Human immunodeficiency virus–associated cytomegalovirus infection with multiple small vessel cerebral infarcts in the setting of early immune reconstitution

Abstract

Cytomegalovirus (CMV) infection is an important cause of neurologic disease in the context of advanced human immunodeficiency virus (HIV) infection and is recognized as a cause of immune reconstitution inflammatory syndrome (IRIS) after initiation of highly active antiretroviral therapy (HAART). Central nervous system vasculitis secondary to CMV has only rarely been described in the context of HIV, despite the established ability of CMV to infect microvascular endothelial cells in the brain. However, we report a case that demonstrates the association between CMV and multiple small vessel cerebral infarct lesions after initiation of HAART.

Cerebrovascular events in HIV-infected patients: an analysis of a cohort of 3203 HIV+ patients during the times of cART

“…The other one resulted from a CMV infection in a patient with a severe reduction in CD4+ cells and a high HI-viral load in plasma and CSF. This is noteworthy because so far Cytomegalovirus has only been associated with HIV and stroke in a few case series [26][27][28]. In another patient IgG antibodies against VZV were found in the CSF besides the presence of further vascular risk factors.…”

Association of HIV and Opportunistic Infections With Incident Stroke: A Nationwide Population-Based Cohort Study in Taiwan

“…3 A series of case reports showed that OIs [e.g., cryptococcal meningitis, cytomegalovirus (CMV), or Candida albicans infection] in HIV patients caused central nervous system vasculitis and may lead to stroke development. 3,12–14 Although accumulating evidence suggests that OIs are associated with increased risk of incident stroke in HIV patients, few large-scale epidemiologic studies have investigated this association. Stroke management and prevention should include identification and prevention of specific stroke risk factors, particularly in high-risk populations.…”

Neurologic Consequences of the Immune Reconstitution Inflammatory Syndrome (IRIS)

“…CMV lumbosacral radiculitis has not been reported with IRIS. A case report suggests that CMV-IRIS could occur as a vasculitis causing multiple small infarcts [29]. Approximately 12% of HIV-1-associated VZV infections develop IRIS, which is more frequent than other OI-IRIS after the first 3 months of successful cART therapy, suggesting that VZV-IRIS immune responses are mediated by naïve CD4+ lymphocytes that emerge later after starting cART [30].…”