Comorbidity Of Spinal Cord Neurocysticercosis And Tuberculosis In A HIV-Positive Patient

摘要

We report a HIV-positive patient on HAART who presented a spinal cord syndrome due to TB spine and an associated intramedullary neurocysticercosis confirmed by T-2 MRI and ELISA test on CSF. Patient improved remarkably with medical treatment and surgical procedure was done. Introduction As far as medical history is known, it is likely that arachnoiditis (ARC) was present in the spines of some Egyptian mummies (estimated to have been buried over 5,000 years ago) in whom typical lesions of spinal tuberculosis were found. This dreadful disease is characterized by longstanding inflammation of the two innermost layers of the sac surrounding the spinal cord (SC) which contains the cerebrospinal fluid (CSF), and not uncommonly expands into the nerve roots, and the cauda equina, occasionally deforming the dural sac by scarring. TB is the commonest infection associated with HIV/AIDS, but TB spine is not the common presentation. Despite the availability of effective preventive measures and chemotherapy, the prevalence of tuberculosis (TB) is increasing in the developing world and in much of the industrialized world as well In developing countries the annual risk of tuberculosis infection in children is 2- 5 per cent. Nearly 8-20 per cent of the deaths caused by tuberculosis occur in children. Early diagnosis plays a vital role in control of TB. Although acid fast bacilli (AFB) microscopy, and conventional Lowenstein Jensen (L-J) culture remain the cornerstone for the diagnosis of TB, these traditional methods are either slow or their sensitivity is quite low.1Worldwide cestode infection “neurocysticercosis” is the commonest parasitic disease of the central nervous system; it may involve the brain parenchyma, the meninges or ventricles and, infrequently it involves the spinal cord. Involvement of spinal cord has variably been reported to be 1-5% 2 Other report its ranging from 0.7%-5.8%3 Between 1978 and 1989 only forty-five cases of intramedullary cysticercosis have been reported in the literature, presenting as quadriplegia or paraplegia. Up to 1998 no more than 49 confirmed cases have been reported in the literature6 but none have been reported in the conus medullaris region until 20037 Therefore the spinal forms of neurocysticercosis are rather rare. The more common presentation is the leptomeningea form. The current theory of downward migration of the parasites from the cerebral to the spinal subarachnoid space cannot explain primary spinal forms, and it is suggested that retrograde flow through the epidural vertebral veins provides an alternative route8 Spinal cysticercosis can be either leptomeningeal (which responds like subarachnoid disease) or intramedullary. A review of 95 published cases of medullar cysticercosis since 1856 shows the incidence of this condition9. As far we know this is the first report about comorbity of TB spine and NCC spine in HIV-positive patient. Case Report A 27-years-old female presented with burning pain on both lower limbs and gradual onset weakness for 6 months leading to inability to walk. She was diagnosed as HIV-positive since 2 years back and she was on HAART (Stavudine 30 mg. lamivudine 150 mg. efarinez 600 mg.) for the past seven months. After five months of symptoms on lower limbs, she developed acute onset retention of urine with overflow incontinence along with constipation. By this time, she also complained of pins and needle sensation on both legs and the diagnosis of peripheral neuropathy HIV's related was made and then treated empirically with amytrptylline (25 mg po BD) and lamotrigine (200mg por TDS) without improvement. In the next two weeks, she gradually became bedridden. she did not give a history of root pain, low backache, trauma to back, prolonged fever or claudicating pain, weight loss, anorexia, diabetes, tuberculosis or any opportunistic infection.On clinical examination, she had a symmetric flaccid paraplegia with sensory bladder, bowel involvement, sensory level for light