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PUBLISHED
August 31, 2025

Whether for a minor injury or a life-saving procedure, hospitals are where sick people rush to in the hopes of getting better. However, when proper infection control protocols are not followed, a patient walking in for a simple blood test might leave the hospital unknowingly carrying HIV-AIDS.

According to the Better Health Channel, basic infection control protocols for HIV-AIDS at hospitals involve the disposal of single-use syringes in approved sharps containers, decontamination and sterilization of reusable medical devices after each use, disposal of single use medical devices, provision of personal protective equipment (PPE) gowns, gloves and eyewear for healthcare workers, and cleaning of spilled body fluids and laundry as per strict guidelines.

Although hospital officials in Pakistan assure the presence of infection control departments at government hospitals, in reality, these bodies remain non-functional and adherence to standard operating procedures (SOPs) is highly unsatisfactory. The human immunodeficiency virus (HIV) living in the bloodstream is easily transmitted through contact with an infected person’s bodily fluids, which could be present on unsterilized medical apparatus and work surfaces. Pakistan’s lack of an effective strategy to prevent diseases is one reason why the number of HIV-AIDS patients, currently around 290,000, continues to grow.

A patient’s family at the Civil Hospital’s Infection Unit revealed that their brother, diagnosed with HIV in 2020, fled the hospital due to unhygienic conditions. After persuasion, the family got him re-registered at the Lyari General Hospital, where he now receives monthly medication. “The appalling condition of hygiene at public hospitals worsens the patient’s mental and physical health, burdening their families. Medical neglect and lack of sanitation are major contributors to the spread of infections in these healthcare facilities,” claimed the family.

Similarly, Asghar, whose elder brother acquired HIV-AIDS during the 2023 outbreak, recounted his family’s tough journey. “My completely healthy brother used to work as a lab technician at a large private hospital in Karachi. Suddenly, his health started deteriorating and it was revealed that he had contracted HIV. Once his treatment started, my brother had to quit his job,” shared Asghar.

Dr Pir Ghulam Nabi Shah Jilani, Deputy Director at the Karachi Health Department, claimed that infection prevention committees were functional in government hospitals. “These committees, comprising qualified doctors and pathologists, are tasked with ensuring sterilization and proper disposal of medical waste. However, their effectiveness remains questionable,” noted Dr Jilani, while speaking of Sindh, where HIV transmission has increased by 139.6 per cent over the past five years, with 1,438 cases reported in 2020 and 3,446 cases recorded in 2024.

Professor Dr Faisal Mahmood, an infectious disease specialist at the Aga Khan University Hospital, emphasized the urgent need to implement infection control protocols at hospitals and clinics. “Patients can be carriers, and hospitals must treat every patient as potentially infectious,” said Dr Mahmood, while mentioning medical protocols, which were clearly ignored in Punjab, where healthcare facilities’ lamentable adherence to infection control dragged multiple patients towards sickness and death.

In October 2024, over 24 nephrology patients acquired the HIV virus at the Nishtar Hospital in Multan, which is the largest facility offering dialysis to over 200 registered patients from South Punjab. During the investigation, it was revealed that a patient with HIV was dialyzed without proper sterilization protocols, which led to the spread of the virus to other patients due to the negligence of hospital staff.

Sources revealed that inspections of other government hospitals also found similar lapses in infection control protocols for HIV. Health Minister Salman Rafiq handed the matter over to the Punjab Healthcare Commission for further investigation. However, doctors at the Nishtar Hospital did not cooperate, and when summoned to the Lahore office, they presented excuses and resisted.

When contacted, the Punjab Healthcare Commission declined to provide further details on the grounds that it was investigating the matter and monitoring adherence to infection control SOPs. Dr Zahid Ansari, former Head of the Sindh Blood Transfusion Authority, clarified the difference between HIV-positive individuals and AIDS patients.

