In Reply: We believe several important issues should be considered regarding NMS and HIV infection. Epidemiologically, one cannot conclude from a series of cases separate from a defined population that the risks of NMS will be higher in persons with HIV infection. There may also be reporting bias; that is, so many case reports of NMS have appeared in the literature that NMS cases with interesting comorbidities may be more likely to be submitted and published than reports of "routine" cases.
If NMS does occur more often in patients with AIDS, such occurrence might be a nonspecific effect of other recognized risk factors such as dehydration, malnutrition, or organic brain disease. In any case, we certainly agree that clinicians should be on the alert for NMS in patients with AIDS. Fever, altered mental status, and autonomic instability are frequent in AIDS, making NMS more difficult to discern.