Abstract Details

Title Immune Reconstitution-related HIV Vacuolar Myelopathy in a 66-year-old Man

Topic Infectious Disease

Presentation(s) P1 - Poster Session 1 (8:00 AM-9:00 AM)

Poster/Presentation
Number 3-010

Objective To describe HIV-associated vacuolar myelopathy (HIV-VM) and highlight the diagnostic approach to tract-specific myelopathy in an immunocompromised patient.

Background Progressive myelopathy in people with HIV has a broad differential diagnosis, including inflammatory, infectious, metabolic, vascular, autoimmune, and neurodegenerative conditions. Although rare in the modern antiretroviral therapy (ART) era, HIV-VM remains an important consideration, particularly in patients with lapses in treatment.

Design/Methods We present a single-patient case report. Data were obtained from chart review, neurologic examination, cerebrospinal fluid analysis, and serial MRI studies.

Results A 66-year-old man with longstanding HIV and diabetes developed vertigo followed by progressive limb weakness, gait imbalance with falls, paresthesias, and urinary urgency over four weeks after restarting ART and receiving a COVID-19 booster. Examination revealed mild symmetric quadriparesis, brisk reflexes, impaired proprioception, and sensory ataxia. CSF analysis showed elevated protein, oligoclonal bands, and increased IgG index without pleocytosis. Cervical and thoracic MRI demonstrated longitudinally extensive, symmetric T2 hyperintensities involving dorsal columns and corticospinal tracts without enhancement. An extensive evaluation for autoimmune, infectious, metabolic, and neoplastic causes was unrevealing. Over nine months, the patient experienced gradual clinical improvement with near-complete radiologic resolution in the absence of immunotherapy. Findings were most consistent with HIV-VM related to immune reconstitution following ART resumption.

Conclusions This case highlights the importance of clinical localization, recognition of tract-specific spinal cord MRI patterns, and cautious interpretation of nonspecific CSF findings in immunocompromised patients. HIV-VM should remain in the differential for progressive myelopathy in the ART era, as appropriate recognition may prevent unnecessary immunosuppressive treatments and underscores the role of immune reconstitution in neurologic recovery.

Authors/Disclosures
Bradley G. Ong, MD (Cleveland Clinic Main Campus - Neurological Institute) PRESENTER	The institution of Dr. Ong has received research support from American Academy of Neurology. The institution of Dr. Ong has received research support from American Headache Society. Dr. Ong has received personal compensation in the range of $0-$499 for serving as a Expert Witness with Chandler Advocacy. Dr. Ong has a non-compensated relationship as a Editorial Board Member with Neurology Resident & Fellow Section that is relevant to AAN interests or activities. Dr. Ong has a non-compensated relationship as a Contributor with Neurology Minute that is relevant to AAN interests or activities.
Alise K. Carlson, MD (Cleveland Clinic)	Dr. Carlson has received research support from Biogen (fellowship grant 16696-P-FEL).