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Table of Contents    
LETTER TO EDITOR
Year : 2021  |  Volume : 69  |  Issue : 3  |  Page : 768-769

This Time in a Reverse Order: Seizure, Progressive Multifocal Leukoencephalopathy, and then AIDS was Diagnosed


1 Department of Neurology, University of Health Sciences, Izmir Bozyaka Education and Research Hospital, İzmir, Turkey
2 Department of Infectious Diseases and Clinical Microbiology, University of Health Sciences, Izmir Bozyaka Education and Research Hospital, İzmir, Turkey

Date of Submission31-May-2017
Date of Decision08-Aug-2019
Date of Acceptance13-May-2021
Date of Web Publication24-Jun-2021

Correspondence Address:
Dr. Neslihan Eskut
Bahar Mah. Saim Çıkrıkcı Cad. No:59 35170, Karabağlar, Izmir
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.319220

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How to cite this article:
Eskut N, Inci I, Ozdemir HO, Gedizlioglu M, Tosun S. This Time in a Reverse Order: Seizure, Progressive Multifocal Leukoencephalopathy, and then AIDS was Diagnosed. Neurol India 2021;69:768-9

How to cite this URL:
Eskut N, Inci I, Ozdemir HO, Gedizlioglu M, Tosun S. This Time in a Reverse Order: Seizure, Progressive Multifocal Leukoencephalopathy, and then AIDS was Diagnosed. Neurol India [serial online] 2021 [cited 2021 Jul 25];69:768-9. Available from: https://www.neurologyindia.com/text.asp?2021/69/3/768/319220




Sir,

Progressive multifocal leukoencephalopathy (PML) is a rare opportunistic infection of the central nervous system caused by John Cunningham virus (JCV). PML frequently occurs in patients with acquired immunodeficiency syndrome, but it is rarely seen in idiopathic CD4 + lymphocytopenia.[1]

A 39 years old male was hospitalized with a new onset seizure. No chronic illnesses were noted. He had a weight loss of 20 kg in the last 6 months. He was alert, orientation was limited, and had difficulty in word finding. On follow up, there were recurrent generalized tonic clonic seizures. EEG showed left frontal 4–6 Hz slow waves. 1000 mg/day valproic acid was started. Patients' CD4 cell count was 446 cells/mm3, and HIV plasma viral load was 42800 copies/mL. CSF analysis showed protein 431 mg/dL, 30 leukocytes/mm3. CSF cultures and cryptococal antigen were negative. Ebstein Barr, herpes simplex 1-2, varicella zoster, cytomegalovirus were not detected by PCR. JCV- PCR was positive in CSF (2680 copies/mL).

Cranial magnetic resonance imaging (MRI) revealed hyperintensity in left frontoparietal on the T2, diffusion-weighted and FLAIR images revealed hyperintense lesion [Figure 1]. The patient was diagnosed with AIDS-related PML.
Figure 1: (a) T2 flair shows hyperintens lesion in flair. (b) T1 w contrast enhanced shows no evidence of enhancement in the PML lesion

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Highly active antiretroviral treatment (HAART) and mirtazapine were initiated. Mirtazapine inhibits 5-hydroxytryptamine-2a serotonin receptor for JCV entry CNS.[2] On the fourth week of the HAART, HIV plasma viral load decreased to 48 copies/mL, CD4 cell count increased to 123 cells/mm3. Patient had right hemiparesia and motor aphasia. MRI showed the lesion had spread to neighboring regions [Figure 2]. Paradoxal immunologic reconstruction inflammatory response (IRIS) was diagnosed. In total, 1 g/day methylprednisolone was started. The oral taper was continued. Hemiparesia significantly improved. Two months later, he interrupted the treatment with his own will then HIV plasma viral load increased; CD4 cell count decreased. He had hemiplegia and mix aphasia. There was deterioration on MRI findings [Figure 3].
Figure 2: (a and b) Contrast enhanced shows that the lesion is mildly enhancing, suggesting IRIS

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Figure 3: (a)T2 flair and (b) T2 weighted MR images show enlargement of the lesion neighboring regions

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The first manifestation was an epileptic seizure related to PML underlying reason of HIV infection in our patient. Kim HK, et al.[3] reported two patients had experienced seizures as a presenting manifestation of the HIV-associated PML.

Nearly one-third of the HIV-infected patients with PML developed paradoxal IRIS after HAART. Low CD4 count and rapid immune recovery by prompt decrease in HIV plasma viral load were predictive factors development of the IRIS.[4] So our case was in high-risk group.

This case was found informative because AIDS-related PML diagnosed during the course of the new onset epileptic seizures and management of paradoxical IRIS.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Puri V, Chaudhry N, Gulati P, Patel N, Tatke M, Sinha S. Progressive multifocal leukoencephalopathy in a patient with idiopathic CD4+ T lymphocytopenia. Neurol India 2010;58:118-21.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Nambirajan A, Suri V, Kataria V, Sharma MC, Goyal V. Progressive multifocal leukoencephalopathy in a 44-year old male with idiopathic CD4+T-lymphocytopenia treated with mirtazapine and mefloquine. Neurol India 2017;65:1061-64.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Kim HK, Chin BK, Shin HS. Clinical features of seizures in patients with human immunodeficiency virus infection. J Korean Med Sci 2015;30:694-9.  Back to cited text no. 3
    
4.
Wattjes MP, Wijburg MT, Vennegoor A, Clifford DB, Nath A. MRI characteristics of early PML-IRIS after natalizumab treatment in patients with MS. J Neurol Neurosurg Psychiatry 2016;87:879-84.  Back to cited text no. 4
    


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