Table of Contents
Washington University Experience | INFECTION | Viruses | PML (JC Virus) | PML - Illustrative Case | 1A0 Case 1 History
Case 1 History ---- The decedent was a 36-year-old man with a PMHx of HIV infection (2001), schizophrenia, hypertension, and chronic kidney disease. He was frequently homeless and non-compliant with antipsychotic and antiretroviral therapy during 2014-2015. In May 2015 he returned home, became compliant with antipsychotic medication and was restarted on HAART. In October 2015, his family noted functional decline with lethargy, social withdrawal, and unsteady gait. A fall prompted admission to an outside hospital for evaluation. A head CT was thought consistent with PML. Abnormal kidney imaging studies were attributable to diffuse infiltrative lymphocytosis syndrome. A second opinion was sought from our hospital.
His altered mental status continued and an MRI was thought consistent with demyelination in the right parietal lobe, left centrum semiovale and the corpus callosum, most likely PML. An LP was performed and the CSF tested positive for JC virus by PCR, with other cultures and viral testing being negative. He had marked proteinuria. He developed worsening lethargy and decreased responsiveness to obtundation. A repeat brain MRI showed worsening of white matter lesions in the frontal and parietal lobes, corpus callosum, and brain stem, consistent with either PML or IRIS. This prompted a course of high-dose corticosteroids as empiric treatment for IRIS. He remained unconscious and exhibited withdrawal only to painful stimuli finally developing sepsis. He had a convulsive seizure with subsequent triple flexion of the lower extremity joints, anisocoria, and loss of gag and corneal reflexes, although his pupils remained reactive to light. A head CT following the seizure showed no evidence of hemorrhage or infarction. The family rejected ventilator therapy and it was decided instead to de-escalate care and focus on comfort. He expired several days later.
