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A 48-year-old man with acquired immunodeficiency syndrome presented to our clinic with 6 days of worsening frontal headache, vomiting, diffuse myalgias, and weakness. On examination he had profound lower extremity weakness, increased patellar tendon reflexes, sensory loss in his feet, and Babinski signs present bilaterally. The patient was hospitalized, and a lumbar puncture revealed a cerebral spinal fluid leukocyte count of 4277 cells/uL with 94% atypical lymphocytes, erythrocyte count of 8673 cells/uL, glucose of 63 mg/dL, and protein of 3480 mg/dL. Magnetic resonance imaging (MRI) found diffuse edema of the thoracic spinal cord consistent with meningomyelitis (Figure).
Of note, he had restarted highly active antiretroviral therapy 3 weeks prior. His CD4+ count and human immunodeficiency virus (HIV)-1 viral load at that time were 103 cells/uL and 284,370 copies/mL, respectively. On admission, his CD4+ count was 79 cells/uL and HIV-1 viral load was 606 copies/mL.
The diagnosis of immune reconstitution inflammatory syndrome (IRIS) was made, highly active antiretroviral therapy was discontinued and dexamethasone 10 mg intravenously (IV) every 6 hours was initiated. The patient's strength and sensation improved. Cerebrospinal fluid polymerase chain reaction was positive for varicella zoster virus at day 4 and IV acyclovir was added. Two months after admission, he was able to ambulate with a walker.
IRIS is a pathologic immune recognition of antigens that occurs after highly active antiretroviral therapy initiation. Although lethal in <10% of AIDS patients,
Clinicians should suspect central nervous system IRIS when patients have an unexplained neurological decline accompanied by new or progressive neuroradiological findings, a decrease in plasma viral load of ≥1 log10, or histopathology demonstrating T-cell infiltration.
Our patient demonstrated neurologic deterioration, transverse myelitis on MRI, and >3 log10 decrease in viral load. His lack of CD4+ recovery is consistent with previous case reports of varicella zoster virus central nervous system IRIS.
Although there are no prospective trials to guide the treatment of varicella zoster virus central nervous system IRIS, high dose IV steroids followed by an oral prednisone taper and IV acyclovir have been employed with clinical improvement.
The decision to discontinue highly active antiretroviral therapy is a difficult one. In mild IRIS, the symptoms are generally self-limited, and highly active antiretroviral therapy should be continued.