Progressive Neurologic Symptoms in the Setting of HIV: A Rare Case of Neurosymptomatic CSF HIV Escape

A 54-year-old man with HIV infection on suppressive antiretroviral therapy (ART) presented with progressive gait difficulty over 1 year. MRI demonstrated increasingly predominant white matter hyperintensity and development of abnormal perivascular enhancement (figure 1). An extensive workup excluded atypical infections, CNS lymphoma, sarcoidosis, vasculitis, and other autoimmune diseases. Serum HIV viral RNA was 160 copies/mL; CSF HIV viral RNA was 1,390 copies/mL with a mild lymphocytic pleocytosis, consistent with a diagnosis of neurosymptomatic CSF HIV escape, viral CSF sequestration despite ART.1 Whereas white matter hyperintensity is nonspecific in HIV, the key to CSF HIV escape diagnosis is recognizing the abnormal perivascular enhancement (figure 2).2 Clinical course and imaging findings improved with modified ART targeting neuropenetration.

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