeficiency virus / acquired immunodeficiency syndrome ( hiv / aids ) disease .
the commonest forms of hiv - associated neuropathies are the distal sensory polyneuropathy and antiretroviral toxic neuropathy ; disorders characterized mostly by sensory symptoms afflicting 40 - 50% of patients whose hiv disease is otherwise controlled by antiretroviral therapy .
however , it is commonly caused by surgical or traumatic injuries , malignant neoplasm , and neurodegenerative disorders .
the relationship of phrenic paralysis with viral infections is rare but also well recognized and exceptionally is a manifestation of a hiv - associated neuropathy , especially when it represents the only manifestation of peripheral neuropathy .
a 42-year - old hiv positive male smoker on antiretroviral therapy ( stavudine , efavirenz , and lamivudine ) with very poor adherence to the medication regimen was admitted because of community acquired pneumonia . since past one year
chest examination revealed paradoxical movement of the diaphragm , during inhalation , when the patient was in the supine position and coarse crepitations near the base of the left lung .
all deep tendon reflexes were normal and there were no other signs of peripheral neuropathy .
cd4 cell count was 170/l and the plasma viral load was 74,746 copies / ml .
serological tests for chagas disease , hepatitis b virus ( hbv ) , and syphilis ( venereal disease research laboratory ( vrdl ) and fluorescent treponemal antibody absorption ( fta abs ) ) were negative whereas imunoglobulin g ( igg ) anti - toxoplasma antibodies were positive .
chest x - ray revealed the elevation of the right and left hemidiaphragms in a full inspired film [ figure 1 ] and its immobility detected through a radioscopic examination .
there were no pulmonary infiltrates , pleural effusion , or mediastinal tumor in the computed tomography ( ct ) scan of the chest .
the forced vital capacity in the sitting position was 1.84 l ( 48% ) and it decreased to 1.29 l ( 34% ) when brought to the dorsal decubitus position ( change of < 30% ) . oxygen saturation while breathing ambient air was 96% .
transdiaphragmatic pressure was 2.99 cm h2o and confirmed the diagnosis of bilateral phrenic paralysis . during the examination ,
a negative deflection of the gastric pressure was observed as a sign of paradoxical movement of the diaphragm .
the electromyography test showed an axonal damage to both phrenic nerves , without compromise in the other territories examined in his four limbs .
patient was started on a new scheme of antiretroviral therapy , without stavudine , and pulmonary rehabilitation exercises .
ten days later , he was discharged from the hospital in a good clinical condition .
the diaphragm is the chief muscle of respiration and its paralysis can lead to dyspnea and can affect ventilatory function .
diaphragmatic paralysis can be unilateral or bilateral ; the clinical symptoms being more prominent in bilateral paralysis .
the diagnoses is usually suspected on chest x - ray and clinical exam and confirmed with sniff test or phrenic nerve stimulation / diaphragm electromyography .
prognosis is usually poor in patients with advanced lung disease , bilateral paralysis , and chronic demyelinating conditions .
it generally manifests as an accompaniment of a generalized polyneuropathy such as the guillain barr syndrome and isolated compromise is rare
. it may be the initial manifestation of a multifocal motor neuropathy , in the course of an amyotrophic neuralgia of the shoulder , or in the cases of post extracorporeal circulation pump paralysis .
postviral neuropathy and phrenic nerve involvement have been described following several viral infections like herpes zoster , poliovirus , west nile virus and hiv infection .
the absence of these causes suggest that the phrenic nerve can be a target in idiopathic neuritis .
hiv - associated neuropathies ( hiv - n ) have become the most frequent neurological disorder associated with hiv infection .
the most common forms of hiv - n are the distal sensory polyneuropathy and antiretroviral toxic neuropathies .
these disorders are characterized mostly by sensory symptoms that include spontaneous or evoked pain that follow a subacute or chronic course and afflicts 40 - 50% of patients whose hiv disease is otherwise controlled by antiretroviral therapy .
advanced hiv disease ( cd4 lymphocyte count 200/l ) predisposes the patient to different neuropathies .
hiv - associated sensory neuropathy is consistently associated with previous exposure to nucleoside reverse transcriptase inhibitors including stavudine ( d4 t ) , which is widely used in resource - limited settings .
stavudine , a nucleoside reverse transcriptase inhibitor , was used as first - line antiretroviral therapy ( art ) in our patient and is said to exacerbate distal symmetrical polyneuropathy in hiv / aids patients .
although recent world health organization guidelines recommend withdrawing d4 t from art , it remains commonly used in resource - limited settings .
genetic variants in mitochondrial dna haplogroups have been associated with increased risk of developing peripheral neuropathy in european non - hispanic and black patients on stavudine .
a medline , embase , and cochrane databases search revealed that one report of a case of a 46-year - old patient , with tcd4 lymphocyte count of 250/l and a plasma viral load of less than 50 copies / ml , who suffered a unilateral phrenic neuropathy that improved after the administration of intravenous igg .
authors suggest that the pathogenicity of phrenic damage is of immune mediated type . in conclusion ,
unilateral or bilateral paralysis of phrenic nerves can be an infrequent manifestation of peripheral neuropathy in patients with hiv infection .
this entity should be considered in the differential diagnosis of patients with hiv infection and respiratory symptoms .
human immunodeficiency virus ( hiv ) disease is widespread all over the world , and the neurological and respiratory complications have been described previously . 
 peripheral neuropathy is one of the commonest neurological complications of the hiv infection . in this report 
 we describe a hiv positive male smoker who was admitted to the hospital because of community acquired pneumonia . 
 bilateral diaphragmatic paralysis was diagnosed for which no other cause was found and was attributed to the hiv infection . 
 isolated phrenic neuropathy and diaphragmatic paralysis in an hiv positive patient is extremely rare and only a single such association has been described previously .