Andrade et al. BMC Infectious Diseases 2014, 14:149 http://www.biomedcentral.com/1471-2334/14/149 CASE REPORT Open Access Transverse myelitis and acute HIV infection: a case report Paulo Andrade*, Cristóvão Figueiredo, Cláudia Carvalho, Lurdes Santos and António Sarmento Abstract Background: Most HIV infected patients will develop some sort of neurologic involvement of the disease throughout their lives, usually in advanced stages. Neurologic symptoms may occur in acute HIV infection but myelopathy in this setting is rare. Up until this date, only two cases of transverse myelitis as a manifestation of acute HIV infection have been reported in the literature. Therapeutic approach in these patients is not well defined. Case presentation: A 35 year-old male Caucasian recently returned from the tropics presented to our hospital with urinary retention and acute paraparesis. After extensive diagnostic workup he was diagnosed with acute HIV infection presenting as transverse myelitis. Full neurologic recovery was observed without the use of anti-retroviral therapy. Conclusion: Acute spinal cord disorders are challenging, as they present a wide array of differential diagnosis and may lead to devastating sequelae. Timely and rigorous diagnostic workup is of the utmost importance when managing these cases. Clinicians should be aware of the protean manifestations of acute HIV infection, including central nervous system involvement, and have a low threshold for HIV screening. Keywords: Transverse myelitis, HIV, Acute infection Background fever, poliomyelitis, typhoid fever and meningococcal dis- HIV-associated neurological syndromes are diverse and ease in advance. Excluding an episode of malaria soon usually diagnosed at advanced stages of the disease [1]. after his arrival to Angola, he was asymptomatic until However, neurological involvement can also occur at early 6 weeks before returning home to Portugal, when he and stages of the infection, making the diagnosis challenging other co-workers had an acute onset of fever, vomiting [2-4]. In tropical areas the differential diagnosis of neuro- and diarrhoea after sharing a meal. Over the following logical disorders is particularly difficult, as a broad range days, while he was still recovering, he woke up suddenly of infectious causes need to be considered. We report a with pain in the umbilical area where he noticed three red case of an acute HIV infection presenting as transverse spotted lesions that became enlarged and necrotic. He was myelitis in a patient returning from sub-Saharan Africa. told by a medical doctor that he had most likely been bit- The diagnostic approaches of acute spinal cord disorders ten by a spider and was treated with local dressings and are also reviewed. analgesia, with improvement. One week later he developed fever, non productive cough, progressive dyspnoea and Case presentation thoracic pain that he described as bilateral, oppressive and A 35-year-old Caucasian male presented to an Emergency “belt-like”. Additionally, generalised myalgia and fatigue Room of a Portuguese tertiary care hospital with urinary gradually installed. He was treated in a local clinic with an- retention and diminished strength in the lower limbs. He tibiotics without resolution of symptoms. Unable to work, had returned a week before from Angola where he had he returned to Portugal and visited another hospital in the been working as a construction worker for the past same day for persisting fatigue and thoracic pain. Inflam- 10 months (Table 1). He had been vaccinated for yellow matory parameters were not elevated and chest roentgen- ography was normal. He was sent home on analgesics. Six * Correspondence: [email protected] days later he presented to our tertiary care hospital Department of Infectious Diseases, Hospital de São João and University of Porto Medical School, Porto, Portugal © 2014 Andrade et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Andrade et al. BMC Infectious Diseases 2014, 14:149 Page 2 of 5 http://www.biomedcentral.com/1471-2334/14/149 Table 1 Timeline of the main clinical events no inflammatory signs. The remainder of physical examin- PRIOR TO HOSPITAL ADMISSION ation was unremarkable. Week 1 Travels to Angola. Routine laboratory data was normal, including complete 9 Week 4 Uncomplicated malaria episode. blood count (Hb 15.6 g/dL, WBC 9.07 × 10 /L with 81% neutrophils, platelets 325 × 109/L), renal and liver function Week 32 Ear piercing. tests. Thick blood smear and rapid diagnostic test for mal- Week 34 Probable gastroenteritis and arthropod