Prolonged Survival and Partial Recovery in AIDS-associated Progressive Multifocal Leukoencephalopathy

Abstract

Among HIV positive patients (human immunodeficiency virus), only medullary syndromes arising after primary infection have been described as spontaneously regressive. The authors report one case of medullary syndrome with a favorable evolution arising independently of the primary infection.

Case Details

Personal Characteristics

39-year-old homosexual man, history of infectious mononucleosis, syphilis, probable hepatitis b, pneumonia, no use of intravenous drugs

Clinical Characteristics

Onset of fatigue and depression, memory difficulties, irritability, clumsiness of the left leg, gait impairment, throbbing headaches, no nausea, vomiting, photophobia, or neck stiffness, left leg weakness, inattention to objects in the left field of vision, saccadic visual pursuit, difficulty in drawing maps and figures, hyperreflexia and a babinski sign on the left, impaired position sense in the left arm and leg, reduced graphesthesia, astereognosis, pseudoathetosis of the left arm, unaffected vibratory perception

Remission Characteristics

Improvement in gait, headaches subsided, strength in left arm and leg improved, vision improved, memory and other mental faculties improved, alert and normally oriented, calculations normal, full visual fields, slight left spastic hemiparesis, normal position sense, improved gait

Treatment & Mechanisms

Proposed Remission Mechanisms

Not discussed

Clinical Treatment

Dexamethasone for 2 weeks, empirically treated with sulfadiazine (17 days) and pyrimethamine (approximately 6 weeks)

Additional Notes

PML was the initial manifestation of AIDS in the patient. Brain tissue obtained by stereotactic biopsy showed features of PML and an unusually prominent inflammatory response. Neurologic improvement did not appear to correlate with clinical or laboratory measurements of immunologic improvement. The patient continued to display neurologic recovery despite the development of other opportunistic infections.