Abstract Details

Title Case Report of CD8 Encephalitis in a Person Living with HIV

Topic Autoimmune Neurology

Presentation(s) P3 - Poster Session 3 (12:00 PM-1:00 PM)

Poster/Presentation
Number 016

Objective To describe a case of CD8 encephalitis in HIV.

Background CD8+ T-cell encephalitis (CD8E) is a complex condition unique to people living with HIV and distinct from HIV encephalitis. It is hypothesized that an imbalance in CD8+/CD4+ T-cells results in a CD8+ T-cell predominant inflammatory response within the brain.

Design/Methods N/A

Results A 37-year-old man with chronic HIV infection, virally suppressed on antiretroviral therapy, and prior right MCA stroke presented with one month of progressive neurocognitive decline. Examination demonstrated prolonged speech latency, inattention, dysarthria, and residual deficits from prior stroke. MRI Brain showed confluent areas of T2/FLAIR hyperintensities involving bilateral subcortical and periventricular regions with patchy enhancement. CSF studies revealed mildly elevated protein and undetectable HIV RNA. Extensive evaluations for metabolic, infectious, rheumatologic, autoimmune encephalitis, and malignant etiologies were negative. High-dose intravenous steroids and IVIG for presumed immune-mediated encephalitis provided mild cognitive improvement and no radiologic improvement. A month later, he presented with worsening encephalopathy. MRI showed worsened T2/FLAIR signal throughout bilateral anterior temporal lobes and basal ganglia with gadolinium enhancement. Repeat CSF studies revealed markedly elevated protein and lymphocytic pleocytosis. Quantitative HIV-1 VL in CSF and blood was 4,350 and 1,150 copies/mL, respectively, despite having been suppressed for the past 8 years. Brain biopsy showed edematous brain parenchyma with abundant parenchymal and perivascular mixed inflammation containing CD8+predominant T-cells, plasma cells, and macrophages. Subsequent treatment with high-dose steroids followed by slow prednisone taper produced ongoing cognitive improvement as well improvement in size and enhancement of multifocal lesions on MRI.

Conclusions CD8E is an elusive diagnosis that must be considered in patients with HIV infection who present with encephalopathy regardless of viral control. Histopathologic findings of parenchymal inflammation with CD8+ T-cells in the setting of CSF escape of HIV is a distinct feature. Corticosteroids are beneficial, though further studies are needed to guide long-term management.

Authors/Disclosures
Allyson Heng, MD (UAB Neurology) PRESENTER	Dr. Heng has nothing to disclose.
Alison E. Burkett, MD	Dr. Burkett has nothing to disclose.
Serdar Akkol, MD, PhD (University of Alabama at Birmingham)	Dr. Akkol has nothing to disclose.
Matthew McCay, MD	Dr. McCay has nothing to disclose.
Sanjith Prahas Krishnam, MBBS	Dr. Krishnam has nothing to disclose.
Neda Wick	Neda Wick has nothing to disclose.
Shruti P. Agnihotri, MD	An immediate family member of Dr. Agnihotri has stock in Pfizer. The institution of Dr. Agnihotri has received research support from Roche/ Genentech.

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