Our patient, a 35-year-old right-handed male, a soldier by occupation and a resident of Greater Noida, Uttar Pradesh, India, presented with the complaints of fever for the past 2 weeks and altered sensorium for the past 4 days following an episode of generalized tonic-clonic seizure. There was no associated upper or lower respiratory tract symptoms, no burning micturation, ear discharge, rashes, or other skin lesions or head trauma. His investigations showed that he was HIV-1 reactive. He had a history of prolonged fever for 1 month a year back and had been diagnosed with tubercular lymphadenitis by the fine-needle aspiration study. He was prescribed rifampicin, isoniazid, pyrazinamide, and ethambutol for the same, and he was continuing to take all of them till date. There was no history of addictions. He was married for 7 years and had two children. Examination revealed normal vitals in a conscious but disoriented patient with a staring look and a Glasgow Coma Scale score of 11/15. General examination revealed pallor and oral thrush. Neurological examination revealed a Folstein's Mini-Mental State Examination (MMSE) score of 12/30 with no signs of meningismus. Due to the condition of the patient, whatever restricted examination of motor system, sensory system, and cranial nerves was possible was normal. Examination of cardiovascular, respiratory, abdominal, and musculoskeletal system was within normal limits.
Investigations revealed an erythrocyte sedimentation rate of 33 mm (1st h) and a mild normocytic normochromic anemia (hemoglobin - 10.4 g%). Other biochemical parameters (liver function, kidney function, and blood sugar) were normal. Urine examination was also normal. A repeat testing of HIV by the ELISA confirmed the presence of antibodies against HIV-1. The CD4 count was 156/mm3, with a CD4 percentage of 14%. The differential diagnosis includes HIV with the likelihood of CNS opportunistic infections or HIV encephalopathy. Cerebrospinal fluid (CSF) examination reveals 10 cells, all mononuclear, with a sugar of 56 mg%, and a protein of 46 mg%. The adenosine deaminase levels were found to be 10 IU/L (within normal limits), and the CSF did not show any organism on Gram stain or Ziehl-Neelsen stain. The India ink staining for Cryptococcus was also negative. The polymerase chain reaction (PCR) in CSF was negative for Mycobacterium tuberculosis, human herpesvirus-6/herpes simpex virus, Toxoplasma gondii, and Cytomegalovirus. The PCR for JC virus could not be carried out due to financial constraints. Serum Widal, venereal disease research laboratory, hepatitis B surface antigen, Hepatitis C RNA, and IgG antibodies against toxoplasma were all negative.
Imaging of the brain revealed bilaterally symmetrical, T2/FLAIR hyperintensities noted in the white matter, involving the bilateral centrum semiovale, periventricular, posterior limb of the internal capsule, and midbrain (cerebral peduncle) suggestive of encephalitis on magnetic resonance imaging [Figure 1].
The patient's attendant did not give consent for a brain biopsy. The final diagnosis was made to be HIVE in a treatment-naive patients with a CD4 count of 156/mm3 with oral candidiasis.
He was started on antiretroviral therapy with triple-drug regimens of tenofovir, lamivudine, and efavirenz along with antieplieptics and fluconazole. After 3 months of follow-up, he was seizure free, and his MMSE revealed marked improvement (from 12/30 to 20/30). The CD4 count also showed improvement from 156/cumm to 325/cumm.