Encephalitis Due to Co-Infection with Cytomegalovirus and Herpes Simplex Virus Type 2 in a Patient with Acquired Immunodeficiency Syndrome

Objective: Unusual clinical course Background: Opportunistic infections are commonly seen in immunocompromised patients. Here, we present an interesting case of a patient with poorly controlled human immunodeficiency virus (HIV) infection who presented with multiple opportunistic infections. Case Report: A 44-year-old woman with medical history of HIV infection (CD4 <20 cells/mu l, viral load 172 996 copies/ml), presented with symptoms of headache for 2 days and changes in mentation. She was recently treated for pulmonary mycobacterium avium complex infection. Her physical examination revealed normal breath sounds and her abdominal examination was unremarkable. She did not have any focal neurological deficits, nuchal rigidity, or papilledema on examination. Computed tomography (CT) head was negative for any acute lesions. She was empirically started on vancomycin and piperacillin-tazobactam. Due to persistent symptoms, a lumbar puncture was performed, which revealed elevated total proteins in CSF, and a viral polymerase chain reaction test was positive for herpes simplex virus type 2 (HSV-2) and cytomegalovirus (CMV). Magnetic resonance imaging of the brain showed mild enhancement of the ventricular lining. She was treated with acyclovir, which was later changed to ganciclovir, with resulting clinical improvement. The patient had clinical improvement and was discharged home. Conclusions: Multiple opportunistic co-infections should be considered in patients with poorly controlled HIV infection.