Successful treatment of CMV ventriculitis immune reconstitution syndrome

In HIV infected patients, cytomegalovirus (CMV) disease of the central nervous system is usually seen when the CD4+ count is less than 100 cells/mm³. Recommended treatment includes intravenous ganciclovir, foscarnet, or both.¹ Ventriculitis is an uncommon but severe manifestation of CMV disease. Mortality is extremely high despite timely initiation of treatment. Little is known about CMV ventriculoencephalitis in the highly active antiretroviral therapy (HAART) era.

Case report

A 38 year old woman with no significant past medical history was diagnosed with Pneumocystis jiroveci (Pneumocystis carinii) pneumonia as her AIDS defining illness in April 2002. On 15 July 2002, HAART was initiated with zidovudine, lamivudine, and efavirenz. Her CD4+ count was 42 cells/mm³ and her HIV-1 RNA level was 95 000 copies/ml. Serum CMV IgG was positive.

Ten days later, she was evaluated for headache of new onset. Computed tomography (CT) of her head was unremarkable. Cerebrospinal fluid analysis showed no white cells, a red cell count of 10/mm³, a protein level of 58 mg/dl, and a glucose of 40 mg/ml. Cryptococcal antigen serology was negative.

Two weeks later, after full compliance with her HIV therapy, she returned with headache, nausea, vomiting, and fever. Her temperature was 38.6°C (101.4°F). Neurological examination was normal and there was no meningism. Ophthalmological examination of the retinae with fully …