normal pressure hydrocephalus ( nph ) can be a relatively common phenomenon which may present with pathologically enlarged ventricular size and normal opening pressure on lumbar puncture , and can be distinguished from obstructive or non - communicating hydrocephalus , in which there is a structural blockage of the cerebrospinal fluid ( csf ) circulation within the ventricular system . it is characterized by a classic triad of dementia , gait disturbance , and urinary incontinence . . however , the most common identified underlying causes are intraventricular and/or subarachnoid hemorrhage ( either from aneurysm or trauma ) , and acute or ongoing chronic meningitis ( from infection , cancer , or inflammatory disease ) . cases like paget s disease at the skull base , mucopolysaccharidosis of the meninges , and achondroplasia are also rarely reported causes of nph . only one prior case report has demonstrated a possible correlation between human immunodeficiency virus ( hiv ) type 2 and nph ; however , correlation has yet been made with hiv type 1 . in this case report , we discuss the first ever reported presentation of a 54-year - old female with symptoms consistent with nph , later discovered to also have untreated hiv type 1 . a 54-year - old female with no significant past medical history presented to emergency room with complaints of nausea and dizziness . as per the family , the patient was in a normal state of health and had full functional ability 5 months prior . thereafter , she gradually began to lose her balance and started developing short - term memory loss along with occasional episodes of urinary incontinence . the memory loss became progressively worse over the course of a few months to the point that she would rely on family members to answer questions and remind her of previous events . during questioning , it was evident that the patient would attempt to think or elaborate her thought process but was unable to recall and explain recent events . as per her family , the patient had also been increasingly losing her balance which had resulted in a progressively increased number of falls and injuries over the past 5 months . she was initially evaluated at different faculties at the initial onset of symptoms but was discharged after neurologic workup was otherwise unremarkable . the patient however continued to experience these symptoms which resulted in her losing her job and was unable to care for herself . upon this presentation , the family elaborated that for the past 1 day she had been experiencing dizziness and episodes of vomiting . on examination , her vital signs revealed a blood pressure of 143/80 mm hg , pulse of 87/min , respiratory rate of 18/min , and temperature of 97.8 f . on general examination , neurological examination showed a short - term memory loss ( unable to repeat three simple words ) , lower extremity muscle wasting , and unsteady gait ; however , there were normal power and normal reflexes , plantar responses were flexor bilaterally , and cranial nerves two to twelve were grossly intact . as mentioned , the patient had a wide based gait and relied on a cane for ambulation . 1 ) was done which demonstrated an increase in the size of ventricles with a possibility of either atrophy or non - obstructing hydrocephalus . laboratory results revealed a positive hiv type 1 test , with cd4 count of 74 and viral load of 453,310 . once the patient and her family members were informed regarding her hiv status , it became clear that the patient was in fact diagnosed with hiv in the past . although she was informed in the past , she had remained in a denial state and had refused therapy for several years . 2 ) was conducted and demonstrated findings of ventriculomegaly and multiple supratentorial and infratentorial foci of abnormal t2 white matter hyperintensity . syphilis serology in both blood and csf was also negative . molecular analysis ( pcr ) for infectious etiologies in csf showed an absence of cytomegalovirus , varicella - zoster , herpes simplex type 1 and type 2 , epstein - barr , human herpes 6 and jc viruses , cryptococcus and tuberculosis . the patient s gait was reassessed 72 h after the lumbar puncture and showed mild improvement . she was assessed by an hiv specialist and decision was made by the patient s caregivers to initiate highly active retroviral therapy ( harrt therapy ) . at this time , patient was stable for discharge with further workup and management as outpatient by the hiv specialist and neurologist . the incidence of nph has varied in different studies from 2 to 20 per million per year [ 2 , 3 ] . idiopathic nph is normally seen in the elderly population , while secondary nph is seen in all age groups . hydrocephalus due to cerebral toxoplasmosis , cryptococcal and tuberculous meningitis in hiv patients is very rare and only few cases have been reported in the literature for hiv type 1 [ 4 , 5 ] . these along with other infectious etiologies had been excluded in this patient during laboratory examination . the mechanism of hydrocephalus in central nervous system toxoplasmosis may be due to compression of csf pathways by ring enhancing lesions , but even in their absence , hydrocephalus may be due to ventriculitis . imaging studies of the brain reveal ventriculomegaly without any marked degree of cortical atrophy [ 7 - 9 ] . the role of csf shunting for obstructive hydrocephalus in hiv patients is still unclear . in a series of 30 patients with post - tuberculous hydrocephalus , nadvi et al did not find any improvement by the csf shunting in the hiv type 1 positive group compared with the hiv negative group . one potential contributor to shunt unresponsiveness is the presence of comorbid neurological conditions that are common in hiv patients . hiv positive patients with tuberculous meningitis may undergo an external csf drainage and after significant improvement may be considered for shunt surgery irrespective of their cd4 count [ 10 , 11 ] . another study showed successful and safe shunting in hiv type 1 patients with hydrocephalus secondary to cryptococcal meningitis . however in the above patient , the hydrocephalus was of non - obstructing type which may be attributed to either ventriculitis or plexitis with an inflammatory exudates . thus , one possible explanation in our case could be the direct effect of inflammatory cells in the csf , affecting csf turnover or hemodynamics . furthermore , the patient had also been ruled out for the secondary causes of the nph like trauma , subarachnoid hemorrhage and meningitis . another that needs to be addressed is whether nph itself can be a direct complication of untreated hiv . therefore , patients with untreated hiv complicated by nph would most likely benefit with haart therapy as an initial management versus shunt surgery . as described in the above case report , early diagnosis and treatment of nph and its underlying cause so the physicians should consider ordering hiv test if no other etiology of nph is found . physicians should be aware of this association as it may improve the prognosis of hiv and nph in the future as it may lead to an earlier diagnosis . as described in the above case report , early diagnosis and treatment of nph and its underlying cause are important to prevent the development of cognitive impairment in such patients . so the physicians should consider ordering hiv test if no other etiology of nph is found . physicians should be aware of this association as it may improve the prognosis of hiv and nph in the future as it may lead to an earlier diagnosis .
normal pressure hydrocephalus ( nph ) is a relatively common disease of adulthood characterized by a typical combination of clinical and radiological findings . in this report 
 , we discuss a 54-year - old female presenting with symptoms suggestive of nph and found to have a history of human immunodeficiency virus ( hiv ) type 1 . 
 she was not treated as she was in denial state and developed nph as a possible complication . in the literature , 
 there has only been one reported case of hiv type 2 causing nph ; however , no relationship has been properly documented with hiv type 1 . 
 these findings bring about a question on whether nph is associated or a complication of hiv with awareness of this association . 
 earlier screening of hiv can be done in patients presenting with such symptoms , thus to prevent further progression of its complications .