Abstract
Objectives Human immunodeficiency virus (HIV) is associated with diverse neurological sequelae. Although less commonly encountered in the era of combined anti-retroviral therapy (CART), treated patients with chronic HIV infection may develop subacute and progressive neurological symptoms. We report a case illustrating the rare phenomenon of HIV cerebrospinal fluid (CSF) escape manifesting as neurodegenerative syndromes. We highlight this condition to promote timely optimisation of CART and reduction in HIV-induced neurotoxicity and neurodegeneration.
Case A 42-year-old man with chronic HIV infection and levodopa-responsive parkinsonism without specific alpha synuclean features was referred with diffuse hyperreflexia. He was compliant with CART. During follow-up, he developed mild upper and lower limb weakness and gait instability. Electromyography was consistent with a widespread motor neuropathy or neuronopathy. MRI showed non-specific supratentorial white matter lesions. Serum HIV viral load was suppressed (<20 copies/ml) however CSF viral load was 35 copies/mL. This serum-CSF discordance was consistent with CSF viral escape. CD4 count was 490/μL. CSF analysis showed mild lymphocytic pleocytosis and elevated neopterin level (240nmol/L) indicating neuroinflammation. Drug resistance genotyping identified full susceptibility to anti-retroviral therapy.
HIV-associated neurological overlap syndrome, with pyramidal, extrapyramidal and lower motor neuron features, was diagnosed. CSF escape was thought to be a significant mechanism. The patient’s HIV CART regime was adjusted to improve CNS penetration.
Conclusions Neurosymptomatic HIV CSF escape is a rare and likely underrecognised complication which can occur despite compliance with CART. When suspected, CSF viral load should be tested and CART optimised to improve CNS penetration and reduce HIV-associated neurotoxicity.