“HIV-positive individuals should not donate blood, and their used medical tools like syringes or razors must not be reused. The virus can be identified through specific blood tests and viral load analysis. Four key diseases — HIV, Hepatitis B, Hepatitis C, and malaria — must be screened in blood tests before transfusions,” emphasized Dr Ansari.

In the Nishtar Hospital incident, it was clear that screening procedures were completely ignored. Despite the gravity of the situation, the issue has once again disappeared into the background in Punjab, where more than 7,000 HIV cases were reported last year.

Shehzad, a 60-year-old dialysis patient at the Jinnah Hospital in Lahore, conveyed his worries after the Multan hospital outbreak. “After hearing about what happened at the Nishtar Hospital, I live in fear. Even routine procedures now feel dangerous. Patients are constantly worried that they may contract a serious illness at any time due to medical negligence,” revealed Shehzad.

Similar concerns have mounted over the poor performance of the Infection Prevention Committee and the Healthcare Commission in Khyber-Pakhtunkhwa, which has observed an 888.1 per cent increase in the incidence of HIV-AIDS over the past three years, with 816 cases reported in 2022, 5,543 cases reported in 2023, and an alarming 8,063 cases recorded in 2024.

Major medical teaching institutions (MTIs) in Peshawar, including the Lady Reading Hospital, Khyber Teaching Hospital, and Hayatabad Medical Complex, along with district-level Tehsil Headquarter Hospitals (THQs) are failing to maintain effective infection control and sterilization systems. Instead of preventing diseases, these hospitals are allegedly turning into hotbeds of infectious outbreaks.

A technician at the Hayatabad Medical Complex, speaking on the condition of anonymity, revealed that standard operating procedures (SOPs) for infection control were not being followed at all. “We have repeatedly requested the administration to provide basic supplies for infection control. However, now we do not even have spirit or syringes available, let alone anything else for infection prevention,” informed the technician.

Dr Amir Taj, an infection control expert, told The Express Tribune that it was unfortunate that both the Infection Control Committee and the Healthcare Commission, which were created for the very purpose of controlling the spread of transmissible infections, were failing to do their job.

“Instead of controlling infections, the Healthcare Commission seems more focused on collecting hospital fees and registration charges. Infections like HIV, Hepatitis, and others are rapidly spreading, costing the government billions of rupees each year. If proper infection control systems were in place at hospitals, patients would recover faster, and the national treasury would also benefit,” opined Dr Taj.

On the other hand, Dr Tariq Hayat, Director of the HIV Control Programme, stated that SOPs for infection control were strictly followed at HIV and Hepatitis control centers operating within hospitals. However, he also acknowledged the fact that awareness sessions on infection control were urgently needed at both public and private hospitals.

Dr Muhammad Naeem, former Director of the Sindh AIDS Control Program, recalled that Larkana faced major HIV outbreaks in 2019 and 2023. “After the Rato Dero outbreak, the Sindh Health Department screened 37,272 people in Larkana. HIV-AIDS was confirmed in 1,811 cases. Contributing factors included reused syringes, abundance of unqualified healthcare providers and unregulated blood transfusion practices,” revealed Dr Naeem.

Speaking to the Express Tribune on the matter, Azam Rehman, spokesperson for the Healthcare Commission, claimed that the commission strictly enforced SOPs for infection control, fining both private and public hospitals found violating the guidelines.

Despite official claims, the current poor adherence to infection control protocols at hospitals across the country demands urgent government intervention, including strict regulation of medical practices, enforcement of hygiene protocols, and establishment of a trace-and-track system for HIV-positive patients. Without swift action, the spread of HIV-AIDS may spiral out of control.

Background

Arnold-Chiari Malformation Type I (ACM-I) is a congenital neurological disorder characterized by the downward displacement of cerebellar tonsils through the foramen magnum, leading to cerebrospinal fluid (CSF) flow obstruction and subsequent neurological deficits.¹ While decompression surgery is the standard treatment for symptomatic ACM-I, it carries significant postoperative risks, particularly CSF leakage and infectious complications, which can result in life-threatening conditions such as septic shock.²

One of the critical concerns in postoperative care for ACM-I patients is early recognition and management of complications, particularly in individuals with underlying conditions that may impair immune response.³ Patients with rheumatoid arthritis (RA), such as the case presented here, are inherently at a higher risk for infections due to chronic inflammation and immunosuppressive therapies (eg, corticosteroids and methotrexate).⁴ These factors can complicate postoperative healing and increase susceptibility to severe infections, making meticulous monitoring in the intensive care unit (ICU) essential.

