Although idiopathic Bell’s palsy is commonly reported, bilateral facial paralysis (BFP) manifestation is very rare, mostly presenting secondary to underlying medical conditions. The exact mechanism of BFP in HIV infection is poorly understood, however, a correlation between direct HIV infection of the geniculate ganglion and/or direct immune response to acute viremia is proposed.

A 52 year old Hispanic female with history of bipolar and generalized anxiety disorders presents to the emergency room after experiencing facial paralysis on the left side for four days. Patient with history of right facial paralysis one month ago that improved with methylprednisolone for 7 days. The patient has a pertinent history of non-intentional weight loss of 20 pounds in the last year and former smoker 1 pack per day for the last 35 years. The physical findings are remarkable for left hyperacusis and left facial paralysis with incomplete left eye closure (House-Brackmann Scale of IV). Laboratories pertinent for elevated ESR of 54, HIV positive for antibodies and CD4 count of 724 cells/uL, (23.3% lymphocytes). CSF microbiology with evidence of atypical cells showing hyperchromatic irregular nuclei and scant cytoplasm. The brain MRI with contrast revealed abnormal contrast enhancement spanning the labyrinthine, tympanic, mastoid and extratemporal parotid segments of both facial nerves. Cervical lymph node biopsy with evidence of polyclonal plasmacytosis. She was treated with HAART therapy upon discharge, with marked clinical improvement.

Here we present an uncommon case of an HIV-positive patient with the first clinical manifestation of BFP, which can occur in both early, as in this case, (without any other symptoms) and advances stages of HIV. Therefore, it is crucial to associate BFP with HIV for early management and prevention of HIV transmission.