Vacuolar myelopathy and vacuolar cerebellar leukoencephalopathy: a late complication of AIDS after highly active antiretroviral therapy-induced immune reconstitution

Acute paraparesis in HIV-infected patient after initiation of highly active antiretroviral therapy

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.

Human immunodeficiency virus-associated vacuolar encephalomyelopathy with granulomatous-lymphocytic interstitial lung disease improved after antiretroviral therapy: a case report

Background

Vacuolar encephalomyelopathy, a disregarded diagnosis lately, was a major neurological disease in the terminal stages of human immunodeficiency virus (HIV)-1 infection in the pre-antiretroviral therapy (ART) era. Granulomatous-lymphocytic interstitial lung disease (GLILD) was classically identified as a non-infectious complication of common variable immunodeficiency; however, it is now being recognized in other immunodeficiency disorders. Here, we report the first case of GLILD accompanied by vacuolar encephalomyelopathy in a newly diagnosed HIV-infected man.

Case presentation

A 40-year-old Japanese man presented with chronic dry cough and progressing paraplegia. Radiological examination revealed diffuse pulmonary abnormalities in bilateral lungs, focal demyelinating lesions of the spinal cord, and white matter lesions in the brain. He was diagnosed with GLILD based on marked lymphocytosis detecting in bronchoalveolar lavage, and transbronchial-biopsy proven T-cellular interstitial lung disease with granulomas. Microbiological examinations did not reveal an etiologic agent. The patient was also diagnosed with HIV-associated vacuolar encephalomyelopathy on the basis of an elevated HIV viral load in cerebrospinal fluid. After initiating ART, the brain lesions and paraplegia improved significantly, and interstitial abnormalities of the lungs and cough disappeared.

Conclusion

This report highlights that even in the post-ART era in developed countries with advanced healthcare services, HIV-associated vacuolar encephalomyelopathy should be considered in the differential diagnosis of a progressive neurological disorder during the first visit. Furthermore, GLILD may represent an HIV-associated pulmonary manifestation that can be treated by ART.

HIV-Associated Vacuolar Encephalomyelopathy

We report a case of human immunodeficiency virus (HIV)-associated vacuolar encephalomyelopathy with progressive central nervous system dysfunction and corresponding vacuolar degeneration of the spinal cord, cranial nerves, and brain, the anatomic extent of which has not previously been described.

HIV neuropathology

Primary human immunodeficiency virus (HIV) neuropathologies can affect all levels of the neuraxis and occur in all stages of natural history disease. Some, like HIV encephalitis, HIV myelitis, and diffuse infiltrative lymphocytosis of peripheral nerve, reflect productive infection of the nervous system; others, like vacuolar myelopathy, distal symmetric polyneuropathy, and central and peripheral nervous system demyelination, are not clearly related to regional viral replication, and reflect more complex cascades of dysregulated host immunity and metabolic dysfunction. In pediatric patients, the spectrum of neuropathology is altered by the impacts of HIV on a developing nervous system, with microcephaly, abundant brain mineralization, and corticospinal tract degeneration as examples of this unique interaction. With efficacious therapies, CD8 T-cell encephalitis is emerging as a significant entity; often this is clinically recognized as immune reconstitution inflammatory syndrome, but has also been described in the context of viral escape and treatment interruption. The relationship of HIV neuropathology to clinical symptoms is sometimes straightforward, and sometimes mysterious, as individuals can manifest significant deficits in the absence of discrete lesions. However, at all stages of the natural history disease, neuroinflammation is abundant, and critical to the generation of clinical abnormality. Neuropathologic and neurobiologic investigations will be central to understanding HIV nervous system disorders in the era of efficacious therapies.

Central nervous system immune reconstitution inflammatory syndrome in AIDS: experience of a Mexican neurological centre

BACKGROUND

Highly active antiretroviral therapy (HAART) restores the inflammatory immune response in AIDS patients and it may unmask previous subclinical infections or paradoxically exacerbate symptoms of opportunistic infections. Up to 25% of patients receiving HAART develop immune reconstitution inflammatory syndrome (IRIS). We describe six patients with IRIS central nervous system (CNSIRIS) manifestations emphasizing the relevance of CSF cultures and neuroimaging in early diagnosis and management.

METHODS

Patients with CNSIRIS were identified among hospitalized HIV-infected patients that started HAART from January 2002 through December 2007 at a referral neurological center in Mexico.

RESULTS

One-hundred and forty-two HIV-infected patients with neurological signs were hospitalized, 64 of which had received HAART, and six (9.3%) developed CNSIRIS. Five patients were male. Two cases of tuberculosis, two of cryptococcosis, one of brain toxoplasmosis, and one possible PML case were found. IRIS onset occurred within 12 weeks of HAART in five patients. Anti-infective therapy was continued. In one case, HAART was temporarily suspended. In long-term follow-up the clinical condition improved in all patients.