This case report discusses the rapid progression from CSF leakage to septic shock in an ACM-I patient, emphasizing the importance of timely microbiological assessment, aggressive infection control, and individualized antibiotic therapy in critical care settings. By examining the challenges encountered in managing this patient, we aim to provide insights into improving postoperative surveillance and early intervention strategies in neurosurgical patients at high risk of sepsis.

Case Presentation

The patient is a 45-year-old married woman with a known history of rheumatoid arthritis for about ten years, which was being managed with medication. She reported no other medical conditions in her medical history. In terms of medication, she had been taking NSAIDs such as ibuprofen and naproxen to manage her pain. At times, under her physician’s guidance, she also took methylprednisolone and methotrexate periodically to control her condition. Recently, she presented to medical facilities with complaints of neck pain radiating to her arms, along with numbness and weakness in the upper limbs. These symptoms had started about a year prior and had intensified in recent months, not responding to prior treatments. During physical examinations, the patient showed muscle weakness in the upper limbs but had no other symptoms, such as gait disturbance, imbalance, headache, or dizziness. In neurological examinations, muscle strength was recorded as 3–4 out of 5 in the right upper limb, 2–3 out of 5 in the left upper limb, and 5 out of 5 in both lower limbs. Initial head and neck X-Ray was obtained (Figure 1).

Figure 1 Radiograph of the cervical spine (A) Flexion lateral view and (B) Extension lateral view (C) anterior-posterior view. The cervical vertebrae are normal and free of fractures and dislocations.

A brain MRI of the patient (shown in Figure 2) was used for further evaluation and differential diagnosis. Based on the image, the extent of tonsillar herniation is estimated to be approximately 8 to 10 millimeters below the foramen magnum, which is consistent with the diagnostic criteria for Chiari Malformation Type I (defined as herniation greater than 5 millimeters).

Figure 2 MRI of the brain without contrast of Arnold-Chiari malformation I. The sagittal view demonstrates the herniated cerebellar tonsils descending below the level of the foramen magnum.

Based on imaging results, a diagnosis of ACM-I was made. Following this diagnosis, the patient underwent posterior fossa decompression surgery, which included decompressive craniectomy, resection of the foramen magnum, C1 laminectomy, V-shaped durotomy, coagulation of the tonsils, and duraplasty. Part of the timeline of events changes is provided in Table 1.

Table 1 Timeline of Events and Daily Vital Signs of the Patient During the Hospitalization

After surgery, she was transferred to the intensive care unit for continued treatment. In addition to postoperative supportive care, she was started on antibiotics: ceftazidime 2 grams every 8 hours and vancomycin 1 gram every 12 hours. According to the neurosurgery team’s recommendations, the patient’s head was maintained in an elevated position during the ICU stay to facilitate venous drainage and minimize the risk of cerebrospinal fluid (CSF) leakage. In addition, lactulose syrup was prescribed as a stool softener to prevent constipation and reduce the likelihood of excessive straining during defecation, thereby minimizing sudden increases in intra-abdominal and intracranial pressures.

On the sixth day of hospitalization, CSF leakage was observed at the surgical site, and the patient developed a fever. Despite receiving broad-spectrum antibiotic treatment, her condition worsened by the sixth day, with a significant increase in white blood cell count (WBC: 15,800). At this point, ceftazidime was discontinued, and meropenem 1 gram every 8 hours was started to control the infection. However, despite these adjustments, her WBC count reached 38,600 by the eleventh day. Part of the timeline of laboratory changes is provided in Table 2.

