Posterior reversible encephalopathy syndrome in a patient with HIV and disseminated Varicella Zoster Virus
Background: The uncommon posterior reversible encephalopathy syndrome (PRES) is characterized by the acute onset of headache, vomiting, altered consciousness, seizures and focal neurological deficits. It was initially described in the setting of hypertension, uremia and immunosuppression. In the last decade there have been emerging reports of PRES in patients with advanced human immunodeficiency virus (HIV)-infection in the presence of hypertension, dialysis, hypercalcaemia and two opportunistic infections: blastomycosis and tuberculosis (TB).
Method: Here we present the case of a 54 year old male being treated for disseminated varicella zoster virus (VZV) in the setting of HIV infection who acutely deteriorated to the point of requiring intubation.
Results: The clinicoradiological diagnosis was of PRES with improvement within 72h with supportive management. Serial neuroimaging correlated with the clinical findings. The pathogenesis of PRES is poorly understood but is thought to stem from vasogenic odema either as a result of loss of endothelial integrity and transudate of fluid across the blood-brain barrier, or secondary to vasospasm resulting in tissue odema in the absence of infarction. How HIV infection impacts on this model is unclear. It is possible the HIV infection causes endothelial dysfunction and disruption of the blood-brain barrier which may be exacerbated by infections in the central nervous system.
Conclusion: This is the first report of PRES in an HIV-infected patient with disseminated VZV. Additionally it is the first case of HIV-associated PRES severe enough to warrant intubation. The phenomenon of PRES in advanced HIV is an important clinical entity for both physicians and critical care doctors to recognize firstly given its potential mortality but also because of its favourable prognosis and reversibility with supportive care and treatment of underlying causes.
Financial disclosures: SS, AO and JC: Nil financial disclosures. BB has received research funding from Eli Lily, Glaxo Smith Kline, ViiV Healthcare and Merk Serono; Travel sponsorship from Abbott; Honouraria from ViiV Healthcare, Boeringer Ingleheim, Abbott, Biogen Idec and Abbvie and has served on Scientific Advisory Boards for Glaxo Smith Kline, Biogen Idec, ViiV Healthcare and Merk Serono. AC has received research funding from Baxter, Gilead Sciences, MSD and Pfizer; consultancy fees from Gilead Sciences, MSD, and ViiV Healthcare; lecture and travel sponsorships from Gilead Sciences, MSD, and ViiV Healthcare and has served on advisory boards for Gilead Sciences, MSD, and ViiV Healthcare.
