AIPMED

ANNALS OF IBADAN POSTGRADUATE MEDICINE

PARAPARESIS IN A PATIENT WITH ADVANCED HIV DISEASE WITHOUT MANIFESTATIONS OF OPPORTUNISTIC INFECTION

A.A. Onifade1 , T.A. Ajadi2 , I.O. Jimoh3 , M.A. Jimoh4 and W.A. Oluogun5

  1. Department of Chemical Pathology, College of Medicine, University of Ibadan, Oyo State
  2. Department of Radiology, Federal Medical Centre, Abeokuta, Ogun State
  3. Mercy Medical and Pathological Centre, Osogbo, Osun State
  4. Department of Radiation Oncology, College of Medicine, University of Ibadan
  5. Department of Histopathology, College of Health Sciences, LAUTECH, Ogbomoso

ABSTRACT

HIV infection had been associated with many symptoms and signs but the least expected is paraparesis in the absence of constitutional clinical features. This case presentation is to highlight the unusual presentation of a 43 year old who presented with difficulty in walking due to gradual weakness in his lower limbs (more on right than left) and difficulty in passing urine of 8 months duration. All the common symptoms and signs associated with advanced HIV infection were absent. Urethroscopy and prostate biopsy were done and showed normal findings. Cranial computerised tomography (CT) scan finding was normal, but lumbo-sacral Magnetic Resonance Imaging (MRI) showed degenerative disease suggestive of immunosuppression. HIV screening (Unigold and ELISA) and HIV confirmatory tests were done that showed reactivity to HIV-1 antibody and CD4 count and plasma viral load results were 226 cells/ mm3 and 126,000 copies/ml respectively. The patient was commenced on antiretroviral therapy and paraparesis started resolving. 

Keywords: HIV infection, Constitutional symptoms, Urinary obstruction, Immunological parameters

Correspondence

Dr. A.A. Onifade

Department of Chemical Pathology,

College of Medicine,

University of Ibadan,

Oyo State 


INTRODUCTION

Since 1981 when Human immunodeficiency virus (HIV) was isolated from patients with opportunistic infections and Kaposi sarcoma, there are over thirty million of people living with this dreadful virus1-3. It was estimated that no infectious organism has claimed more lives in history than HIV4 . It was reported that about two-thirds of people living with HIV/AIDS are from sub-Saharan Africa. Although public awareness and other measures had reduced the spread of HIV infection, the burden is still high in sub-Saharan Africa3 .

HIV targets immune cells and uses the host cell components to multiply. Completion of multiplication processes and subsequent budding of the newly produced HIV cells (virions) from host immune cell results in death (lysis). The newly produced virions readily infect new target immune cells resulting in depletion of CD4 expressing cells. Reduction in immune cells caused by HIV infection is associated with opportunistic infections that usually lead to constitutional clinical features5,6 

The clinical features of advanced HIV infection vary but weight loss, fever, cough, diarrhoea and fungal infection manifestation are commonly observed. World Health Organisation (WHO) and Centre for Disease and Control (CDC) developed staging criteria based on common clinical features. WHO and CDC staging criteria had been helpful as a guide especially during the period that CD4 count and HIV-RNA (viral) load were not readily available to physicians7,8 . Because the burden of HIV infection is associated with reduction and subsequent deficiency of immune cells, clinical manifestation differs in many ways in patients. The clinical presentation of HIV infection at early or advanced stage is not commonly associated with isolated neurological deficits in lower limb with absence of constitutional symptoms or signs.

The unusual clinical features of urinary obstruction in a middle-aged male patient without urethral stricture, trauma or malignancy initiated extensive investigation that led to association of HIV infection and compression syndrome secondary to opportunistic infections as presented in this case report

CASE PRESENTATION

OR is a 43 year old man that presented in a private hospital with history of painful micturition and poor urinary stream (4 years duration), severe low back pain and right lower limb weakness of 2 years duration. There was neither associated history of urethral discharge nor bleeding during or without ejaculation. There was neither previous history of trauma or instrumentation in abdomen nor perineal surgical procedure. There was associated history of occasional abdominal swelling with hiccups that may last for 2-3 days before spontaneous resolution. The patient was well built (body mass index of 28.5) not in obvious distress, afebrile and anicteric. Chest, abdomen and rectal examinations were essentially normal. There was neither muscular atrophy nor obvious physical deformity at the back in both erect and supine position. However, there was mild loss of sensation to fine touch. There were reduced power movement at both lower limbs more on the right (3/5) than left (4/5). He was treated for sexually transmitted diseases (STD) by a chemist/pharmacist about 5 years prior to presentation. The persistence of the symptoms coupled with staggered gait while walking, he presented at tertiary health facilities where he had retrograde urethrocystogram (RUCG) and prostate biopsy. These procedures were followed with urinary retention thus catheterisation. Subsequent catheterisation following these procedures was associated with persistent mucoid and blood stained discharge especially immediately after removing catheter. Cranial computed tomography scan (CT) was done and lumbo-sacral magnetic resonance imaging (MRI) was requested.