Reversible HIV-Associated Nephropathy and Concomitant Encephalomyelopathy as the Initial Presentation of Advanced,...

Human immunodeficiency virus (HIV) can cause severe multiorgan dysfunction when left untreated. Concurrent, severe renal and central nervous system manifestations as the primary presentation of advanced HIV are rare in modern clinical practice. We report a case of a young female presenting with dialysis-dependent acute kidney injury (AKI) from HIV-associated nephropathy (HIVAN) and paraplegia from HIV encephalomyelopathy, both of which demonstrated remarkable recovery following antiretroviral therapy (ART). A 31-year-old female presented with a 1-week history of pyrexia, malaise, and rapidly progressive bilateral lower limb weakness. She is a PLHIV (people living with HIV) and was diagnosed seven years ago; she had defaulted from follow-up before starting ART. Laboratory investigations revealed stage 3 AKI, with serum creatinine rising from 403 umol/L on admission to 1112 umol/L within two weeks, alongside high-grade proteinuria. Serology confirmed a plasma HIV-1 RNA viral load of 3,440,753 copies/mL and a CD4 T-cell count below the limit of detection (<8 cells/uL). A renal biopsy demonstrated classic histopathological features of HIVAN, showing collapsing glomerulopathy. Magnetic resonance imaging (MRI) of the brain and spine demonstrated extensive, diffuse abnormal T2-weighted fluid-attenuated inversion recovery (T2/FLAIR) signal intensities involving the cerebral hemispheres, basal ganglia, brainstem, and a long segment of the cervical cord, consistent with an advanced neuro-axis injury. Cerebrospinal fluid (CSF) analysis and CSF culture ruled out opportunistic neuro-infections. The patient was initiated on regular haemodialysis and an intensive antiretroviral regimen consisting of dolutegravir/lamivudine, darunavir, and ritonavir, alongside co-trimoxazole prophylaxis until her CD4 count was over 200 cells/mm³. Over a five-month follow-up period, the patient demonstrated an impressive clinical response. Her plasma viral load decreased to 41 copies/mL, serial neuroimaging revealed substantial resolution of the extensive intracranial and spinal cord lesions, together with recovery of motor power to 5/5 in all 4 limbs, and recovery of renal function, which allowed for the successful cessation of long-term haemodialysis. This case underscores that advanced HIVAN requiring renal replacement therapy and extensive HIV-related central nervous system pathology can be profoundly reversed with timely, potent antiretroviral therapy. Clinicians must maintain a high index of suspicion for HIV in patients presenting with unexplained concurrent multiorgan dysfunction, as early intervention can avert permanent end-stage organ failure and severe neurological disability.