Abstract Introduction Disseminated Mycobacterium avium complex (MAC) infection is one of the most frequent opportunistic infections in advanced acquired immunodeficiency syndrome (AIDS), with up to 20-40% of untreated patients with CD4 counts below 50 cells/µL. Cytomegalovirus (CMV) disease is also common in this population, often presenting as retinitis, colitis, or esophagitis, and less commonly as encephalitis or ventriculitis. Co-infection with both MAC and CMV is not unusual in end-stage HIV infection, as both thrive under profound immunosuppression. Existing reports describe MAC + CMV coinfection primarily in gastrointestinal, pulmonary, or lymphatic systems rather than the central nervous system (CNS). However, no cases of simultaneous CMV ventriculitis and disseminated MAC have been ever reported. Case Presentation A 63-year-old man with untreated HIV/AIDS, chronic pancytopenia, and prior candida esophagitis presented with failure to thrive, severe malnutrition, and worsening lethargy. Laboratory results revealed a CD4 count of 36 cells/µL and HIV viral load of 267,437 copies/mL. The patient was septic; blood cultures grew acid-fast bacilli identified as MAC. Despite treatment for MAC, he developed progressive encephalopathy and respiratory failure requiring intubation and vasopressors. CT head showed mild-moderate generalized parenchymal volume loss and chronic microvascular ischemic change. Magnetic resonance imaging showed periventricular and ependymal FLAIR hyperintensities with restricted diffusion, consistent with ventriculitis. Cerebrospinal fluid analysis demonstrated elevated protein (168 mg/dL), low glucose (29 mg/dL), and mild pleocytosis; CSF CMV-PCR was positive, while cryptococcal antigen, JC virus PCR, and AFB cultures were negative. Ophthalmologic examination showed no CMV retinitis. These findings confirmed concurrent CMV ventriculitis and non-CNS disseminated MAC infection. Despite comprehensive antimicrobial therapy, the patient developed refractory metabolic acidosis and multiorgan failure and was transitioned to comfort care. Discussion This case illustrates an exceptionally rare presentation of dual opportunistic infections-systemic MAC and CMV-restricted ventriculitis - in a profoundly immunocompromised AIDS patient. Literature review indicates that CMV ventriculitis in AIDS remains extremely uncommon, with only a few published cases (20-30 cases). Spatially dissociated opportunistic infections can occur in end-stage AIDS. To our knowledge, this seems to be the first reported instance of concurrent disseminated MAC infection without CNS involvement alongside confirmed CMV ventriculitis. This case also underscores the importance of awareness and integrating MRI findings with molecular diagnostics to distinguish overlapping CNS pathologies in patients with advanced HIV infection. Prompt neuroimaging and CSF PCR testing are essential for early recognition and targeted therapy to improve outcomes in this critically ill population. This abstract is funded by: NA
Manjappachar et al. (Fri,) studied this question.