Case Report A 63-year-old male with a long history of poor social interactions presented acutely confused. There was no alcohol or recreational drug use. Baseline bloods and routine microbiology were normal. CT and MRI of the brain found no causative pathology. Lumbar puncture (LP) only revealed a raised protein (1.47). An HIV test was positive; CD4 170 cells/μl, viral load (VL) 238 281 copies/ml. The patient refused antiretroviral (ARV) treatment, depressive episode was diagnosed and mirtazapine commenced. Three days later he went into status epilepticus. A repeat MRI brain was unchanged and LP showed: protein 0.84; glucose 4; WBC 5/cmm; India ink, CRAG, virology, acid fast bacilli and cytology were negative. Seizures were unremitting and nevirapine and truvada were commenced and mirtazapine withdrawn: seizure activity ceased. Gradually he improved and his CD4 rose to 280 cells/μl, HIV VL <50. Despite treatment, the patient re-presented with seizures on several occasions. No trigger was identified, and reported ARV adherence good. Repeat investigations revealed no new abnormality. In the absence of an adequate explanation for seizures, neuro-imaging was reviewed by a specialist neuroradiologist. Nodules within the frontal horns of the lateral ventricles were identified, indicating a diagnosis of subependymal nodular heterotopia (SNH).
Discussion This is the first report of SNH in an HIV positive adult. SNH are congenital, occurring during foetal neuronal proliferation and have no known association with HIV. Patients usually present in their 2nd decade with seizures and exhibit cognitive difficulties. SNH presenting in the 7th decade of life with status epilepticus is rare and we postulate that the cerebral atrophy associated with untreated HIV infection may have precipitated seizures in a predisposed individual. This case described demonstrates the importance including non-HIV related causes, when considering the aetiology of seizures in patients with HIV.
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