Neurological manifestations of cytomegalovirus infection with immune reconstitution syndrome in patients with poorly-controlled HIV

Abstract

Cytomegalovirus reactivation is a complication of advanced HIV disease, with the main manifestation being retinitis. Other neurological manifestations are quite rare. The immune reconstitution syndrome has been reported, mainly as a uveitis. We present three cases of AIDS-associated cytomegalovirus disease with atypical neurological manifestations possibly as CMV related immune reconstitution syndrome. Three HIV positive patients, all with recent changes in their antiretroviral therapy regimen, presented with various neurological manifestations - painful polyradiculopathy, multiple ischemic infarcts and ventriculoencephalitis. Symptoms developed within 4 to 6 weeks of regimen change. CMV was diagnosed in each of the cases through cerebrospinal fluid polymerase chain reaction (CSF PCR), with supporting evidence from neuroimaging. Treatment with ganciclovir resulted in clinical improvement in all cases. New onset neurological deficits after initiation or change of ART should raise the suspicion for cytomegalovirus immune reconstitution inflammatory syndrome. Early diagnosis and prompt treatment of neurological CMV may achieve good outcomes with resolution of neurologic signs and symptoms.