Cytomegalovirus-Associated Central Pontine Myelinolysis in a Severely Immunocompromised HIV/AIDS Patient

Central pontine myelinolysis (CPM) is most commonly associated with rapid correction of hyponatremia, yet emerging evidence indicates that additional factors, particularly in immunocompromised individuals, may also play a role. We report a case of a 35-year-old male with untreated HIV/AIDS and stage IV Hodgkin lymphoma undergoing chemotherapy, who presented with acute hypoxic respiratory failure. Despite no fluctuations in serum sodium and normal serum osmolarity and electrolytes, MRI revealed a classic trident-shaped lesion in the central pons consistent with CPM. Extensive workup showed a markedly elevated cytomegalovirus (CMV) viral load, while cerebrospinal fluid findings were inconclusive. In the context of profound immunosuppression and absence of other identifiable causes, CMV-associated CPM was strongly suspected. Initiation of antiviral therapy led to partial neurological improvement, but the patient ultimately left the hospital against medical advice. This report underscores the importance of considering opportunistic infections such as CMV as potential contributors to CPM in patients with advanced HIV, even in the absence of classic metabolic triggers. Broader awareness of these atypical etiologies may facilitate earlier recognition and more targeted management in this vulnerable population.