CMV RADICULOPATHY MIMICKING SYNDROME

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Cytomegalovirus (CMV) is an opportunistic pathogen capable of affecting the central nervous system in immunosuppressed individuals and can present as meningoencephalitis or radiculopathy that is difficult to diagnose. We report the case of a 26-year-old man, previously healthy, who sought care with a 15-day history of fever, frontotemporal headache, weight loss, and ascending weakness in the lower limbs, progressing to paraparesis and inability to walk. He was initially investigated under suspicion of Guillain–Barré syndrome. Cerebrospinal fluid (CSF) analysis revealed pleocytosis with neutrophil predominance, low glucose, and elevated protein, ruling out the initial hypothesis and suggesting infectious meningitis. HIV serology was positive (CD4+ 19 cells/µL; viral load 880,000 copies/mL), prompting investigation for opportunistic infections. A urinary LF-LAM test was positive, leading to initiation of RIPE therapy and dexamethasone for suspected neurotuberculosis. Imaging (CT and MRI of brain and spine) showed no compressive or inflammatory lesions. Cultures and expanded CSF testing (TRM-TB, AFB smear, fungal and bacterial cultures, and meningitis panel) were negative. The patient developed urinary retention, persistent motor deficit, and worsening CSF leukocyte count on repeat lumbar puncture, raising suspicion of CMV polyradiculopathy. Ganciclovir was initiated, and given the possibility of refractory or resistant infection, foscarnet was added, totaling 28 days of combined therapy. CSF PCR for CMV returned positive. By the end of treatment, there was marked clinical response, with reduced CSF cellularity and progressive functional improvement. Electroneuromyography showed acute demyelinating sensory-motor polyradiculoneuritis consistent with Guillain–Barré syndrome. However, the context of severe immunosuppression and inflammatory CSF supported the diagnosis of a Guillain-Barré-like syndrome secondary to CMV meningo-radiculitis. This case illustrates the diagnostic complexity of neurologic manifestations in AIDS, in which opportunistic infections can mimic autoimmune diseases. Considering CMV, even without retinal signs or classic manifestations, was decisive given the subacute, refractory course, abnormal CSF, and lack of response to initial empiric therapies.

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