Immune Reconstitution Syndrome Presenting With Cerebral Varicella Zoster Vasculitis in HIV-1-Infected Patient: A Case Report

Abstract

Neurologic dysfunction complicating HIV infection may occur in up to 70% of AIDS patients. The advent of highly active antiretroviral therapy has reduced central nervous system opportunistic infections. Immune reconstitutions after highly active antiretroviral therapy also lead to atypical presentations of neurologic opportunistic infections. We report a man who developed an encephalitic illness 10 months after institution of highly active antiretroviral therapy and improvement in his CD4 count. Varicella zoster vasculitis involving the brain was suspected. Acyclovir therapy resulted in complete clinical and radiologic recovery. Symptomatic reactivation of varicella zoster infection within the encephalon during therapeutic immunologic reconstitution is rare and should be suspected, especially in patients with neurologic syndrome consistent with encephalitis with recent history of herpes zoster and multiple, discrete areas of infarct or demyelination on brain magnetic resonance imaging. The clinical and neuroradiologic features of this condition and its relevance to the immune reconstitution syndrome are discussed.

Immune reconstitution disease of the central nervous system

“…There are a few reports of CNS VZV IRD, including one patient with transverse myelitis [55] and two patients with encephalitic presentations [56,57]. Both encephalitis patients had a prior history of cutaneous VZV [56,57]. Diagnosis was confirmed in all cases by a positive CSF VZV PCR.…”

“…In the pre-HAART era the prevalence of clinical CNS VZV disease was 0.7-7% [53,54]. There are a few reports of CNS VZV IRD, including one patient with transverse myelitis [55] and two patients with encephalitic presentations [56,57]. Both encephalitis patients had a prior history of cutaneous VZV [56,57].…”

“…Diagnosis was confirmed in all cases by a positive CSF VZV PCR. Treatment with methylprednisolone and acyclovir [55] or acyclovir alone [56,57] resulted in favourable outcomes.…”

Atypical Nervous System Manifestations of HIV

“…94,107,108 Corticosteroids are often used when there is devastating disease in the CNS causing severe edema, and in some cases have been continued long term. 94 IRIS-related encephalitis without opportunistic infections has been treated with steroids in clinical Table 2 Manifestations of Neurologic IRIS 73,89,97,103,104,108,[122][123][124][125][126][127][128][129][130][131][132][133][134][135][136][137] Acute inflammatory demyelinating polyneuropathy practice when there is significant clinical neurologic deterioration, generally with good response, but the duration of the treatment necessary is unknown. Most patients seem to require several months of treatment with prednisone to maintain the clinical response (VV's and TAC's experience).…”

Central nervous system–immune reconstitution inflammatory syndrome in resource-limited settings

“…Although CNS-IRIS is less common than IRIS outside of the nervous system, CNS-IRIS has a high morbidity and mortality [4–7]. Important opportunistic infections leading to CNS-IRIS include cryptococcal meningitis, CNS tuberculosis, progressive multifocal leukoencephalopathy (PML) due to JC virus and, more rarely, Candida meningitis, Mycobacterium avium complex meningoencephalitis, Toxoplasma encephalitis and varicella zoster meningoencephalitis [8–14]. In some cases, CNS-IRIS may occur in the absence of an opportunistic infection.…”