Neurological manifestations in patients infected with human immunodeficiency virus can significantly increase overall morbidity and mortality. These complications are neither limited to a specific location in the nervous system nor a focal time period in the disease’s progression. A literature review yielded several cases of peripheral facial palsy associated with HIV seropositivity, but few cases have been reported where the patient had bilateral peripheral facial palsy. In this paper, we present a patient with bilateral peripheral facial palsy and aseptic meningitis in the context of newly diagnosed HIV.
Human immunodeficiency virus (HIV) is a retrovirus that affects the immune system by targeting T cells with CD4 receptors. Since its identification, the medical community has become increasingly knowledgeable regarding the many opportunistic infections that can affect these immunosuppressed individuals. Unfortunately, neurological manifestations associated with HIV seropositivity are also increasing the morbidity and mortality rates of these patients. The virus can affect the nervous system at any level producing a variety of clinical presentations [
This paper presents a patient with early stage neurological complications, bilateral peripheral facial palsy, and aseptic meningitis, in the context of newly diagnosed HIV.
A 41-year-old homosexual male presented for bitemporal headache, inability to close his right eye, perioral numbness, and myalgias. In the prior two weeks, he had extensive diagnostic workup for abdominal pain. He was subsequently diagnosed with viral hepatitis and HIV, confirmed with western blot. He had tested negative for HIV one year before. Two days after hospital discharge he developed a bitemporal headache that originated posteriorly and was not relieved with Vicodin. He also complained about difficulties closing his eyes, right worse than left, and inability to close his mouth completely causing food to dribble out of his mouth. He denied any visual changes or difficulty swallowing. He denied ever having either of these complaints previously. He had not travelled outside of the United States and knew of no illnesses among his personal contacts. He has had three partners in the past year with his last sexual encounter six weeks ago. He denied any intravenous drug use, is a nonsmoker, and drinks socially once a month. Review of systems also revealed mild photophobia, shoulder pain, cough, periorbital paresthesias, night sweats, and nausea otherwise, negative for fevers, weight loss, dyspnea, and chest pain.
At admission, his vitals were stable. Objectively, the patient appeared to be quite anxious, shaking intermittently. His neurological exam was significant for an inability to smile, frown, close his eyes completely, or puff out his cheeks (Figures
At admission, his CBC & CMP were unremarkable. A lumbar puncture was done and the cerebrospinal fluid (CSF) contained protein of 87.6, glucose of 47, WBC of 41, lymphocytes of 98%, monocytes of 2%, and gram stain and cultures showed no organisms. CSF analysis was negative for
His CT of the head and MRI of the brain without contrast showed no acute intracranial abnormalities.
He was ultimately diagnosed and treated for lymphocytic predominant meningitis with bilateral peripheral facial neuropathy secondary to HIV. He was given supportive care for the meningitis and neuropathy, started on Atripla for HIV infection and referred to the infectious disease clinic for followup on an outpatient basis.
This patient’s bilateral peripheral facial palsy and aseptic meningitis can be attributed to his recently diagnosed HIV seroconversion. The extensive diagnostic work-up did not reveal another infectious agent that could have contributed to his neurological complications. This is important as thorough histories along with adequate laboratory tests are critical in determining a possible etiology for bilateral diplegia [
Bilateral peripheral facial palsy with recent HIV seroconversion has been previously reported in few other case reports and is considered to be a rare occurrence [
Kim et al. reported a similar case of bilateral peripheral facial palsy and aseptic meningitis in a patient with HIV [
Fortunately for these two patients, their neurological manifestations were quickly associated with HIV, and, consequently, the underlying infection could be treated. A review article on facial palsies encourages physicians to consider more exotic causes before labeling such presentations as Bell’s palsy, which is a diagnosis of exclusion and an idiopathic condition [
Bilateral peripheral facial palsy is currently a rare manifestation, especially in the context of HIV infection.
The authors declare that have no conflict of interests.