CNS HIV Escape Presenting as VP Shunt Malfunction - A Rare Clinical Entity

Background Ventriculoperitoneal (VP) shunt malfunction is a common neurosurgical problem. In contrast, central nervous system (CNS) HIV Escape is exceedingly rare and is almost never the initial presentation of HIV infection. This case highlights a unique neurosurgery–infectious disease intersection where CNS HIV Escape clinically mimicked shunt failure. Case Description: A 38-year-old male presented with severe headache, vomiting, and altered sensorium. MRI revealed obstructive hydrocephalus, for which a VP shunt was placed with subsequent clinical improvement. One year later, he developed confusion and visual blurring. MRI demonstrated diffuse periventricular hyperintensities with stable ventricular size and a functioning shunt. CSF analysis, including routine parameters, was unremarkable. However, markedly elevated CSF HIV RNA in the setting of undetectable plasma HIV RNA confirmed the diagnosis of CNS HIV Escape. The patient was started on antiretroviral therapy with high CNS penetration, resulting in significant clinical improvement. Conclusion CNS HIV Escape can closely simulate VP shunt malfunction and may rarely present as the first manifestation of HIV infection. Recognizing this uncommon entity can prevent unnecessary surgical intervention and underscores the importance of CSF viral studies in atypical neurological presentations.