Bilateral diaphragmatic paralysis in an HIV patient: Second reported case and literature review
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, ordinary physical activity would result in breathlessness in the patient. There was no history of thoracic trauma or preexisting respiratory or cardiac diseases.\nClinical examination showed stable vital signs. 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.\nRoutine laboratory investigations were within normal limits. CD4 cell count was 170/μl 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. Electrocardiogram was normal. Chest X-ray revealed the elevation of the right and left hemidiaphragms in a full inspired film [] and its immobility detected through a radioscopic examination. The cardiomediastinal silhouette was normal. 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. Patient was lost to follow-up.