A 59-year-old man with an unexplained fever was admitted to the hospital. Dizziness, fatigue, loss of appetite, fear of cold, afternoon fever, occasional babbling during fever, paroxysmal cough, and cough with a small amount of white sputum. Asthma, hemoptysis, nausea, vomiting, headache, abdominal pain, or diarrhea were not present in significant amounts. On admission, his vital signs were as follows: 92 beats per minute, 39.0°C axillary temperature, 132/91 mmHg blood pressure, and 22 breaths per minute. He tested positive for HIV in an outpatient setting.
Cerebrospinal fluid (CSF) examination was conducted after admission: CSF protein quantification 2360.00 mg/L, blood glucose 1.58 mmol/L, lactate dehydrogenase 52.00 U/L, CMV viral load 3.4×103 copies/ml, and positive CSF Mycobacterium tuberculosis (MTB) recombination assay. CSF Gene X-pert MTB/RIF test (gene X-pert MTB/RIF) showed MTB infection, and no rifampicin resistance was found. All other CSF tests were negative. The individual had a chest CT and a brain MRI done to determine the severity of the illness. The corpus callosum knee had aberrant signal on the MRI, with low T1WI, high T2WI, high FLAIR, high DWI, and low ADC signal, and no enhancement was shown on enhanced scans. Chest CT showed few lesions in both lungs, enlarged mediastinal lymph nodes, and a small amount of pleural effusion bilaterally.
Anti-tuberculosis treatment with isoniazid, pyrazinamide, levofloxacin, and amikacin was given because rifampicin injection and rifampicin capsule both caused pruritus and rash reactions. An increase in the amount of CMV load in the CSF to 24.7×103 copies/ml led to the beginning of antiviral treatment with ganciclovir 0.25 g/dose 15 days after the chest CT revealed a reduction in the pulmonary lesions and pleural effusion. Following antiviral therapy with tenofovir fumarate, lamivudine, and efavirenz with 70 cells/µl CD4+ T lymphocytes at baseline and improvement in clinical symptoms, the CMV load in the CSF decreased to 4.89×103 copies/ml after 9 days of treatment. Anti-tuberculosis treatment and antiviral therapy was continued after discharge with the consider as CMV encephalitis, tuberculous encephalitis and pulmonary tuberculosis.
Due to chills, fever, cough, and sputum, low fever, cough, small amount of white mucus sputum, loss of appetite, nausea, vomiting, fatigue, and numbness in both legs for three days, the patient was readmitted to the hospital on day 33 after starting antiretroviral therapy. The CMV viral load in CSF was 22.6×103 copies/ml, the protein level was 1605.80 mg/L, the glucose level was 2.28 mmol/L, and the mycobacterium tuberculosis recombination assay was negative. The CD4 + T lymphocytes was 105 cells/µl. MRI revealed an enlarged lesion in the corpus callosum knee, as well as a decreased diffusion-weighted image signal. In comparison to the previous CT of the chest, the lesions in the right upper lobe parietal segment and left lower lobe dorsal segment were larger. The patient expressed dissatisfaction about continuing to take medication after being discharged. During this hospitalization, no further infections were found. Relapsing - immune reconstitution inflammatory syndromes was considered as the most likely diagnosis. The original anti-tuberculosis treatment and antiviral medication was supplemented with a minor quantity of dexamethasone. Five days later, the CMV viral load had dropped to 4.37×103 copies/ml. Then the patient did not cooperate with treatment and the CMV viral load up to 22.7×103 copies/ml ten days later and the patient was discharged automatically.
The patient was hospitalized for the third time 19 days later and the CMV viral load was up to 35.0×103 copies/ml. Continue anti-tuberculosis and antiviral treatment with ganciclovir 24 days later, the CMV viral load dropped to 0.54×103 copies/ml. The patient got cerebral MRI and chest CT examination and showed that there were less brain and chest lesions than there were prior to treatment. The HIV-RNA viral load was less than 20 copies of per ul. Figure 1( Fig. 1) shows the dynamic changes of recurrent IRIS of an AIDS patient with CMV encephalitis and pulmonary tuberculosis.
Two-year outpatient follow-up did not show any consequences or recurrence of CMV infection.