AIDP/CIDP Anal Pap Smear

1. AIDP/CIDPAnal Pap Smear Jeffrey A. Beal, M.D. Faculty, Florida/Caribbean AIDS Education Training Center

2. III.35 AIDP/CIDP Discuss the clinical presentation, differential diagnosis, and management of acute and chronic inflammatory demyelinating polyneuropathy in HIV+ patients

3. III.16 Anal Pap Smears • Describe an anal Pap smear, how it is performed, and its potential use for screening for anal intraepithelial neoplasia in men and women, and discuss indications for referral to a specialist for patients with abnormal Pap smears

4. Acute or Chronic Inflammatory Demyelinating Polyneuropathy (AIDP or CIDP) • Demyelinating Polyneuropathies are diagnosed in 1/3 of HIV+ Patients referred for peripheral nerve disease • Cause: autoimmune-induced inflammatory response and breakdown of peripheral nerve myelin

5. Acute or Chronic Demyelinating Polyneuropathy (AIDP or CIDP) • AIDP • Rapid onset and progression • Often develops during HIV seroconversion or during early HIV infection • CIDP • More common in middle to late stages of HIV disease • Slower onset and progression over several weeks or months

6. Acute or Chronic Demyelinating Polyneuropathy (AIDP or CIDP) • Characteristic features: • AIDP: Progressive ascending lower and upper extremity weakness, more distal than proximal • CIDP: Patchy (can be both distal and proximal) lower and upper extremity weakness • Respiratory paralysis in AIDP • Cranial neuropathy (VII, X, XII) in both

7. Acute or Chronic Demyelinating Polyneuropathy (AIDP or CIDP) • AIDP & CIDP: • Mildly impaired sensation, mild pain • Autonomic dysfunction with cardiac arrhythmia, urinary retention, and blood pressure instability • Hyporeflexia or areflexia • Thomas, et. al.; eMedicine Journal, January 18, 2002, Vol. 3, No. 1

8. Acute or Chronic Demyelinating Polyneuropathy (AIDP or CIDP) • CSF  increased protein with lymphocytic pleocytosis • EMG and nerve conduction velocity studies show marked slowing of nerve conduction velocities and conduction block • Nerve Biopsy macrophage-mediated segmental demyelination

9. Acute or Chronic Demyelinating Polyneuropathy (AIDP or CIDP) • Treatment of AIDP: • Plasmapheresis or IVIG, not corticosteroids • Concomitant GCV, FOS, or, Cidofovir if CD4 < 50 • Treatment of CIDP • Prednisone • Intravenous immunoglobulin as effective as plasma exchange

10. III.16 Anal Pap Smears • Describe an anal Pap smear, how it is performed, and its potential use for screening for anal intraepithelial neoplasia in men and women, and discuss indications for referral to a specialist for patients with abnormal Pap smears

11. Anal Pap Smear • The incidence of anal cancer among HIV infected MSM is higher than that among HIV-negative MSM • Goedert JJ, Cote TR, Virgo P, et al. Spectrum of AIDS-associated malignant disorders. Lancet. 1998;351:1833-1839

12. Anal Pap Smear • The incidence of anal cancer is also elevated among HIV-positive women compared to the general population. • Frisch M, et.al, Human papillomavirus-associated cancers in patients with human immunodeficiency virus infection and acquired immunodeficiency syndrome. J Natl Cancer Inst. 2000; 92:1500-1510

13. Anal Intraepithelial Neoplasia • “Left untreated, anal cancer is fatal. If detected at an early stage, however, survival is excellent among both HIV + and HIV – MSM. Like cervical cancer, anal cancer is probably preventable.” • Screening for and Treatment of Anal Intraepithelial Neoplasia Joel Palefsky, MD HIV/AIDS Update 2002 MEDSCAPE 2002

14. Anal Pap Smear • Palefsky XIV AIDS Conf reported • Prior to HIV, anal cancer incidence in MSM was 35 in 100,000 • Since 1998 the risk has more than doubled and now exceeds the risk of cervical cancer in women • Survey of >350 men in SF, anal swabs and anoscopy found early neoplasia in 52% • Risk independent of CD4 and is not decreased with HAART

15. Anal Pap, Who to screen? • MSM • HIV infected women • HIV infected Men with history of IDU • Women with a history of high-grade CIN/cervical cancer or vulvar intraepithelial neoplasia/vulvar cancer • Men and Women with history of perianal condlyoma • Screening for and Treatment of Anal Intraepithelial Neoplasia Joel Palefsky, MD HIV/AIDS Update 2002 MEDSCAPE 2002

16. Anal Pap Smear • Anal cytology sensitivity appears similar to cervical Pap smears, although the grade of dysplasia may not correlate as well with the histology

17. Anal Pap Smear • Procedure: • Moistened Dacron swab inserted 1-1.5” into anal canal • Rotate swab and withdraw in a tight spiral motion. Sampling process of 15-20 seconds. • Smear on glass slide and fix immediately or use Thin Prep liquid based media

18. Anal Pap Smear • No universally accepted guidelines • Not yet considered Standard of Care • Recommendations: • Perform at initial exam and if normal, repeat in 6 months • If initial 2 Pap smears are Normal, repeat annually. Consider more frequent when CD4 < 500 cells/mm3 • Abnormal results refer for high-resolution anoscopy and biopsy

19. Anal Pap Smear • Cost/Benefit Analysis: • Screening q 2 years beginning during acute HIV infection hypothetical cohort HIV + MSM • Cost of $13,000 per quality-adjusted life year • Annual screening augmented this benefit at a cost of $16,000 per QALY saved • TMP-SMX for PCP prophylaxis results in cost of $13,000 per year of life saved. Goldie, et.al.; May 19, 1999; JAMA

20. Anal Intraepithelial Neoplasia • “Treatment of AIN has not been shown to prevent anal cancer. This is a serious impediment. Unfortunately, it becomes a self-fulfilling prophecy: we will not know until we try it. Cervical cytology screening was practiced for many years before it became clear that it was contributing to the reduction in cervical cancer incidence.” • Screening for and Treatment of Anal Intraepithelial Neoplasia Joel Palefsky, MD HIV/AIDS Update 2002 MEDSCAPE 2002

21. III.35 AIDP/CIDP Discuss the clinical presentation, differential diagnosis, and management of acute and chronic inflammatory demyelinating polyneuropathy in HIV+ patients

22. III.16 Anal Pap Smears • Describe an anal Pap smear, how it is performed, and its potential use for screening for anal intraepithelial neoplasia in men and women, and discuss indications for referral to a specialist for patients with abnormal Pap smears