Table 2 A Timeline of Some of the Patient’s Laboratory Changes

After the laboratory changes, the patient’s hemodynamic status became unstable, leading to the need for intubation to provide cardiopulmonary support. On the ninth day, the patient was taken back to the operating room for extensive debridement and washing of the surgical site. Additionally, CSF culture results indicated infection with Acinetobacter baumannii, which is sensitive to colistin. Based on the CSF culture report, infectious disease, and clinical pharmacology consultations were carried out. Following these consultations, the patient’s previous antibiotics were discontinued, and broad-spectrum antibiotics were started, including intravenous and intrathecal colistin and intravenous ampicillin-sulbactam 3 grams every 6 hours. Due to the positive Candida culture from the urinary catheter, the patient’s Foley catheter was replaced. On day 7 of hospitalization, the patient developed septic shock with persistent hypotension (BP 85/55 mmHg, HR 118 bpm, SpO₂ 90%). Norepinephrine infusion was started at 0.1 μg/kg/min and was gradually titrated to 0.5 μg/kg/min by day 9 in an effort to maintain MAP ≥65 mmHg. However, the patient’s condition remained unstable despite maximal vasopressor support. Additionally, the antifungal drug caspofungin 75 mg was administered as a bolus and gradually increased to 50 mg daily. Despite maximal supportive care in the intensive care unit, including broad-spectrum antibiotics and high-dose norepinephrine infusion, the patient’s condition deteriorated and she ultimately died on hospital day 11 due to refractory septic shock.

Discussion and Conclusion

This case underscores the importance of proper and timely management of postoperative complications in patients with ACM-I. Although posterior fossa decompression surgery is considered the standard treatment for these patients and can lead to symptom improvement, complications such as CSF leakage and severe infections can result in adverse outcomes. In this case, despite aggressive medical and supportive management in the intensive care unit, the patient’s condition rapidly deteriorated, ultimately leading to death from refractory septic shock.

A review of the medical literature reveals that ACM-I, particularly after posterior fossa decompression surgery, can be associated with postoperative complications such as meningitis, abscess, and septic shock. For instance, the results of our study are in significant agreement with previous research findings. A survey by Passias et al⁵ showed that patients with ACM-I who underwent surgery faced substantial risks, including postoperative complications such as neurological issues, anemia, and respiratory distress. This study also indicated that patients who underwent spinal fusion, particularly those with fusion levels of four or more, had a significantly higher incidence of complications. These findings align with the results of our study, as our patient also experienced severe complications after surgery. This study emphasizes the importance of postoperative care and careful monitoring of patient’s conditions.

Additionally, the results of other studies have shown that comorbidities such as cardiovascular, pulmonary, renal diseases, and malignancies can increase the risk of postoperative complications in these patients.^5–7 In our study, underlying rheumatoid arthritis and other potential predisposing factors may have contributed to the increased surgical risk. Therefore, it is recommended that future studies examine the impact of underlying conditions on surgical outcomes. This highlights the importance of comprehensive patient evaluation and management of these conditions before surgery, which can help reduce postoperative complications.

Meticulous attention to the quality of dural closure is a critical step in preventing postoperative cerebrospinal fluid (CSF) leakage and its potentially severe complications, such as meningitis and septic shock. To minimize the risk of postoperative CSF leakage following posterior fossa decompression, several surgical and postoperative strategies have been recommended in the literature. These include performing an intraoperative Valsalva maneuver to identify occult dural tears, avoiding full-thickness dural coagulation to preserve dural integrity, meticulous multilayer dural closure with watertight suturing techniques, and the use of graft augmentation when necessary.² Postoperatively, maintaining appropriate head elevation, minimizing excessive straining or coughing, and close monitoring for early signs of leakage are essential preventive measures. Considering our patient’s background of rheumatoid arthritis and a history of long-term corticosteroid use, which can impair wound healing, such precautions are particularly important.^2,8

In another study by Alexander et al,⁹ the relationship between ACM-I and severe infections post-surgery is established. The results of this study align with our findings. In the case of our patient, despite appropriate treatment measures, she developed postoperative complications, including septic shock, which is consistent with the findings reported in the literature.¹⁰ This comparison highlights that even when the best treatment practices are applied, ACM-I can lead to severe and life-threatening complications. These findings emphasize the need for careful monitoring and continuous follow-up of patients after surgery and the importance of effective infection management.

