Acute paraplegia in a patient with AIDS and a normal CSF examination

Abstract

We report a case of tuberculous myeloradiculitis in a patient with AIDS. The case highlights the difficulty in reaching a diagnosis for the neurological symptoms of a patient with a normal CSF examination and the need for HIV screening of KEYWORDS: tuberculosis, HIV, myeloradiculitis.A 35-year-old Zimbabwean woman living in London, England, presented to the local accident and emergency department with a history of cough, shortness of breath, nausea, vomiting, diarrhea, and weight loss of 3 months' duration. Her chest X-ray showed miliary shadowing. She was admitted to the hospital and commenced on antituberculous medications and offered an HIV test. Two weeks later, her sputum grew acid-fast bacilli (AFB) and her HIV-1 test came back positive. Her baseline T-lymphocyte CD4 cell count was 6 cells/mm 3 (reference range 455-1320), and her HIV-1 RNA viral load (VL) was 4,760,000 copies/mL. However, because of her multiple symptoms, her antiretroviral therapy was postponed. Four weeks later the patient's general condition improved, but she started to experience pain in her right thigh, followed by progressive right leg weakness without sensory loss. This new change affected her mobility, and she fell while walking. Within a week the patient developed progressive flaccid paraparesis with radicular sensory disturbance. This was followed by acute onset of flaccid paraplegia, extensor plantars, sensory loss to T10, and urinary incontinence. Her cerebrospinal fluid (CSF) examination revealed normal protein, glucose, and white cell count and no AFB or malignant cells, A second CSF after 3 weeks was abnormal, with protein of 0.79 g/L, normal glucose, 7 white cells (no malignant cells), and positive oligoclonal bands. The CSF screening for AFB-PCR, treponemes, toxoplasma, cryptococcal antigen Epstein-Barr virus, cytomegalovirus (CMV), herpes simplex virus, human T-lymphotropic virus, and JC virus was negative. Neurophysiological studies confirmed the presence of severe multilevel radiculopathy. The MRI scan of her head and spine showed multiple intraparenchymal cerebral tuberculomata and cavitation at T 9-11 that enhanced postgadolinium (see Fig. 1). She was commenced on highly active antiretroviral therapy (HAART) and steroids. Ten weeks later her HIV-1 RNA VL became undetectable in the ultrasensitive assay (cutoff 50 copies/mL), and she regained sensation in both legs and was able to stand with support. Posttreatment MRI appearances demonstrated