CONCLUSIONS

CNSIRIS associated to opportunistic infections appeared in 9% of patients receiving HAART. Interestingly, no cases of malignancy or neoplasm IRIS-related were found. Frequent clinical assessment and neuroimaging studies supported diagnosis and treatment. Risk factors were similar to those found in other series.

Triad of visual, auditory and corticospinal tract lesions: a new syndrome in a patient with HIV infection

OBJECTIVE

A case of a rapidly progressive degeneration of the visual, auditory and corticospinal tract in a patient with a HIV infection is presented.

METHODS AND RESULTS

The HIV-infected patient suffered from severe and rapidly progressive sensorineural hearing loss, blindness, dysarthria, dysphagia and tetraparesis. MRI showed degeneration of the visual, auditory and corticospinal tract. Diffusion tensor imaging showed reduced fractional anisotropy of the corticospinal tract. HAART and other salvage therapies did not save the patient from death 5 months after the onset of the symptoms.

CONCLUSION

The triad of auditory, visual and corticospinal lesions has been described in rare syndromes and hereditary diseases. This is the first case of this syndrome associated with a HIV infection.

Diffusion tensor MR imaging (DTI) metrics in the cervical spinal cord in asymptomatic HIV-positive patients

INTRODUCTION

This study was conducted to compare diffusion tensor MR imaging (DTI) metrics of the cervical spinal cord in asymptomatic human immunodeficiency virus (HIV)-positive patients with those measured in healthy volunteers, and to assess whether DTI is a valuable diagnostic tool in the early detection of HIV-associated myelopathy (HIVM).

METHODS

MR imaging of the cervical spinal cord was performed in 20 asymptomatic HIV-positive patients and in 20 healthy volunteers on a 3-T MR scanner. Average fractional anisotropy (FA), mean diffusivity (MD), and major (E1) and minor (E2, E3) eigenvalues were calculated within regions of interest (ROIs) at the C2/3 level (central and bilateral anterior, lateral and posterior white matter).

RESULTS

Statistical analysis showed significant differences with regard to mean E3 values between patients and controls (p = 0.045; mixed-model analysis of variance (ANOVA) test). Mean FA was lower, and mean MD, mean E1, and mean E2 were higher in each measured ROI in patients compared to controls, but these differences were not statistically significant.

CONCLUSION

Asymptomatic HIV-positive patients demonstrate only subtle changes in DTI metrics measured in the cervical spinal cord compared to healthy volunteers that currently do not support using DTI as a diagnostic tool for the early detection of HIVM.

Pilot study of intravenous immunoglobulin in HIV-associated myelopathy

There is no effective treatment for HIV-associated myelopathy (HIVM). The introduction of highly active antiretroviral therapy (HAART) has made little difference to its natural history. Spinal cord pathology reveals vacuolization and inflammation. Intravenous immunoglobulin (IVIg) is used successfully in a number of inflammatory conditions associated with HIV. In view of the potential for reversibility of the inflammatory response in HIVM, we treated 17 patients with IVIg twice over a 56-day study period. There was improvement in composite Medical Research Council (MRC) strength scores 28 days following the first infusion (increase in score: 3.94; p = 0.021). The second infusion did not produce further improvement, however there was little reduction from peak strength. These pilot data suggest that further investigation of the use of IVIg in HIVM is warranted.

Atteintes du système nerveux central et infection par le VIH-1

Central nervous system complications are common in HIV-1 infected patients and occur either as a result of concomitant immunosuppression (opportunistic infections, lymphoma and tumors), as a primary manifestation of HIV infection, or as an adverse effect of therapy (immune restoration and toxicity). These complications contribute largely to patient morbidity and mortality. In the era of highly active antiretroviral therapy (HAART) these disease states have changed in presentation, outcome and incidence. We review in detail the epidemiology, pathogenesis, clinical features, diagnosis, and management of these disorders.

Recurrent vacuolar myelopathy in HIV infection

OBJECTIVES

Vacuolar myelopathy is the major cause of spinal cord disease in HIV-1 infection. However, the pathogenesis remains unclear. Diagnosis is mainly based on characteristic clinical symptoms in combination with characteristic MRI changes. Usually, it is a slowly progressive chronic disease affecting HIV-infected individuals with low CD4 T-cell counts.

CASE

Here, we report an uncommon case of vacuolar myelopathy in an HIV-infected woman with recurrent clinical symptoms and MRI changes of vacuolar myelopathy and with a preserved CD4 T-cell count when symptoms occurred for the first time.

CONCLUSIONS

This is the first case, to show that vacuolar myelopathy can have relapsing-remitting clinical symptoms and MRI changes.