title: Diagnostic challenges in vacuolar myelopathy: a didactic case report.
abstract: BACKGROUND
  Because of the diagnostic complexity and potential pitfalls in interpreting test results, HIV-vacuolar myelopathy (HIVM) is far more often diagnosed postmortem thanin vivo. In the era of highly active antiretroviral therapy (HAART), the topic of neuro-AIDS has become increasingly important. This case report covers some of the diagnostic problems encountered in vacuolar myelopathy based on magnetic resonance imaging (MRI) fiber-tracking pictures of the spine in a patient with HIVM, including a 1-year follow-up.
  
  
  METHODS
  A 49-year-old man felt progressive weakness, and difficulties while walking, and he suffered from incomplete voiding. A week before admission, follicles appeared on the right side of his neck and shoulder. His medical history included a chronic HIV infection treated with HAART and a B-cell lymphoma in complete remission after chemotherapy. The initial exam revealed thoracic hyposensitivity level distal to dermatome Th9, spastic paraparesis of the lower limbs and herpes zoster infection in dermatome C3/C4. A lesion of the thoracic myelon could be ruled out in the MRI scan, chemotherapy-induced polyneuropathy was stable, and no acute opportunistic infection of the CNS was found. HIV load in cerebrospinal fluid (CSF) was markedly elevated. An HIV-associated vacuolar myelopathy was diagnosed, revealing the HIV itself as etiology.
  
  
  CONCLUSIONS
  A negative or unspecific MRI scan excludes possible other causes, but by no means rules out HIV-related myelopathy. Furthermore, peripheral and central viral load should always be assessed to avoid missing a possible 'CSF HIV-escape'.
authors.affiliation: Department of Neurology, Paracelsus Medical University Salzburg, Salzburg, Austria; Spinal Cord Injury and Tissue Regeneration Center Salzburg (SCITReCS), Salzburg, Austria.
authors.forename: Florian
authors.initials: F
authors.lastname: Ernst
authors.affiliation: Division of Neuroradiology, Paracelsus Medical University Salzburg , Salzburg, Austria.
authors.forename: Fritz
authors.initials: F
authors.lastname: Klausner
authors.affiliation: Department of Neurology, Paracelsus Medical University Salzburg, Salzburg, Austria; Spinal Cord Injury and Tissue Regeneration Center Salzburg (SCITReCS), Salzburg, Austria.
authors.forename: Waltraud
authors.initials: W
authors.lastname: Kleindienst
authors.affiliation: Department of Neurology, Paracelsus Medical University Salzburg , Salzburg, Austria.
authors.forename: Heinrich
authors.initials: H
authors.lastname: Bartsch
authors.affiliation: Department of Internal Medicine III with Hematology, Medical Oncology, Hemostaseology, Infectious Diseases, Rheumatology, Oncologic Center, Laboratory of Immunological and Molecular Cancer Research, Paracelsus Medical University Salzburg , Salzburg, Austria.
authors.forename: Ninon
authors.initials: N
authors.lastname: Taylor
authors.affiliation: Department of Neurology, Paracelsus Medical University Salzburg, Salzburg, Austria; Spinal Cord Injury and Tissue Regeneration Center Salzburg (SCITReCS), Salzburg, Austria.
authors.forename: Eugen
authors.initials: E
authors.lastname: Trinka
keywords: Central nervous system infections; Disability; Infection; Neurological manifestations; Spinal cord