TSP/HAM during HIV/HTLV-1 Coinfection • CID 2005:41 (15 September) • e57
M A J O R A R T I C L E
Tropical Spastic Paraparesis/Human T Leukemia
Virus Type 1–Associated Myelopathy in HIV
Type 1–Coinfected Patients
Mark A. Beilke,1,2Shanker Japa,1,2Christiane Moeller-Hadi,1and Sheryl Martin-Schild1
1Tulane University Health Sciences Center and
New Orleans, Louisiana
2Charity/Tulane/Louisiana State University General Clinical Research Center,
(TSP/HAM) is rarely reported in the United States. The causative agents of TSP/HAM are HTLV-1 and, possibly,
its cosmopolitan variant, human T leukemia virus type 2 (HTLV-2). Among HTLV-1– or HTLV-2–monoinfected
individuals, the estimated lifetime risk for development of TSP/HAM is !2%. However, it has been suggested that
HIV/HTLV coinfection may increase the risk for development of TSP/HAM.
A total of 2239 human immunodeficiency virus (HIV)–infected patients were tested for HTLV-1
and HTLV-2 infection at the New Orleans Outpatient Clinic (Louisiana) during the period 1991–1998. HTLV-1–
infected patients with suspected myelopathy were referred for additional evaluation.
Four cases of TSP/HAM (9.7%) were identified among 41 individuals with Western blot–confirmed
HTLV-1 infection. The diagnosis was confirmed with use of molecular diagnostic assays and viral isolation. No
TSP/HAM cases were identified among 65 patients with HIV–HTLV-2 coinfection. An additional patient with
HIV–HTLV-1 coinfection also received a diagnosis of TSP/HAM at the New Orleans Veteran’s Affairs HIV Out-
patient Clinic (Louisiana). All patients had normal CD4+T cell counts at the time of diagnosis.
Given the high rates of HIV-HTLV coinfection in the United States, a heightened suspicion for
TSP/HAM should be considered in HIV-infected patients who present with normal CD4+T cell counts and
myelopathy in the absence of other acquired immunodeficiency syndrome–defining conditions.
Tropical spastic paraparesis/human T leukemia virus type 1 (HTLV-1)–associated myelopathy
In 1985, it was proposed that human T leukemia virus
(HTLV) type 1 (HTLV-1) was the etiologic agent of
tropical spastic paraparesis/HTLV-1–associated myelo-
pathy (TSP/HAM) on the basis of evidence accumu-
lated in HTLV-1 seroprevalence studies from Marti-
nique, Trinidad, Jamaica, Japan, and Colombia [1–4].
The causative role of HTLV-1 has been validated
through several lines of evidence: (1) the isolation of
HTLV-1 from CSF specimens obtained from patients
with TSP/HAM , (2) intrathecal synthesis of HTLV-
1 antibodies , (3) detection of viral genome in in-
volved tissues [7, 8], (4) oligoclonal expansion of
Received 26 April 2005; accepted 30 May 2005; electronically published 29
Reprints or correspondence: Dr. Mark A. Beilke, Tulane University Health
Sciences Center, Section of Infectious Diseases, SL-87, 1430 Tulane Ave., New
Orleans, LA 70112 (firstname.lastname@example.org).
Clinical Infectious Diseases2005;41:e57–63
? 2005 by the Infectious Diseases Society of America. All rights reserved.
HTLV-1–specific cytotoxic T lymphocytes in the CSF
, and (5) development of TSP/HAM after transfu-
sion of blood from an HTLV-1–infected donor to an
HTLV-1–seronegative recipient . It has also been
suggested that the antigenically related virusHTLVtype
2 (HTLV-2) also causes TSP/HAM, although less de-
finitive evidence of a causal role exists [11, 12].
TSP/HAM is rarely diagnosed in the United States,
given the low prevalence of HTLV-1 among low-risk
individuals . Among American Red Cross blood
donors, the seroprevalence of HTLV-1/HTLV-2 anti-
bodies is only 0.03%, and TSP/HAM is estimated to
develop in only 1%–2% of HTLV-1–infected individ-
uals over their lifetimes [13, 14]. Moreover, testing for
HTLV-1 infection outside of blood donation situations
is rarely conducted in the United States, except in high-
risk populations. However, among HIV-infected indi-
viduals in large metropolitan areas, the prevalence of
coinfection with either HTLV-1 or HTLV-2 may ap-
proach 5%–10% [15–17].
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TSP/HAM during HIV/HTLV-1 Coinfection • CID 2005:41 (15 September) • e63
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