Acute unilateral cerebellitis, Epstein-Barr virus, and HIV

Abstract

A 31-year-old man presented to the emergency depart ment with a 2-day history of severe headache, nausea, and vomiting. He reported intermittent tremors in his left hand and ataxic gait for 2 weeks. Neuro logical examinations showed dysarthria and left-sided dys metria on fi nger-tonose and heel-knee-shin tests. Brain MRI showed a poorly defi ned hetero geneous hyper intensive lesion of the left cerebellar hemisphere (fi gure, A [axial T2-weighted] and B [axial T1-weighted]) and obstructive hydrocephalus caused by a cerebellar mass-eff ect (fi gure, C [sagittal T1-weighted]). Serology investi gations for bacteria, fungi, and viruses indicated un remark able results; tests for HIV and EpsteinBarr virus (EBV) were positive. HIV viral load was 2554 copies per mL and CD4 count was 235 cells per μL. CSF analysis showed pleocytosis and increased protein concentration; bacterial and fungal cultures and examinations for syphilis, cryptococcus, toxo plasmosis, and acid-fast bacilli were negative. EBV PCR of CSF was positive. Stereotactic biopsy of the cerebellum was done, and histopathological examination indicated infl ammatory infi ltration with abundant lymphocytes and histiocytes without evidence of malignant disease. Furthermore, EBVencoded RNA was expressed in infi ltrating cells. Highly active antiretroviral therapy (tenofovir, lamivudine, efavirenz), antiviral therapy (ganciclovir), and steroids (beta methasone) were prescribed for EBV-related acute cerebellitis. Follow-up brain MRI showed regression of the cerebellar infl ammatory lesion (fi gure D–F), indicating a substantial improvement in the clinical condition. He recovered well without substantial neurological sequelae. CNS infection in patients with HIV can be associated with various pathogens including viruses, toxoplasmosis, syphilis, and cryptococcus. The clinical manifestations, specifi c area involved, and immune status of patients can assist with the diff erential diagnosis. In our patient, cerebellitis was a characteristic sign distinguishable from other causes. The possibility of an EBV infection should be considered in the diff erential diagnosis of CNS lesion in patients with HIV, and EBV-related malignant diseases should be diff erentiated, to ensure appropriate treatment.