An HIV-Infected Man With Muscle Weakness and Spasms

A 41-year-old man was referred for complaints of muscle weakness, stiffness, and chronic back pain for 10 months. The patient stated that, when he stretched his legs, they would not relax, and he could not put them down because of thigh stiffness. He was found to be HIV-positive 10 years previously and had chronic back pain related to a car accident 3 years prior to presentation. He had also had a previous lumbar laminectomy.

He complained of some neck and back stiffness. MRI of the neck showed a bulging disk, and MRI of the back was essentially normal except for postoperative changes.

The patient had been on lamivudine and abacavir for his HIV. Because of the weakness and an elevated serum creatine kinase (CK) of 3700 IU/L (normal, 60–210 IU/L), he underwent a muscle biopsy elsewhere, and this showed “inflammation and mitochondrial changes.” He had had an EMG that showed scattered denervation potentials and normal nerve conduction tests.

Viral load was low and lymphocyte counts had been stable.

Past medical history and family history were noncontributory, except for a brother who died of leukemia. He stated that he had lost over 20 lb. He smoked and drank alcohol only occasionally.

Examination revealed normal mentation and cranial nerves. His gait had a mild waddle. Manual muscle testing revealed neck flexors and extensors to be 5/5; shoulder abduction and extension, 5−/5; biceps and triceps, 4+/5; wrist extensors, flexors, hand muscles, and finger extensors and flexors, 5−/5. Iliopsoas strength was 5−/5 and the glutei were 5−/5. Quadriceps were 4/5; adductors, 5−/5; and hamstrings, 5−/5. Distal lower extremity strength was normal. Reflexes in the upper extremities were 2+. He only had trace reflexes in the knees and ankles. Sensation to vibration and pinprick were normal in the legs and arms. There were no fasciculations or myotonia present. Straight leg raising test was negative. While the patient was seated, his knee was extended; he had slow relaxation, but there were no contractures and the knee could be flexed completely on passive range-of-motion testing. The rest of the examination was unremarkable.

Forced vital capacity was 3.88 L, which is 79% of predicted.