Multiple sclerosis and HIV: a case of multiple sclerosis-immune reconstitution inflammatory syndrome associated with antiretroviral therapy initiation

Abstract

Studies have suggested that the incidence of multiple sclerosis (MS) in HIV-infected (HIV+) patients is lower than that of the general population. Here, we present a case of MS in an HIV+ patient with a relatively suppressed CD4 cell count who developed clinical and radiographic disease worsening in the setting of antiretroviral therapy (ART) initiation. A 47-year-old HIV+ woman (CD4 cell count 216 cells/µl) presented with decreased vision in her right eye. Magnetic resonance imaging (MRI) revealed optic nerve enhancement and open ring-enhancing lesions in the brain concerning for demyelinating disease. Cerebrospinal fluid was tested extensively for infection and malignancy with no abnormal findings. She received five days of intravenous methylprednisolone. Nine days later, she was restarted on ART. Three weeks later, she was readmitted with left eye vision loss and left hemiplegia (CD4 cell count 342 cells/µl). Repeat imaging showed multiple new enhancing lesions. Several cases have described severe MS relapses and unusually widespread demyelinating lesions on MRI after withdrawal of immunosuppressive drugs. We posit that the clinical and radiographic progression that occurred in our patient after initiation of ART represented an immune reconstitution response to ART. Caution may be warranted when initiating ART in HIV+ patients with suppressed CD4 cell count and active MS.

Human immunodeficiency virus and multiple sclerosis: a review of the literature

“…Compared with reports of HIV-related autoimmune disorders, the majority of published MS-HIV cases in the literature report a close temporal association of MS occurrence with the stages of acute HIV-1 infection or HIV seroconversion, but only rarely with the period following HAART induction [ 9 ]. To the best of our knowledge, only one published report describes a HIV-positive patient with a relatively suppressed CD4+ cell count, who developed clinical and radiographic MS worsening in the setting of HAART initiation [ 1 ]. Contrarily, several cases of MS have been reported in adult and pediatric patients during the early stages of HIV disease [ 3 , 15 , 23 ].…”

Is there a Low Risk of Multiple Sclerosis in HIV Patients?

“…In addition, we observed a higher incidence of these diseases in similar age groups. Despite this, there are few reported cases of patients affected by both diseases [9]. The risk of multiple sclerosis in HIV patients could be up to 62% lower when compared to the general population [2].…”

“…Among these complications encephalopathy by HIV is mentioned, caused directly by viral action and diseases associated with immunosuppression such as neurotoxoplasmosis, progressive multifocal leukoencephalopathy (PML), cryptococcosis and primary CNS lymphoma [28]. The white matter lesions or also called demyelinating more frequent in HIV are the encephalopathy by HIV and the PML [9,28,29]. The HIV encephalopathy is clinically characterized by progressive cognitive decline associated with behavioral and motor symptoms [7].…”

“…There are cases of HIV whose patients have improved lesions and decreased the number of MS outbreaks after starting antiretroviral treatment. In addition, most of them present a high CD4 + count at the time of diagnosis of MS [9]. There are also cases of atypical MS or with findings suggestive of optic neuromyelitis (NMO), also known as Devic's disease or Devic's syndrome, with improvement after the introduction of ART [36].…”

“…In such cases it may be difficult to distinguish a MS outbreak [9]. Prospective studies indicate the occurrence of IRIS by ART in up to 40% of cases [33].…”