The human immunodeficiency virus (HIV) has predilection to affect the central nervous system (CNS). In the setting of advanced immunosuppression, the CNS can be affected by a variety of both infectious and non-infectious entities. We present a case of a rare coinfection of the CNS due to herpes simplex-1 (HSV-1) and cytomegalovirus (CMV) infection.

HSV-1 and CMV coinfection of the CNS in patients with acquired immunodeficiency syndrome (AIDS) is a rare but described phenomena. Presentation may be atypical and insidious and evolve as a subacute progression of cognitive dysfunction that can mimic HIV-associated neuro cognitive disorders (HAND) or with predominant involvement of the brainstem. A low threshold to search and treat concomitant HSV and CMV CNS infection is recommended in patient with AIDS.

A 53-year-old man with long-standing HIV-infection and poor antiretroviral medication adherence presented with a 6-month history of memory loss, hiccups, imbalance, and difficulties with attention, concentration and behavioral changes. The cerebrospinal fluid tested positive for HSV-1 infection by polymerase chain reaction (PCR). A magnetic resonance imaging (MRI) of the brain showed generalized atrophy and very subtle restricted diffusion on the lateral ventricles. Due to failure to improve despite antiviral therapy and development of internuclear ophthalmoplegia 10 days into hospitalization, a repeat MRI of the brain and CSF sampling was performed. The imaging study showed worsening ventriculitis and the CSF was positive for CMV by PCR. Despite aggressive treatment, the patient passed away.

Infection of the CNS by members of the Herpesviridae family may coexist in patients with HIV/AIDS. The presentation can be atypical and mimic or coexist with other entities such as HAND. Prompt identification and appropriate treatment is key to improving survival. More studies are necessary to understand the risk factors, pathophysiology, and possible synergistic effect of HIV and herpesviruses in CNS co-infection.