Working Diagnosis:
Right brachial neuritis secondary to human immunodeficiency virus.

Treatment:
Physical therapy was initiated with the goal of maintaining passive range of motion, increasing active range of motion, and improving functional strength of his right shoulder.

Outcome:
Four months after initial diagnosis he was continuing physical and occupational therapy with minimal return of muscle strength. His passive range of motion was intact and he was pain free at that time. He was lost to follow up at 6 months. If further follow-up presents itself, we would attempt a trial of oral prednisone and gabapentin and repeat electromyography/nerve conduction study.

Author's Comments:
Brachial neuritis is a clinical diagnosis. It is characterized by severe pain, often burning or stabbing, in the shoulder. It is soon followed by a patchy weakness of the extremity. The pain may last up to 8 weeks before resolving. The onest of weakness is variable from 24 hours to 2 weeks. Laboratory studies are generally normal when diagnosing brachial neuritis without HIV. Imaging is often not useful for diagnosing neuritis but it can rule out other causes of shoulder pain. Electromyography can help localize the nerves involved; brachial neuritis has a predilection for the suprascapular and long thoracic nerves. The course of brachial neuritis is usually benign with a 36% chance of full recovery in one year, 75% chance in two years, and 89% chance in three years. The mainstays of treatment are: physical therapy, pain control (usually requiring narcotics), surgery is an option but some studies have shown no improvement compared to conservative therapy, and steroids are theorized to help but studies have mixed results.

A small number of case reports describe brachial neuritis in the early stages of HIV infection which makes this case interesting because it is a classic example of brachial neuritis in a growing subset of the population.

Editor's Comments:
Brachial neuritis is a clinical diagnosis. It's onset is abrupt, with two thirds of patients reporting the development of pain in the middle of the night. The pain is severe, throbbing in nature, constant and exacerbated by movement of the shoulder. Pain is followed by the development of progressive weakness and muscle atrophy.

While the majority of cases of brachial neuritis are idiopathic, some patients will often report a recent history of viral illness, surgery, vaccination, or trauma. Systemic lupus erythematosus, polyarteritis nodosa, lymphoma and HIV have been associated with brachial neuritis.

Patients will often present with their affected arm supported by the contralateral arm. They exhibit pronounced muscular tenderness on palpation and after 2 weeks of symptoms may start to show signs of atrophy on inspection of the affected muscles. Passive range of motion is extremely painful and often resisted by affected patients. Weakness may be demonstrated on strength testing in the affected muscles. Sensation may or may not be affected.

Laboratory testing, imaging, and electrodiagnostic testing may fail to produce any clear objective findings to support the diagnosis; however, this testing may need to be done to exclude other diagnoses.

This case highlights the importance of taking a detailed history of the patient's presenting complaint and past medical history as well as performing a thorough physical exam in order to make an accurate clinical diagnosis.

References:
1. Honig K, McCarty E. 2010. Shoulder Injuries. Netter's Sports Medicine. 358.
2. Bromberg M. Feb 2012. Brachial Plexus Syndromes. UpToDate.
3. Miller JD, Pruitt S, McDonald TJ. Nov 2001. Acute brachial plexus neuritis: an uncommon cause of shoulder pain. American Family Physician. 62(9): 2067-72.
4. Calabrese, L, et al. Dec 1987. Acute Infection with Human Immunodeficiency Virus Associated with Acute Brachial Neuritis and Exanthematous Rash. Annals of Internal Medicine. 107(6): 849-851
5. Abad, A, et al. 15 April 2002. Shoulder Girdle Syndrome Revealing Primary HIV Infection. Clinical Infectious Disease. 34(8): 1162-1163.
6. Alfen, N, Engelen, B. 2006. The clinical spectrum of neuralgic amyotrophy in 24 cases. Brain. 129: 438-450
7. Touze, L, et al. July 2003. Bilateral amyotrophic neuralgia (Parsonage Turner syndrome) with HIV seroconversion. Rev Neurol (Paris). 159(6-7 Pt 1): 685-687.
8. Ashworth, N, Meier, R. 18 Jan 2012. Brachial neuritis. Medscape Reference. .

The views expressed in this case report are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government. Opinions, interpretations, conclusions, and recommendations herein are those of the authors and are not necessarily endorsed by the U.S. Army.

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