An 8-Year-Old Boy With Ascending Paralysis

[A case of neuromyelitis optica spectrum disorder after human immunodeficiency virus infection treated with rituximab]

The patient was a 58-year-old Japanese man. At age 52 years, he was diagnosed with human immunodeficiency virus (HIV) infection and had been receiving highly active antiretroviral therapy (HAART). He presented to the emergency department with acute upper left and right lower extremity paralysis. Spinal cord magnetic resonance imaging showed intramedullary signal changes over three vertebral bodies in the cervical spinal cord. Anti-aquaporin-4 antibody was positive in serum, and neuromyelitis optica spectrum disorder (NMOSD) was diagnosed. Steroid pulse therapy and plasma exchange were performed but had limited effects. In Japan, there is no report of NMOSD after HIV infection treated with rituximab. Rituximab administration should be considered in refractory cases of NMOSD after HIV infection.

HIV infection associated neuromyelitis optica spectrum disorder: Clinical features, imaging findings, management and outcomes

INTRODUCTION

HIV Infection associated NMOSD (HIV-NMOSD) is a recently recognized entity. Management of patients with HIV-NMOSD is a challenge. Here we report our own experience of HIV-NMOSD along with a complete review of all the cases of HIV-NMOSD reported in literature.

OBJECTIVE

Describe the clinical features, radiological findings, treatment patterns and outcomes in patients with HIV-NMOSD.

METHODS

The details of all cases of HIV- NMOSD were searched from our NMOSD registry. A literature search was also done using the terms NMO, NMOSD and HIV infection in PUBMED, Google Scholar and EMBASE. The details of all the reported cases and cases from our registry were collected and analyzed.

RESULTS

Six cases of HIV-NMOSD were identified from the literature and one from our registry. There were four males and three females with age ranging from 8 years to 49 years. Duration of HIV infection ranged from newly detected to 15 years. Optic neuritis followed by myelitis was the commonest presentation, occurring in 5 out of 7 patients. 3 patients were anti-aquaporin 4 antibody positive while 3 were negative and in one anti- aquaporin 4 antibody assay was not done. All patients received immunomodulatory treatment. 5/7 patients had poor recovery from acute attacks but no patient had further relapses while on immunomodulatory treatment and antiretroviral therapy.

CONCLUSION

HIV associated NMOSD is a recently recognized entity. A high index of suspicion is needed to diagnose these patients. In all patients with HIV infection presenting with optic neuritis or/and myelitis, anti aquaporin 4 antibody status should be checked and in all patients of NMOSD, HIV infection should be ruled out.