Till date there are only few case reports of HIV infection
in children, presenting with stroke and none with epilepsia
partialis continua (EPC) as their first manifestation [1,2].
EPC as a neurological manifestation of HIV has been
described previously, only rarely in children [3,4]. Here we
report a child presenting with stroke and EPC, later
diagnosed to be infected with HIV.
A 6-year old boy, developmentally normal,
admitted with illness beginning with fever and abnormal
jerky movements of right upper limb lasting initially for
few seconds, progressing over next few days to involve right
lower limb followed by involvement of right half of face.
Seizures, at presentation, persisted during most times with
amplitude decreasing during sleep. Child on examination had
cervical lymph nodes palpable, liver 2 cm and spleen 2 cm
palpable below costal margins. Patient had reduced level of
alertness without meningeal signs and normal fundus. Child
had right upper motor neuron facial nerve palsy, weak gag,
aphasia and right hemiplegia. Reflexes were exaggerated in
all four limbs with ankle clonus present. Lab investigation
revealed prothrombin time 11 seconds, partial thromboplastin
time 22 seconds, total serum protein 9.4 g%, albumin to
globulin ratio 2.3/7.1, HIV ELISA positive, anti nuclear
antibody negative, toxoplasma IgG 1:1600 and IgM <1:800,
VDRL non reactive, anticardiolipin antibodies and factor V
Leiden mutation absent. Contrast MRI of the brain (34th day
of illness) revealed infarct involving left basal ganglia
and left insular region (middle cerebral artery territory)
and frontal cortex (anterior cerebral artery territory) with
MRA showing no evidence of any vascular malformation.
Multivoxel spectroscopy was suggestive of bilateral basal
ganglia infarct. Later patient’s sib and both parents were
tested and found positive for HIV. Cerebrospinal fluid (CSF)
examination (1 month of illness) results showed leucocytes
absent, proteins 38.2 mg/dL, sugar 39 mg/dL, Gram stain
negative, culture sterile, cryptococcus (India ink
staining), Japanese encephalitis (PCR and serology), Herpes
simplex virus 1 and 2 (PCR & serology), tuberculosis
(adenosine deaminase, culture and PCR) were found to be
negative. Electroencephalogram (EEG) was suggestive of
diffuse encephalopathy left more than right with focal
epileptiform discharges. Cardiac echocardiography was
normal.
Cerebrovascular complications are
associated with perinatal HIV infection, albeit as a rare
presentation. Mechanisms underlying the increased risk for
ischemic stroke in HIV infected include opportunistic
infections, meningitis and vasculitis, primary HIV
vasculopathy, altered coagulation, and cardioembolic events
[5]. In absence of vasculitis, HIV-related vasculopathy may
cause stroke, which was the most likely etiology in our
case.
References
1. Visudtibhan A, Visudhiphan P,
Chiemchanya S. Stroke and seizures as the presenting signs
of pediatric HIV infection. Pediatr Neurol. 1999;20:53-6.
2. Lodha R, Upadhyay A, Kapoor V, Kabra
SK. Clinical profile and natural history of children with
HIV infection. Indian J Pediatr. 2006;73:201-4.
3. Bartolomei F, Gavaret M, Dhiver C,
Gastaut JA, Gambarelli D, Figarell-Branger D, et al.
Isolated, chronic, epilepsia partialis continua in an
HIV-infected patient. Arch Neurol. 1999;56:111-4.
4. Ferrari S, Monaco S, Morbin M, Zanusso
G, Bertolasi L, Cerini R, et al. HIV-associated PML
presenting as epilepsia partialis continua. J Neurol Sci.
1998;161:180-4.
5. Dobbs MR, Berger JR. Stroke in HIV infection and AIDS.
Expert Rev Cardiovasc Ther. 2009;7:1263-71.