Home Nervous System HIV with Opportunistic Neuroinfection
Clinical History
Examination
Investigations
Diagnosis
Treatment
Discussion
References

34 year old male with complaints of
-Fever since 2 days, moderate grade, associated with chills and rigors
-Unresponsiveness since 2 days

Known case of HIV since one year, non adherent to Anti-retroviral therapy medication

Known case of Miliary TB was treated with Anti-Tubercular therapy (ATT) 1 year back.

Known case of Seizure disorder on medication
(Tab. Levetiracetam)

CNS Examination:
-Patient was conscious, not oriented, was not obeying oral commands
-Neck Rigidity was present
-Kernig sign was positive

  • Bilateral pupils are equal and reactive
  • Cerebellar Signs – Not Elicited

CVS: S1 S2 heard. No Murmurs

Respiratory System: Bilateral normal vesicular breath sounds heard. No adventitious sounds

Per Abdomen: Soft, Non-tender, No organomegaly. Bowel sounds heard.

Fundoscopy: Normal

CSF Analysis:
Cell count: 42
98% Lymphocytes,
2% Neutrophils
CSF LDH: 223 U/L

ZN Staining:
Negative for AFB
Cryptococcal Capsular Polysaccharide Antigen: Positive in Serum and CSF

CD4 count: 63cells/mm3
HIV Viral Load: 36936 copies/mL
Sodium: 121mEq/L
Potassium – 3.5mEq/L
Chloride – 85mEq/L

USG Abdomen and pelvis: Bulky Kidneys and Splenomegaly.
CT Brain: Bilateral ill-defined hypo-densities in the frontal, insular and temporal lobes suggestive of Progressive Multifocal Leukoencephalopathy (PML)

HIV with
-TB Meningitis,
-Cryptococcal Meningitis,
-Progressive Multifocal Leukoencephalopathy,

Hyponatremia probably due to SIADH.

Anti Tubercular Treatment as per DOTS Regime
3% Normal saline infusion for correction of hyponatremia
Inj. Dexamethasone 4mg IV
Inj. Amphotericin B 1mg/kg in 500ml of 5% Dextrose for 14 days
Tab Fluconazole 800 mg OD for 14 days
Tab Co-trimoxazole DS 1 OD
Tab. Levetiracetam 500mg BD
Referred to Anti Retroviral Treatment Centre for further Management

HIV positive patients are at an increased risk of opportunistic infections (O.I) like Tuberculosis. It can present as Pulmonary and Extra-Pulmonary manifestations.

Neuroinfections like TBM and Cryptococcal meningitis are common, predisposition to certain infection depends on CD4 count. These can give rise to complications with a high mortality rate. (1) Starting ART early prevents these complications. Resistance to drugs and failure to ART is mostly due to non- adherence to the treatment. It is important to monitor all patients regularly for clinical, immunological and virological failure(2).

  1. Vinnard C, Macgregor RR. Tuberculous meningitis in HIV-infected individuals [Internet]. Current HIV/AIDS reports. U.S. National Library of Medicine; 2009. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3131531/
  2. Bezabih YM, Beyene F, Bezabhe WM. Factors associated with first-line antiretroviral treatment failure in adult HIV-positive patients: a case-control study from Ethiopia [Internet]. BMC infectious diseases. BioMed Central; 2019 [cited 2019Sep20]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6582596/

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