Acute paraparesis in HIV-infected patient after initiation of highly active antiretroviral therapy
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CASE REPORT
Acute paraparesis in HIV-infected patient after initiation of highly active antiretroviral therapy Preeti Dalal 1 & Karuna Anot 1 & Gupta Monica 1
&
Sanjay D’Cruz 1
Received: 28 February 2020 / Revised: 28 February 2020 / Accepted: 3 July 2020 # Journal of NeuroVirology, Inc. 2020
Abstract Neurological syndromes occur in around 40–70% of HIV-infected people. Direct central nervous system involvement by the virus usually manifests as HIV encephalitis, HIV leucoencephalopathy, vacuolar leucoencephalopathy or vacuolar myelopathy. Indirect involvement is usually associated with neurotropic opportunistic infections which include tuberculosis, toxoplasmosis, cryptococcosis and viral encephalitis such as herpes simplex, varicella-zoster, cytomegalovirus and Human polyomavirus 2. We report a case of transverse myelitis in a recently diagnosed HIV patient who was otherwise asymptomatic initially and developed paraparesis after 1 month of initiation of antiretroviral therapy. After ruling out opportunistic infections and other causes of compressive and non-compressive myelopathy, development of transverse myelitis was attributed to immune reconstitution inflammatory syndrome in view of baseline low CD4 count and their improvement after HAART initiation. Prompt treatment with corticosteroids successfully reversed the symptoms. Keywords Highly active anti-retroviral therapy . Transverse myelitis . Imuune reconstitution inflammatory syndrome
Introduction Spinal cord involvement in HIV can either be in the form of compressive or non-compressive myelopathy. Noncompressive myelopathy can present as primary HIVassociated transverse myelitis usually occurring at presentation or at seroconversion and arises mainly because of immune dysregulation and the existing pro-inflammatory state (Aboulafia and Taylor 2002, Mathew et al. 2019). HIV preferentially depletes CD4 regulatory T cell, shifting the host immune response to cytotoxic CD8 T cells which causes immune-mediated demyelination in the spinal cord leading to transverse myelitis. Secondary causes of transverse myelitis or myelopathy include cytomegalovirus (CMV) radiculomyelitis, herpes simplex virus (HSV) sacral radiculomyelitis, varicella-zoster myelitis, spinal cord tuberculosis, spinal cord syphilis and lymphomas. Occasionally, other neurological manifestations can occur in early stages of HIV-like peripheral neuropathy, radiculopathy, facial palsy * Gupta Monica [email protected] 1
Department of General Medicine, Government Medical College Hospital, Level 4 D Block, Sector 32 Chandigarh 160030 India
and Guillain-Barre syndrome (Niu et al. 1993). HIVassociated vacuolar myelopathy occurs in late stages and mainly in untreated patients.
Case presentation A 35-year-old male was incidentally diagnosed with HIV infection 1 month back when his wife was routinely screened for HIV during her pregnancy. Patient gave history of multiple unprotected sexual exposures prior to his marriage, although there was no history of any intravenous needle use. Patient h
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