Authors
Victoria R. Starnes, Medical Student, The University of Toledo College of Medicine Victoria Soewarna, Medical Student, The University of Toledo College of Medicine Caitlyn Hollingshead, MD, Assistant Professor, The University of Toledo College of Medicine Joel A. Kammeyer, MD, MPH, Assistant Professor, The University of Toledo College of Medicine
Introduction
Acute transverse myelitis (ATM) is an inflammatory spinal cord injury that may be an isolated process or caused by a secondary disease (1). Symptoms of ATM include lower limb weakness, urinary incontinence, numbness, or paresthesia. Diagnosis is made by clinical presentation and MRI or lumbar puncture revealing acute inflammation. Prior to the availability of antiretroviral therapy (ART), ATM was seen in patients with primary HIV infection due to opportunistic infections (2). We present a case of ATM attributed to cytomegalovirus secondary to uncontrolled HIV.
Case Presentation
A 33-year-old Caucasian HIV-positive male presented with lower extremity weakness and bipedal paresthesia in a stocking distribution. He had been diagnosed with HIV in 2017 but had never initiated ART due to financial constraints. His initial CD4 count was 7 cells/mm3 and his viral load was 208,000 copies/mL. The patient was afebrile and was mildly tachycardic. He had no other acute focal neurological deficits aside from those mentioned. Ocular examination revealed yellow-white retinal lesions with indistinct margins in the left eye. Laboratory values on admission were significant for pancytopenia with a WBC count of 1.2x109/L. A lumbar puncture revealed 1 nucleated cell/mm3, however a viral meningitis panel detected herpes simplex virus 1 (HSV-1), cytomegalovirus (CMV), and varicella zoster virus (VZV). A cytomegalovirus DNA quantitative PCR revealed 6,381,260 IU/mL. Treatment was initiated with valganciclovir 900 mg oral twice daily for 14 days for induction therapy, bictegravir-emtricitabine-tenofovir alafenamide one tablet daily, and sulfamethoxazole-trimethoprim one tablet oral daily. His weakness and strength improved. Unfortunately, this patient was subsequently lost to follow up and the outcome is unknown.
Discussion
With developments in management of HIV with ART, opportunistic infections are seen less often. Our patient underscores that advanced presentations can still occur and are often secondary to gaps in education and accessibility. This case highlights the necessity for comprehensive patient education and the importance of adhering to ART regimens to maintain a high CD4+ count and prevent progression of the disease. The ATM was thought to be secondary to CMV given the viremia and retinitis; the positive HSV-1 and VZV PCR in the cerebrospinal fluid were felt to be due to cross-reactivity. Herpesviruses share common antigens, and cross-reactivity between VZV, HSV-1, and CMV has been well-described (3). Cases of ATM have been described secondary to VZV, HSV-1, and CMV, making the etiologic agent of the ATM challenging to discern in this case. Furthermore, ocular manifestations are challenging to differentiate amongst herpesviruses; the characteristic yellow-white retinal lesions with indistinct margins differentiated cytomegalovirus from the progressive ocular retinal necrosis seen with varicella chorioretinitis. The cytomegalovirus viremia prompted our treatment approach with a course of induction therapy with valganciclovir. Identifying barriers to treatment, such as lack of education regarding available resources, allows physicians to close the knowledge gap to improve accessibility of treatment. In instances of secondary infection, it is important to treat quickly. Knowledge of the infectious differential of ATM, including CMV, HSV, and VZV, and swift therapy with ganciclovir is important in decreasing risk for neurologic sequelae.
References
- Kerr DA, Ayetey H. Immunopathogenesis of acute transverse myelitis. Curr Opin Neurol. 2002;15:339-47. [PMID: 12045735] doi:10.1097/00019052-200206000-00019
- Hamada Y, Watanabe K, Aoki T, et al. Primary HIV infection with acute transverse myelitis. Intern Med. 2011;50:1615-7. [PMID: 21804292] doi:10.2169/internalmedicine.50.5186
- Balachandran N, Oba DE, Hutt-Fletcher LM. Antigenic cross-reactions among herpes simplex virus types 1 and 2, Epstein-Barr virus, and cytomegalovirus. J Virol. 1987;61:1125-35. [PMID: 3029407] doi:10.1128/JVI.61.4.1125-1135.1987
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