Use of therapeutic plasma exchange in the management of acute hemorrhagic leukoencephalitis: a case report and review of the literature.
BACKGROUND
Acute hemorrhagic leukoencephalitis (AHLE) is a rare, fatal, central nervous demyelinating disease characterized by a rapid fulminant clinical course. Successful management requires early diagnosis, aggressive management of cerebral edema, and immunosuppression. Therapeutic plasma exchange (TPE) is infrequently used and commences after initial management fails.


METHODS
A 31-year-old man presented with right arm weakness, whose symptoms rapidly progressed to hemiplegia and aphasia. The patient was initially managed with glucocorticosteroids. Decompressive craniotomy and brain biopsies were performed when his intracranial pressure increased. Brain biopsy findings were consistent with AHLE. Mycoplasma pneumonia immunoglobulin G and immunoglobulin M serologies revealed recent infection. Despite surgical and medical management, he decompensated on Day 11, and TPE was initiated. The patient received a total of 10 TPE treatments. On the fourth day of TPE treatment, he was extubated. Twenty-one days after TPE began, he was ambulating with near normal muscle strength and was discharged. Four months after initial presentation, the patient has normal strength and is working full-time.


CONCLUSIONS
AHLE has a fulminant course requiring accurate and rapid diagnosis. Successful therapy requires aggressive management of intracranial pressure and immunosuppression. Two other reports of AHLE document successful management with TPE. Each of these patients survived with minimal neurologic impairments. Given the likely immune-mediated nature of this disease, combined treatment of steroids, surgery, and TPE may lead to shorter hospital stays and improved neurologic outcomes. Clinical studies are needed to further study the effect of TPE on neurologic outcome in AHLE.
Ryan
Lori J
LJ
Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, University of Minnesota Medical Center University of Minnesota, Minneapolis, Minnesota 55455, USA. stor0151@umn.edu
Bowman
Robert
R
Zantek
Nicole Dodge
ND
Sherr
Gregory
G
Maxwell
Robert
R
Clark
H Brent
HB
Mair
David C
DC
D000328:Adult; D000907:Antibodies, Bacterial / Q000097:blood; D001037:Aphasia / Q000097:blood / Q000382:microbiology / Q000473:pathology; D001706:Biopsy; D001921:Brain / Q000382:microbiology / Q000473:pathology; D003399:Craniotomy; D005938:Glucocorticoids / Q000627:therapeutic use; D006429:Hemiplegia / Q000097:blood / Q000382:microbiology / Q000473:pathology; D006801:Humans; D007074:Immunoglobulin G / Q000097:blood; D007075:Immunoglobulin M / Q000097:blood; D004684:Leukoencephalitis, Acute Hemorrhagic / Q000097:blood / Q000175:diagnosis* / Q000209:etiology / Q000382:microbiology / Q000473:pathology / Q000628:therapy*; D008297:Male; D009175:Mycoplasma Infections / Q000097:blood / Q000150:complications / Q000175:diagnosis / Q000473:pathology / Q000628:therapy; D009177:Mycoplasma pneumoniae; D010951:Plasma Exchange; D013997:Time Factors
D000907:Antibodies, Bacterial; D005938:Glucocorticoids; D007074:Immunoglobulin G; D007075:Immunoglobulin M