Diagnostic challenges in vacuolar myelopathy: a didactic case report

Spinal Cord Series and Cases, 2016 · DOI: 10.1038/scsandc.2016.20 · Published: September 15, 2016

Simple Explanation

This case report discusses the difficulties in diagnosing HIV-vacuolar myelopathy (HIVM) due to the complexity of test results. The report presents a case of a 49-year-old man with progressive weakness and walking difficulties, highlighting the diagnostic challenges encountered. The patient's symptoms included thoracic hyposensitivity, spastic paraparesis, and herpes zoster infection, further complicating the diagnosis.

Study Duration

1 year follow-up

Participants

A 49-year-old man with chronic HIV infection

Evidence Level

Case Report

Key Findings

1
A negative or unspecific MRI scan does not rule out HIV-related myelopathy in HIV-positive patients with myelopathy symptoms.
2
Peripheral and central viral load should always be assessed to avoid missing a possible ‘CSF HIV-escape.’
3
Spinal cord atrophy supports the diagnosis of vacuolar myelopathy.

Research Summary

This case report highlights the diagnostic challenges in HIV-vacuolar myelopathy, emphasizing that a negative MRI scan does not exclude the condition. The importance of assessing both peripheral and central viral load is stressed to avoid missing a 'CSF HIV-escape.' The report also presents unique MRI fiber-tracking pictures showing no significant spinal axonal loss, correlating with histopathological findings.

Practical Implications

Diagnostic Approach

Clinicians should consider HIV-associated myelopathy even with negative or nonspecific MRI results in HIV-positive patients presenting with myelopathy symptoms.

Viral Load Monitoring

Routine assessment of both peripheral and central (CSF) viral load is crucial in HIV-positive patients with neurological symptoms to detect potential CSF HIV-escape.

Treatment Strategies

Escalating HAART therapy with medications having higher CNS penetration should be considered in cases of high CSF viral load and suspected HIV-associated myelopathy.

Study Limitations

1
The study is a single case report, limiting the generalizability of the findings.
2
SSEPs may be of limited use due to impaired peripheral nerve conduction.
3
The association of vacuolar myelopathy and a productive HIV infection within the spinal cord is not mandatory.

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