Objective:

To describe HIV-associated vacuolar myelopathy (HIV-VM) and highlight the diagnostic approach to tract-specific myelopathy in an immunocompromised patient.

Background:

Progressive myelopathy in people with HIV has a broad differential diagnosis, including inflammatory, infectious, metabolic, vascular, autoimmune, and neurodegenerative conditions. Although rare in the modern antiretroviral therapy (ART) era, HIV-VM remains an important consideration, particularly in patients with lapses in treatment.

Design/Methods:

We present a single-patient case report. Data were obtained from chart review, neurologic examination, cerebrospinal fluid analysis, and serial MRI studies.

Results:

A 66-year-old man with longstanding HIV and diabetes developed vertigo followed by progressive limb weakness, gait imbalance with falls, paresthesias, and urinary urgency over four weeks after restarting ART and receiving a COVID-19 booster. Examination revealed mild symmetric quadriparesis, brisk reflexes, impaired proprioception, and sensory ataxia. CSF analysis showed elevated protein, oligoclonal bands, and increased IgG index without pleocytosis. Cervical and thoracic MRI demonstrated longitudinally extensive, symmetric T2 hyperintensities involving dorsal columns and corticospinal tracts without enhancement. An extensive evaluation for autoimmune, infectious, metabolic, and neoplastic causes was unrevealing. Over nine months, the patient experienced gradual clinical improvement with near-complete radiologic resolution in the absence of immunotherapy. Findings were most consistent with HIV-VM related to immune reconstitution following ART resumption.

Conclusions:

This case highlights the importance of clinical localization, recognition of tract-specific spinal cord MRI patterns, and cautious interpretation of nonspecific CSF findings in immunocompromised patients. HIV-VM should remain in the differential for progressive myelopathy in the ART era, as appropriate recognition may prevent unnecessary immunosuppressive treatments and underscores the role of immune reconstitution in neurologic recovery.