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HIV Vacuolar Myelopathy — SCE Infectious Diseases MCQ

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ModerateCNS InfectionHIV Vacuolar MyelopathySCE Infectious Diseases

A 40-year-old man with HIV on ART develops progressive spastic paraparesis with bladder dysfunction over 6 months. MRI spine shows cervical/thoracic cord signal change without compression. His CD4 is 450, VL <50. HTLV-1 serology is negative. VZV PCR and syphilis are negative. B12 is normal. What diagnosis should be considered?

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Correct answer: B — HIV-associated vacuolar myelopathy — a diagnosis of exclusion; caused by HIV-mediated damage to posterior and lateral columns of the spinal cord; no specific treatment beyond ART optimisation

HIV-associated vacuolar myelopathy (HIVM) is a progressive myelopathy affecting the posterior and lateral columns (resembling subacute combined degeneration of B12 deficiency). It is a diagnosis of exclusion — all treatable causes must be ruled out (HTLV-1, syphilis, VZV, B12/copper deficiency, cord compression, NMOSD). HIVM can occur even with suppressed VL, reflecting prior or ongoing low-level HIV-mediated CNS damage. There is no specific treatment beyond ART optimisation. Symptomatic management: spasticity treatment (Baclofen), bladder management, physiotherapy.

Reference: BHIVA 2022 – Neurological complications; NICE 2024