Clinical Reasoning: Subacute paresis in a 28-year-old man with HIV

A 28-year-old man with a history of HIV infection (genotype 1 subtype B) who was not on antiretroviral treatment presented with 2–3 months of progressive weakness of his extremities. He had been on fluconazole therapy for 8 months for Cryptococcal meningitis. He initially noticed right followed by left lower and bilateral upper extremity weakness. Review of systems was negative for sensory symptoms or dysautonomia. His examination was notable for severe proximal (Medical Research Council [MRC] scale 1–2/5) more than distal weakness, affecting both flexor and extensor muscle groups (MRC scale 3/5), and neck flexion (MRC scale 2/5) weakness. He had left more than right brisk deep tendon reflexes throughout (+3) and sustained clonus in his ankles. He was alert and oriented. His cranial nerve and sensory examination was unremarkable. Negative inspiratory force and vital capacity were −22 cmH2O and 0.7 L, respectively.