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DON'T BE REASSURED BY AN UNDETECTABLE SERUM HIV VIRAL LOAD
  1. Priya Shanmugarajah,
  2. Kalani Weerasinghe,
  3. Daniel Warren,
  4. Helen Ford
  1. Leeds General Infirmary

Abstract

The immunologically privileged CNS can act as a reservoir for HIV-1 replication and mutation. Antiretrovirals can differ in their CNS penetration. Patients on HAART with serologically undetectable HIV-1 viral load can present with new neurological symptoms.

A 48 year-old right-handed woman with a 4 year history of HIV, presented with focal motor and secondary generalised seizures, a week after alteration of established HAART. She had previous VZV encephalitis and HIV-associated neurocognitive disorder. The CD4 count was 212 with undetectable serum HIV-1 viral load. However, HIV-1 viral copies were detectable in the CSF. Extensive investigations excluded opportunistic infection and neoplasm. MRI demonstrated a progressive leucoencephalopathy; CT-angiography revealing intracranial angiitis with multifocal arterial aneurysm formation. She was treated with high-dose IV steroids and reducing oral steroids. We reinstated nevirapine and zidovudine was added to the high CNS penetrative HAART regime. HIV-1 viral copies were undetectable on repeat CSF. She had no further seizures but she remained dependent for ADLs.

We postulate that the acute intracranial angiitis was secondary to neuro-IRIS following a change in the HAART treatment. This case illustrates the importance of recognizing the CNS as a HIV reservoir and the possibility of neuro-IRIS occurring at later stages of the disease.

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