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Triple Central Nervous System Pathogen Infections and Vascular Events in Advanced Human Immunodeficiency

Sakshi Puri1, Rupak Chatterjee2, Insha Aleena3

  • 1Consultant, Department of Neurology, Apollo Multispeciality Hospital, Kolkata, West Bengal, India, Corresponding Author.

The Journal of the Association of Physicians of India
|August 3, 2026
PubMed

Insights

Central nervous system infections in people living with HIV (PLHIV) are complex. This study found triple-pathogen CNS infections are challenging, often linked to immune reconstitution inflammatory syndrome (IRIS) after starting antiretroviral therapy (ART).

Area of Science:

  • Neurology
  • Infectious Diseases
  • HIV Medicine

Background:

  • Central nervous system (CNS) infections are a significant cause of illness and death in people living with HIV (PLHIV).
  • Opportunistic CNS infections are known, but simultaneous infections with multiple pathogens are rare and difficult to diagnose.
  • Advanced immunosuppression and recent initiation of antiretroviral therapy (ART) increase risk.

Purpose of the Study:

  • To describe a case series of HIV-positive individuals with multiple CNS pathogens.
  • To highlight diagnostic and therapeutic challenges in managing these complex infections.
  • To underscore the role of immune reconstitution inflammatory syndrome (IRIS) in unmasking coinfections.

Main Methods:

  • Retrospective case series of 11 HIV-positive patients presenting with meningitis symptoms within 3 months of ART initiation.
  • Involved cerebrospinal fluid (CSF) analysis, PCR testing, neuroimaging, and comprehensive microbiological workup.
  • Data collected over a 2-year period from two tertiary centers.

Main Results:

  • All 11 patients were diagnosed with triple-pathogen CNS infections.
  • Common pathogens included *Mycobacterium tuberculosis*, *Cryptococcus neoformans*, and HSV-1; others included *Toxoplasma gondii*, *Treponema pallidum*, and CMV.
  • Median CD4 count was <70 cells/µL, and coinfections often appeared with ART initiation, suggesting IRIS. Mortality rate was 45%.

Conclusions:

  • Managing CNS coinfections in PLHIV, especially with IRIS, presents significant diagnostic and therapeutic challenges.
  • A high index of suspicion, early multiplex diagnostic testing, and multidisciplinary care are essential.
  • Noninfectious complications like stroke and thromboembolism highlight the broad spectrum of HIV-related neurological disease.
Abstract

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