Mycobacterial acute lumbosacral polyradiculopathy as the initial manifestation of AIDS

Acute lumbosacral polyradiculopathy (ALP) is a well characterized syndrome in AIDS and is most frequently caused by cytomegalovirus (CMV). Mycobacterial infection of the central nervous system may occasionally manifest as spinal radiculomyelitis, with clinical features that can be indistinguishable from those of ALP. As far as we know, tuberculosis has not been reported as an etiologic agent of ALP in AIDS patients, although focal spinal mycobacterial meningomyelitis has been reported. We present a patient who developed a mycobacterial ALP as the initial manifestation of AIDS. This patient presented with an ALP and neutrophilic meningitis associated with disseminated mycobacterial disease. Although mycobacterial species could not be identified, it was most likely Mycobacterium tuberculosis, because this case fulfills the Ahuja diagnostic criteria for highly probable tuberculous meningitis. CMV infection seems unlikely, because his CD4 count was 200 x 10 super(6) cells/L and because the test for viral antigenemia and PCR detection of virus in CSF were negative. Tuberculous leptomeningitis is thought to be frequently associated with involvement of the spinal cord and nerve roots. No clinical features nor imaging data supported a myelitis involvement in our patient, who instead demonstrated meningoradicular affection. For these reasons, we believe tuberculosis should be included in the differential diagnosis of ALP in AIDS, because neither the clinical features nor spinal fluid findings differentiate a mycobacterial from a CMV cause. Empiric treatment with antituberculous drugs should be considered, especially in patients with a low probability for CMV infection and in countries were tuberculosis is prevalent. Prompt treatment is imperative to preserve neurologic function.