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HIV-associated myelopathy

Summary

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  • Progressive spastic paraparesis and sensory ataxia in HIV patients
  • Vacuolar myelopathy of the spinal cord, predominantly affecting thoracic region
  • MRI shows cord atrophy and T2 hyperintensity in posterior and lateral columns1

Pathophysiology

  • Exact mechanism unclear, but likely multifactorial:
    • Direct HIV infection of spinal cord cells
    • Immune-mediated damage to myelin and axons
    • Metabolic disturbances, including vitamin B12 deficiency
  • Vacuolar changes in white matter, predominantly in lateral and posterior columns
  • Axonal degeneration and demyelination

Demographics

  • Occurs in 5-10% of HIV-infected individuals
  • More common in advanced stages of HIV infection (CD4 count <200 cells/μL)
  • Typically affects adults aged 30-50 years
  • No significant gender or racial predilection

Diagnosis

  • Clinical presentation:
    • Gradual onset of lower limb weakness and spasticity
    • Sensory ataxia and impaired vibration sense
    • Urinary and bowel dysfunction
  • Exclusion of other causes of myelopathy (e.g., compression, infection)
  • CSF analysis: may show mild pleocytosis and elevated protein
  • Serum vitamin B12 levels should be checked

Imaging

  • MRI findings:
    • Spinal cord atrophy, particularly in thoracic region
    • T2 hyperintensity in posterior and lateral columns
    • Symmetrical involvement, typically extending over multiple segments
    • No contrast enhancement
  • Differential diagnosis:
    • Vitamin B12 deficiency myelopathy
    • HTLV-1-associated myelopathy
    • Primary progressive multiple sclerosis

panels-1

  • 45-year-old patient presented with weakness and brisk upper limb reflexes. The patient had a recent diagnosis of HIV with a CD4 count of 10.
  • MRI showed an "inverted V" pattern of high signal in the dorsal columns.

Treatment

  • Antiretroviral therapy (may slow progression) with correction of any B12 deficiency and symptomatic management

Differential diagnosis (dorsal/lateral column myelopathy)

Imaging differential Differentiating feature
Subacute combined degeneration (B12) Identical dorsal-column "inverted V" sign; distinguished by low B12/high methylmalonic acid
Copper deficiency myelopathy Dorsal-column signal indistinguishable from SCD; history of bariatric surgery or zinc excess
HTLV-1 myelopathy Thoracic cord atrophy with lateral column signal; positive HTLV-1 serology
Compressive myelopathy Structural cord compression rather than symmetric column signal
NMOSD / transverse myelitis Longitudinally extensive, often enhancing, central cord lesion

  1. Ayele et al. HIV-associated neurocognitive disorder and HIV-associated myelopathy in a patient with a preserved CD4, but high viral load-a rarely reported phenomenon: a case report and literature review. 2020. BMC infectious diseases - Open in new tab. ↩