HIV in Children
GRAND ROUNDS AND TEACHING FILES
Continued neurological damage inspite of ART
Ira Shah
Consultant in Pediatric Infectious Diseases and Pediatric Hepatology, Nanavati Hospital, Mumbai, India
Incharge, Pediatric HIV and TB Clinic, B J Wadia Hospital for Children, Mumbai, India

A 7 years old HIV infected boy on antiretroviral therapy since April 2009 presented with altered sensorium in Nov 2011. In April 2009 at 3 years 4 months of age he had left sided hemiparesis. MRI brain showed infarct in right basal ganglia, internal capsule, corona radiata, perisylvian frontotemporoparietal cortical and sub cortical region with complete occlusion of right main stem middle cerebral artery (MCA). At that time, antiphospholipid antibodies IgM (17.4 MPL units/ml) and IgG (19.2 GPL units/ml) were positive. He was also detected to be HIV infected at that time. His CD4 count was 1645 cells/cumm (28%) in April 2009. He was started on Stavudine (d4T), 3TC and NVP along with aspirin. His hemiparesis gradually improved with physiotherapy and he was doing well on follow up with latest CD4 count is Feb 2011 being 3302 (59%) and CD4 ratio CD8 of 1.53. In Nov 2011, due to altered sensorium a repeat MRI brain was done that showed gliotic changes in the right MCA and posterior cerebral artery (PCA) territory with cortical laminar necrosis with mild atrophy of brain (Figure 1). On angiography, right MCA showed chronic stenosis at M, segment & non visualization of P3 segment of right PCA (Figure 3). EEG showed asymmetry between 2 hemispheres with left side showing high amplitude delta. There were no intermittent epileptiform discharges noted. HIV viral load was 12,100 copies/ml. CSF was normal. ART was shifted to AZT, 3TC and lopinavir/ritonavir (LPVr). However the child succumbed to his illness in Dec 2011. No other viral markers could be done due to unaffordability.


Why was there continued neurological damage inspite of ART?
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