bite. aria were negative. HIV test (4th generation ELISA) was Week 35 Fatigue, fever, myalgia, non-productive cough, positive and Inno-Lia™ test was indeterminate (positive thoracic pain (belt-like). gp41 band). Chest roentgenography was normal. Cerebro- Treated with antibiotics. spinal fluid (CSF) examination revealed 302 leukocytes/μL, Week 40 Persisting fatigue and thoracic pain. glucose 0.56 g/L and protein content 0.74 g/L. Gram stain Returns to Portugal and seeks medical care. was negative. Magnetic Resonance Imaging (MRI) of the Discharged on analgesics. brain was normal, but MRI of the medulla showed ex- HOSPITAL ADMISSION tensive hyperintense signal in the long TR sequence Day 1 Worsening fatigue and thoracic pain. throughout C4 to T11, especially in the posterior columns, Urinary retention, paraparesia and hypoaesthesia. suggesting inflammatory/infectious aetiology (Figure 1). HIV screening positive, Inno-Lia™ indeterminate. He was admitted with a diagnosis of acute transverse myelitis and treatment with ceftriaxone (2 g IV bid), ganci- MRI suggestive of myelitis. clovir (400 mg IV tid) and methylprednisolone (1 g IV qd Ceftriaxone, gancyclovir and methylprednisolone. for 3 days and then tapered to 1 mg/Kg/d) was started. Day 3 Worsening neurologic symptoms. Over the two following days his clinical condition deteri- Mild CSF pleocytosis and protein elevation. orated, with intensifying upper thoracic pain, progressing Doxycicline and human immunoglobulin. Stops gancyclovir. hypoaesthesia up to T10 and dysaesthesia becoming more Day 10 Progressive and complete resolution of symptoms. disabling and characterised by numbness and ice cold sen- sation. Constipation and urinary retention were also HIV-1 RNA detection on blood and CSF. 760/mm3 T-CD4 count. present. ™ Day 21 HIV screening positive, Inno-Lia indeterminate. A second lumbar puncture performed at day 3 re- Discharged home. vealed 15 leucocytes/μL, glucose 0.98 g/L and protein OUTPATIENT CLINIC content 0.86 g/L. India ink stain was negative. Month 3 Assymptomatic. Doxycicline (100 mg bid) and human immunoglobulin Inno-Lia™ positive. (30 gr IV qd) were associated at this point. Ganciclovir Month 12 Assymptomatic. was discontinued after negative CMV results (Table 1). Significant improvement was observed within the next Progressive decline of T-CD4 count to below 400/mm3. days and one week later the patient was able to walk un- Anti-retroviral therapy instituted. assisted, with complete resolution of dysaesthesia, urinary CSF: cerebrospinal fluid; MRI: magnetic resonance imaging. retention and constipation. Three weeks after admission he was discharged home asymptomatic, having completed complaining of worsening fatigue, thoracic pain and urin- 21d of ceftriaxone, 7d of methylprednisolone, 7d of doxy- ary retention. cicline and 5d of human immunoglobulin. Past medical history was irrelevant. The patient denied HIV testing was repeated before discharge: 4th gener- unprotected sexual contacts in the past ten months, intra- ation ELISA was positive and Inno-Lia™ remained indeter- venous drug use, blood transfusions or past surgical pro- minate (positive gp41 band). All cultures were negative, as cedures. He had performed an ear piercing two months well as several serology and PCR-based technique tests before in Angola. (Table 2). Convalescent titters were repeated for Borrelia, On admission the patient was afebrile. Blood pressure Rickettsia conorii, West Nile Virus and Dengue, all nega- was124/68mmHg,hispulsewasregularwith80beats tive. HIV-1, subtype K RNA copies were quantified in per minute and respirations 14 breaths per minute. blood and CSF: 743.000 and 77.700 cp/mL respectively. By Neurological examination revealed diminished motor the time these results were known the patient was already strength in lower extremities (grade 3/5), reduced tact- improving significantly and no antiretroviral therapy was ile and pain sensations below L1, normal deep tendon started. His CD4 count was 408/mm3 on admission and reflexes and bilateral indifferent plantar responses. No 760/mm3 in a second determination before discharge. cognitive dysfunction or neck rigidity was noticed. Oph- Three months later the patient presented to the out- thalmologic and cranial nerves examination was nor- patient clinic and was asymptomatic. HIV Inno-Lia™ test mal. A periumbilical triangular scar was observed, with was then positive (positive p17, p24, p31, gp41 and gp120). Andrade et al. BMC Infectious Diseases 2014, 14:149 Page 3 of 5 http://www.biomedcentral.com/1471-2334/14/149