Objective: Postinfectious ocular flutter and truncal ataxia have been described after infections with enterovirus, cytomegalovirus and human immunodeficiency virus (HIV). We report a patient with HIV who had ocular flutter, generalized myoclonus with ataxia whom responded to steroids and clonazepam.

Background: NA

Methods: NA

Results: Case report: A 31-year-old man with treatment naive HIV, presented with right hand tremors past 4 months. His tremor progressed involving bilateral lower limbs causing falls and unsteady gait. He was unable to sit up independently due to profound ataxia and was confined to bed.Examination showed postural and action tremor of both hands. There was ocular flutter on horizontal gaze bilaterally. All cranial nerve examinations were normal. He had generalized myoclonus and ataxia. Tone of all four limbs were normal with no weakness or sensory deficits and normal reflexes. Lumbar puncture showed raised opening pressure (30cmH2O) with cerebrospinal fluid (CSF) predominantly 100% lymphocyte cells with normal CSF protein and glucose ratio. CSF Cryptococcal antigen, Mycobactrium tuberculosis, bacterial and fungal cultures were negative. Serum rapid plasma reagent (RPR) for syphilis was reactive (1:4) but CSF Venereal Disease Research Laboratory test (VDRL) was negative. Hepatitis B,C serology and Toxoplasma IgG/IgM were negative. His CD4 count was low (141 cells/mm3). Tumour markers, paraneoplastic screen, C3, C4 and rheumatoid factor were within normal limits. Brain magnetic resonance imaging (MRI) was normal. He was initially treated with benzathine penicillin and trimethoprim/sulfamethoxazole for 2 weeks but ataxia persisted. He was then started on intravenous hydrocortisone. Tab clonazepam was added 2 days later. He showed improvement of symptoms after 4 days of hydrocortisone and 1 day of clonazepam commencement. Patient was able to sit up independently and ambulate with a walking frame after 4 days of combined treatment.

Conclusions: Ocular flutter, generalized myoclonus and ataxia syndrome is a rare neurological disorder commonly associated with paraneoplastic syndrome, brainstem encephalitis, metabolic-toxic disturbances and postviral infections. This is a case of ocular flutter, generalized myoclonus and ataxia syndrome associated with HIV who showed significant neurological improvement with combined treatment of steroid and clonazepam.

References: 1. Wiest G, Safoschnik G, Schnaberth G, Mueller C. Ocular flutter and truncal ataxia may be associated with enterovirus infection. J Neurol. 1997;244(5):288-292. 2. Kaminski HJ, Zee DS, Leigh RJ, Mendez MF. Ocular flutter and ataxia associated with AIDS-related complex. Neuro-ophthalmology 1991;11:163–167.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/ocular-flutter-generalized-myoclonus-and-ataxia-syndrome-associated-with-human-immunodeficiency-virus-a-case-report/