Cytomegalovirus ventriculoencephalitis presenting with hydrocephalus in a patient with advanced HIV infection

A 38-year-old lady with advanced human immunodeficiency virus (HIV) infection presented to the emergency department with headache, vomiting and fluctuating alertness for 3 weeks. On examination, she had tachycardia, bilateral papilledema, restriction of upward gaze, gaze-evoked nystagmus and signs of meningeal irritation. Magnetic resonance imaging of the brain showed hydrocephalus and periventricular high T2-signal regions with restriction on diffusion-weighted imaging. Polymerase chain reaction done on the cerebrospinal fluid obtained after the insertion of an external ventricular drain was positive for cytomegalovirus (CMV). She was treated with intravenous ganciclovir followed by oral valganciclovir with which she made a dramatic recovery. CMV ventriculoencephalitis can present with hydrocephalus in HIV-infected individuals. A high index of suspicion must be maintained to diagnose this disease and start appropriate therapy on time.