The Journal of the Association of Physicians of India · 2026
Triple Central Nervous System Pathogen Infections and Vascular Events in Advanced Human Immunodeficiency Virus-Implications for Early Diagnosis and Multidisciplinary Management: A Case Series from Two Tertiary Centers.
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Puri Sakshi, Chatterjee Rupak, Aleena Insha, Das Sarbajit
Аннотация
BACKGROUND: Central nervous system (CNS) infections remain a major cause of morbidity and mortality in people living with HIV (PLHIV), particularly in the setting of advanced immunosuppression and recent initiation of antiretroviral therapy (ART). While individual opportunistic CNS infections are well-documented, simultaneous infections with multiple pathogens are rare and diagnostically challenging.
METHODS: We report a case series of 11 HIV-positive individuals aged 25-50 years, presenting within 3 months of ART initiation to two tertiary centers over a 2-year period. All patients exhibited clinical features of meningitis and underwent cerebrospinal fluid (CSF) analysis, PCR testing, neuroimaging, and comprehensive microbiological workup.
RESULTS: All 11 patients were diagnosed with triple-pathogen CNS infections. The most common combination was Mycobacterium tuberculosis, Cryptococcus neoformans, and herpes simplex virus type 1 (HSV-1). Additional pathogens included Toxoplasma gondii, Treponema pallidum, and CMV. Median CD4 count was <70 cells/µL. Coinfections were frequently unmasked shortly after ART initiation, suggestive of immune reconstitution inflammatory syndrome (IRIS). Despite aggressive treatment, mortality was 45%. One complex case included CNS vasculitis, ischemic stroke, pulmonary embolism, and multiple systemic infections.
CONCLUSION: This series underscores the diagnostic and therapeutic complexities of managing CNS coinfections in PLHIV, especially in the context of IRIS. A high index of suspicion, early multiplex diagnostic testing, and multidisciplinary management are crucial. Furthermore, the presence of noninfectious complications such as stroke and thromboembolism highlights the broader spectrum of HIV-related neurological disease. Early recognition and targeted treatment can improve outcomes in this high-risk population.
METHODS: We report a case series of 11 HIV-positive individuals aged 25-50 years, presenting within 3 months of ART initiation to two tertiary centers over a 2-year period. All patients exhibited clinical features of meningitis and underwent cerebrospinal fluid (CSF) analysis, PCR testing, neuroimaging, and comprehensive microbiological workup.
RESULTS: All 11 patients were diagnosed with triple-pathogen CNS infections. The most common combination was Mycobacterium tuberculosis, Cryptococcus neoformans, and herpes simplex virus type 1 (HSV-1). Additional pathogens included Toxoplasma gondii, Treponema pallidum, and CMV. Median CD4 count was <70 cells/µL. Coinfections were frequently unmasked shortly after ART initiation, suggestive of immune reconstitution inflammatory syndrome (IRIS). Despite aggressive treatment, mortality was 45%. One complex case included CNS vasculitis, ischemic stroke, pulmonary embolism, and multiple systemic infections.
CONCLUSION: This series underscores the diagnostic and therapeutic complexities of managing CNS coinfections in PLHIV, especially in the context of IRIS. A high index of suspicion, early multiplex diagnostic testing, and multidisciplinary management are crucial. Furthermore, the presence of noninfectious complications such as stroke and thromboembolism highlights the broader spectrum of HIV-related neurological disease. Early recognition and targeted treatment can improve outcomes in this high-risk population.