Tumefactive demyelination: A rare presentation of HIV

How to cite this article:
Rajendra JS, Rahul H, Kadam N, Swayam P. Tumefactive demyelination: A rare presentation of HIV. Ann Trop Med Public Health 2014;7:216-7

 

How to cite this URL:
Rajendra JS, Rahul H, Kadam N, Swayam P. Tumefactive demyelination: A rare presentation of HIV. Ann Trop Med Public Health [serial online] 2014 [cited 2020 Aug 14];7:216-7. Available from: https://www.atmph.org/text.asp?2014/7/4/216/152599

Sir,

Tumefactive demyelination is defined as a demyelinating plaque of more than 2 cm in diameter and is considered as intermediate between multiple sclerosis and acute demyelinating encephalomyelitis (ADEM). [1] Although neurological manifestations in human immunodeficiency virus (HIV) infection are common, demyelinating diseases are rarely seen. [2] Not many case reports of tumefactive demyelination in HIV have been published so far. We herein report a previously undiagnosed HIV positive patient presenting with features of tumefactive demyelination as initial manifestation of HIV infection.

A 30-year-old manual laborer presented with two episodes of left partial seizures with secondary generalization followed by progressive left hemiparesis and altered sensorium since 25 days. On examination, the patient was stuporous with motor power Medical Research Council (MRC) grade 0/5 in left upper and lower limbs. Contrast magnetic resonance imaging (MRI) brain showed bilateral, asymmetric, incomplete ring enhancing lesions predominantly involving white matter of right frontoparietal and left frontal lobe with mass effect and midline shift towards left, along with involvement of genu and splenium of corpus callosum, without diffusion weighted restriction [Figure 1] [Figure 2] [Figure 3]. Laboratory investigations with enzyme-linked immunosorbent assay (ELISA) revealed that the patient was HIV positive. We advised a stereotactic biopsy, but patient’s relatives refused for any invasive procedure. Thus, based on the contrast MRI features, a diagnosis of tumefactive demyelination was made and the patient was treated with antiretroviral therapy and injectable methylprednisolone followed by tapering dose of oral steroids over 2 months to which he showed significant response and improved.{Figure 1}{Figure 2}{Figure 3}

Radiological hallmarks of tumefactive demyelination are important to be recognized as it may avoid invasive procedure of the brain. Open ring sign, corpus callosum involvement, increased apparent diffusion coefficients within tumefactive demyelinating lesions, and rapid resolution with steroid therapy are MRI features suggestive of tumefactive demyelination. [1] Other possible intracranial space occupying lesion in an HIV positive patient are lymphoma, glioma, toxoplasma infection, and pyogenic abscess. All these conditions were radiologically excluded due to open ring enhancement, increased apparent diffusion coefficients, and improvement with steroids. [3],[4] Although, a stereotactic biopsy to confirm the nature of lesion would have been ideal, but we could not get the tissue diagnosis as the patient’s relatives refused for any invasive procedure.

This case highlights the importance of radiological features of tumefactive demyelination especially in an HIV positive patient as tissue diagnosis is difficult in these patients and biopsy result may not be able to differentiate low grade glioma and tumefactive demyelination in many cases, and management is dependent on radiological features.

References

 

1.
Nadkar MY, Deore RA, Singh R. Tumefactive demyelination. J Assoc Physicians India 2008;56:901-3.
2.
Uriel A, Stow R, Johnson L, Varma A, du Plessis D, Gray F, et al. Tumefactive demyelination – an unusual neurological presentation of HIV. Clin Infect Dis 2010;51:1217-20.
3.
Kim DS, Na DG, Kim KH, Kim JH, Kim E, Yun BL, et al. Distinguishing tumefactive demyelinating lesions from glioma or central nervous system lymphoma: Added value of unenhanced CT compared with conventional contrast-enhanced MR imaging. Radiology 2009;251:467-75.
4.
Given CA 2nd, Stevens BS, Lee C. The MRI appearance of tumefactive demyelinating lesions. AJR Am J Roentgenol 2004;182:195-9.

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1755-6783.152599

Figures

[Figure 1]AnnTropMedPublicHealth_2014_7_4_216_152599_f1.jpg, [Figure 2]AnnTropMedPublicHealth_2014_7_4_216_152599_f2.jpg, [Figure 3]AnnTropMedPublicHealth_2014_7_4_216_152599_f3.jpg

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