HIV-associated vacuolar myelopathy, or AIDS-associated myelopathy, is a rare initial presentation of HIV. One of the common HIV-associated neurocognitive disorders, HIV-associated vacuolar myelopathy presents with advanced immunosuppression in patients and is frequently associated with dementia. However, most cases are subclinical with characteristic findings identified through physical examination and/or imaging modalities. HIV-associated vacuolar myelopathy is characterized by progressive spastic paraparesis, gait disturbance and lower extremity sensory abnormalities including vibratory sensation. Magnetic resonance imaging findings in the spinal cord are abnormal in some patients with HIV-associated myelopathy, characteristically showing spinal cord atrophy at the level of the thoracic spine, but they may also be normal. Unfamiliarity with this as initial presentation of HIV infection may lead to failure to diagnose and intervene appropriately. We present a case of newly diagnosed HIV with myelopathy and dementia with minimal spinal cord involvement on magnetic resonance imaging.