ABSTRACT

Background: Profound immunosuppression renders people living with HIV/AIDS highly susceptible to severe and overlapping opportunistic infections, especially polymicrobial. Moreover, the biological behavior of concurrent infections in the human host, whether it is synergistic, antagonistic, symbiotic, mutualistic or commensal is not well understood especially in advanced HIV disease. We report a rare and complex case of co‐existent disseminated cryptococcosis, neurosyphilis and herpes simplex virus infection in an advanced HIV patient and highlight the diagnostic difficulties and management issues.

Case report: A young man with a history of occasional smoking and alcohol consumption presented with painful genital ulcer and lip rash, intermittent fever and vomiting for 2 months. He was recently diagnosed as HIV reactive and not yet started on antiretroviral therapy. A detailed clinical assessment was performed including serial laboratory investigations, cerebrospinal fluid analysis, serial serum cryptococcal antigen and rapid plasma reagin tests and sequential magnetic resonance imaging of the brain. Central nervous system lesions were interpreted and concurrent infections confirmed with multidisciplinary consultation. Therapeutic response, adverse events, and complications were noted in the hospitalization.

Neuroimaging showed multiple ring-enhancing central nervous system lesions initially presumed to be tuberculomas but reclassified as cryptococcomas on longitudinal assessment. The patient had positive serum cryptococcal antigen persistently and confirmed neurosyphilis and herpes genitalis/labialis. Her hospital course was complicated by aspiration pneumonia, catheter-related infections, septic shock, and drug-induced pancytopenia. Neurological and systemic status improved with targeted antimicrobial therapy and supportive care, although residual neurological deficits were present at discharge.

Conclusion: This case highlights the importance of high clinical alertness to the presence of multiple opportunistic infections in advanced HIV disease, co-existing and interacting in a severely immunocompromised host. Precise identification of lesions in the central nervous system, early pathogen-directed therapy and coordinated multidisciplinary management are essential for improving outcomes in patients with advanced HIV and polymicrobial opportunistic infections.