Acetyl-l-carnitine and nucleoside reverse transcriptase inhibitor-associated neuropathy in HIV infection.

OBJECTIVES: Antiretroviral toxic neuropathy (ATN) is associated with dideoxynucleoside reverse transcriptase inhibitor use in patients infected with HIV, possibly as a result of mitochondrial toxicity. Acetyl-l-carnitine (ALC) has been linked to symptomatic improvement in ATN. We present an open-label single-arm pilot study to evaluate changes in intra-epidermal nerve fibre (IENF) density and mitochondrial DNA (mtDNA) copies/cell among subjects treated with 3000 mg ALC daily. METHODS: Punch skin biopsies were examined at baseline and after 24 weeks of therapy. Participants reported neuropathic symptoms using the Gracely Pain Intensity Score. Neurological examinations were completed. RESULTS: Twenty-one subjects completed the study. ALC was generally well tolerated. The IENF density did not change in cases completing 24 weeks of ALC therapy, with median (90% confidence interval) IENF changes of -1.70 (-3.50, infinity) (P=0.98) and 2.15 (-0.10, infinity) (P=0.11) for the distal leg and proximal thigh, respectively. Fat mtDNA copies/cell did not change with therapy. Improvements in neuropathic pain (P<0.01), paresthesias (P=0.01), and symptoms of numbness (P<0.01) were noted. Similarly, improvement was noted on the Gracely Pain Intensity Score. CONCLUSIONS: ALC therapy coincided with improvements in subjective measures of pain in this open-label single-arm study. However, changes were not observed in objective measures of IENF density or mtDNA levels, providing little objective support for use of ALC in this setting.

Focal neurological deficits and West Nile virus infection.

Our experience with West Nile virus infection revealed that 54% of 28 patients had a focal neurological deficit at presentation. A meningitis or encephalitis syndrome was absent in 47% of patients with focal deficits. Details of the variety of deficits, the time to development of deficits, and the associated radiological and laboratory findings are also discussed in the present report.

Listeria and atypical presentations of Listeria in the central nervous system.

Listeria monocytogenes infection of the central nervous system is often not recognized and treated appropriately in the crucial early stages of the disease. Most consider patients with underlying disease or immunocompromised states to be at risk, although healthy individuals may present with a neurologic syndrome caused by L. monocytogenes. Earlier suspicion and treatment remains our best means of reducing the morbidity and high mortality rate of this treatable disease. In addition to meningitis and meningoencephalitis, infection of the brainstem (rhomboencephalitis) is challenging to recognize and therefore initiate appropriate early therapy. Cerebritis and abscess can also occur. Furthermore, empirical therapy for meningitis or the other manifestations of nervous system involvement is often inadequate. This review addresses the clinical microbiology, pathogenesis, spectrum of neurological involvement, and treatment of central nervous system infection related to L. monocytogenes.