Sudden sensorineural hearing loss with vertigo as an initial presenting symptom of HIV/AIDS patient.

Abstract

Otolaryngologic manifestations are common in patients with AIDS, and such manifestations are generally attributed to HIV itself or to opportunistic infections. Although there have been a few case reports of sudden sensorineural hearing loss (SSNHL) and vertigo in patients already diagnosed with HIV infection [1–5], there has been no report of SSNHL with vertigo as the first clinical manifestation of HIV infection. We report a 27-year-old man with SSNHL with vertigo as an initial presenting symptom of HIV infection. A previously healthy 27-year-old man visited our emergency department with a chief complaint of right-sided SSNHL with vertigo for 3 days. The symptom was accompanied by symptoms of upper respiratory tract infection (URI), such as sore throat, cough and sputum. The patient did not complain of headache, febrile sense, malaise, or neck stiffness. Otoendoscopic examination revealed normal tympanic membrane on both sides, and the Weber test using a tuning fork demonstrated lateralization to the left side. Video Frenzel Goggles examination showed spontaneous nystagmus beating toward the right side, and a bithermal caloric test revealed no canal paresis. Gaze-evoked nystagmus or skew deviation was not observed. Other neurologic examinations including a cerebellar function test revealed no abnormality. A chest x-ray finding was within normal limits, and a pure tone audiometry showed the right side 35 dB of sensorineural hearing loss with speech discrimination score of 80% (Fig. 1a). A postcontrast 3D fluid attenuated inversion recovery (3D FLAIR) image of internal auditory canal MRI (IAC MRI) demonstrated high-signal intensity in the right inner ear organs including cochlea, vestibule and semicircular canals (Fig. 1b), which suggested disruption of blood–labyrinth barrier in the perilymphatic space because of inner ear inflammation. The patient was admitted to the otolaryngology department to treat SSNHL with vertigo, and received systemic steroid administration.Fig. 1: (a) A pure tone audiometry shows 35 dB of sensorineural hearing on the right side (left panel) and normal hearing on the left side (right panel). (b) Postcontrast 3D fluid attenuated inversion recovery (FLAIR) image demonstrates enhancement of the cochlea, vestibule and semicircular canals (yellow arrow).A chest computed tomography was conducted as the patient had URI symptoms despite of normal chest X-ray, and it revealed multifocal ground glass opacity in both lungs, suggesting bronchopneumonia. Initial HIV antibody screening, which was performed at the time of admission, was reported as positive. Western blot test of HIV Ab was also positive, and a real-time PCR test showed highly elevated titer (34 900 copies/ml). T-cell subset count test revealed decreased CD4+ (13 counts/μl, 1.2%), increased CD8+ (494 counts/ μl, 47.3%) levels, and decreased CD4+/CD8+ ratio (0.03). Screening tests for tuberculosis, syphilis, toxoplasma and pneumocystis jirovecii infection were all negative. An antiretroviral therapy with a combination regimen of abacavir, dolutegravir and lamivudine was started. With treatment for SSNHL, hearing loss and vertigo were alleviated, and a pure tone threshold improved to 13 dB with speech discrimination score of 100% on the right side. Chronic hearing loss is highly prevalent among people with HIV [6], which can occur as a result of HIV infection itself, opportunistic central nervous system infections causing meningitis or encephalitis (e.g. toxoplasmosis, syphilis, herpes and cytomegalovirus), or side effects of antiretroviral therapy. On the other hand, sudden onset hearing loss has been reported in only a limited number of patients with HIV infection [1–5], and the mechanism that contributes to the association between HIV infection and SSNHL is still unclear [4]. SSNHL is defined as sensorineural hearing loss of at least 30 dB in three contiguous audiometric frequencies occurring over 3 days or less, and viral infection, inner ear ischemia or hemorrhage, and disruption of cochlear membrane have been suggested as possible causes [7]. In our patient, who was young and previously healthy, sudden onset hearing loss with vertigo eventually led to the final diagnosis of HIV infection. The present study, to the best of our knowledge, reports the first case, which manifests SSNHL with vertigo as an initial presenting symptom of HIV infection. Another interesting finding was that postcontrast 3D FLAIR images showed enhancement of the cochlea, vestibule and semicircular canals in the affected ear, suggesting the breakdown of blood–labyrinth barrier in the perilymphatic space because of inner ear inflammation [7–11]. This is the first demonstration of blood–labyrinth barrier breakdown in a patient with HIV infection, and we assume that the inner ear inflammation may be caused by HIV/AIDS-associated opportunistic infections. The present study may suggest that serological tests for HIV infection can be considered in patients with SSNHL with vertigo, and a well designed cost-effectiveness analysis related to this topic should be carried out in the future. Acknowledgements This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIP) (2021R1F1A1062019). Conflicts of interest There are no conflicts of interest.