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Washington University Experience | INFECTION | Viruses | PML (JC Virus) | PML - Gross Pathology | 1A0 Case 1 History
Case 1 History ---- The patient was a 35 year old male known to be HIV positive (IV drug abuse and homosexual behavior) for 8 years prior to this hospital admission, however, he had no history of opportunistic infections other than 2 episodes of shingles. Approximately l month prior to admission when he developed difficulty speaking, abnormal gait and difficulty swallowing with frequent coughing and possible aspiration after meals. He had a rapid progression of his symptoms and was wheel chair bound within 2 weeks of their onset. A brain biopsy at St. Louis University in 9/92 reportedly showed PML even though he had a CD4 count greater than 600. Over the following 2 weeks he had progressive deterioration and became bed bound requiring 24 hour care. He presented to Barnes Hospital on 9/20 when his caretaker felt he was no longer able to care for him . Medications on admission were AZT, Erythromycin and Nystatin oral solution. Physical examination on admission to Barnes Hospital was notable for bibasilar rales heard on auscultation of the lungs, with tachypnea and episodes of Cheynes-Stokes breathing. There was mark wasting in all muscle groups.
Neurologic examination showed a disoriented patient with limited expressive speech, diffusely weak with increased tone, and followed simple commands inconsistently. Cranial nerve examination was within normal limits. Motor examination was notable for diffuse weakness throughout with diffusely increased tone and increased deep tendon reflexes. His increased tone appeared somewhat worse on the left than the right. MRI results from St. Louis University Hospital two weeks earlier had shown bilateral hemispheric lesions, cerebellar and brain stem lesions. A CD4 count sent shortly after admission to BJH was 729. By the 4th hospital day he was stuporous. On the 9th hospital day he developed fevers and was begun on antibiotics for a presumed aspiration pneumonia and a cellulitic area on his chest. One blood culture from this day grew out oxacillin resistant staph aureus. On the 11th hospital day a gastrostomy tube was placed for enteral feedings. The patient remained stuporous and his neurologic exam was notable for unequal pupils, with the right pupil 4mm and the left pupil 2.5mm. On the 14th hospital day he developed increased fever to 104 degrees F and was unresponsive. He continued in this state over the following days with progressive tachypnea and Cheynes-Stoke breathing. At the wishes of his family only supportive care was provided. On 10/10 he was found apneic and pulseless and was pronounced dead.
