Multiple sclerosis typical clinical and MRI findings in a patient with HIV infection

Multiple sclerosis (MS) is a demyelinating disease seldom included in the differential diagnosis of leukoencephalopathy in HIV-positive patients.

We describe the clinical findings and laboratory results of a 43-year-old male with HIV infection and MS, and reviewed 11 more cases reported in the literature.

The first episode of MS occurred either during or after the recognition of the HIV infection except in the few cases reported in 1989. There has been a very strong male predominance. Age at onset was between 30 and 40 years old. The most common clinical course was relapsing and remitting. Most of the cases had a normal CD4+ cell count, usually exceeding 500 cells/mm³. Despite that CD4+ cell counts were invariable high, all the patients had multiple tests to rule out opportunistic infections and HIV-associated illness. The clinical suspicion of MS was only considered after ruling out other opportunistic infections and was supported with brain imaging showing multiple white matter evanescent lesions, the presence of black holes, and a high myelin basic protein titer in the CSF.

MS is usually considered late in patients with HIV. A typical MS course with suggestive MRI lesions and absence of severe immune suppression should suggest the diagnosis. It is possible that as with other MS patients, earlier initiation of specific treatments for MS will prevent the high burden of the disease and disability in these patients, but stronger evidence for specific recommendations remains to be obtained.