India HIV Clinical Case Discussion (2015-06-17) - Case 1

HIV-infected Indian man with CD4 account 423 and undetectable plasma viral load on HAART, who presents with neurological symptoms and a CNS HIV viral load of >1 million copies/ml. C/o inability to swallow, regurgitation of food, and involuntary hand movements. H/o pulmonary TB, herpes zoster ophthalmicus, and Lt-sided hemiparesis w/ involvement of facial nerve. 

Upper GI scopy S/o tracho-esophageal fistula w/ esophageal candidiasis. HRCT chest done, followed by fistula tract biopsy S/o CMV esophageal ulcer.

Patient experiences major Wt. loss and malnutrition, recurring involuntary LUL movements w/ spasticity of all 4 limbs. 

CNS reveals Rt. LMN and Lt. UMN facial paralysis. Rt-sided eye-pthisis bulbi. Wasting of muscles and hypertonia. Hemiplegic gait. 

Labs: 

• 
  Bb= 14.1, TLC= 8000, PLT= 2.4
• 
  S. cholesterol= 240, S. triglyceride= 220. 
• 
  CT Brain- hypodensity in Lt. frontal region S/o infarct, and old infarct in Rt. frontal region.

What is the differential diagnosis?