Therefore, the results of previous studies have also shown that postoperative complications in patients with ACM-I are rare but potentially dangerous.¹¹ This case highlights the importance of heightened vigilance in postoperative care and the need for close monitoring of patients’ status, especially in cases of CSF leakage and early signs of infection.^12,13 Additionally, there is a need for further research to explore more effective strategies for preventing and managing these complications.

In this case, the approach taken to manage and treat ACM-I and septic shock post-surgery was significant in several respects. First, the accurate and early diagnosis of Chiari malformation using appropriate imaging techniques was a strength in managing this case, which led to the correct decision for posterior fossa decompression surgery. Additionally, broad-spectrum antibiotics in managing postoperative infection, although they ultimately could not prevent the fatal septic shock, demonstrated the correct approach to infection control. Limitations of this case include the failure to prevent CSF leakage and the lack of timely infection control, both of which contributed to the patient’s deteriorating condition.

The conclusion of this evidence-based study is derived from the patient’s condition and their response to the treatments provided. The decision for decompressive surgery was made due to the severity of the patient’s symptoms and confirmation of the diagnosis through imaging. Although appropriate therapeutic measures were implemented, CSF leakage and subsequent infection led to septic shock and, ultimately, the patient’s death. These results indicate that even with proper management, the prognosis for patients with ACM-I can be challenging.

This case emphasizes the importance of precise management and continuous monitoring of patients after surgery for ACM-I. Previous studies have recommended thorough clinical examinations in the postoperative period to diagnose the most common complications, including aseptic meningitis, CSF leakage, infections, and hydrocephalus.^14,15 Therefore, specialized care to prevent infections and manage postoperative complications is essential. This study also highlights that awareness of the potential for septic shock and its early prediction can play a significant role in reducing mortality associated with this complication. As a result, more precise planning for preventing and managing postoperative complications can lead to better therapeutic outcomes.

Abbreviations

ACM-I, Arnold-Chiari Malformation Type I; CSF, Cerebrospinal fluid; ICU, Intensive Care Unit; CBC, Complete Blood Count; WBC, White Blood Count; RBC, Red Blood Cell; LDH, Lactate Dehydrogenase; B/C, Blood Culture Test; U/C, Urine Culture; CRP, C-reactive protein.

Data Sharing Statement

The data supporting this study’s findings are available from the corresponding author upon reasonable request.

Ethics Approval

This study was conducted under the principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of Tabriz University of Medical Sciences, with approval number (IR.TBZMED.REC.1402.840). According to institutional policies, this approval covers the entire research process, including the preparation and publication of case reports. Therefore, no additional institutional approval was required for publication.

Consent for Publication

The present study was conducted in one of the educational and medical centers in Iran. In these centers, during hospitalization, informed consent is obtained from all patients for the participation of students from different disciplines in the treatment processes of these patients and the use of their clinical records for education and research. In this study, written informed consent was obtained from the patient and his family for the use of their personal and clinical information in this case report, and it was ensured that confidentiality and anonymity were maintained. Since the patient unfortunately died during hospitalization, due to the importance of the issue, informed consent was obtained again from the patient’s family for its preparation, reporting, and possible publication.

Acknowledgments

We would like to express our sincere appreciation to the Clinical Research Development Unit, Imam Reza General Hospital, Tabriz, Iran, for their valuable cooperation and support in conducting this research. Additionally, we extend our heartfelt gratitude to all the staff of the intensive care unit for their dedicated assistance and contributions throughout the study.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Funding

This study was funded by Tabriz University of Medical Sciences Faculty of Medicine.

Disclosure

The authors declare that they have no competing interests in this work.

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