title: Immune reconstitution associated with progressive multifocal leukoencephalopathy in human immunodeficiency virus: a case discussion and review of the literature.
abstract: OBJECTIVE
  To report the neuropathological findings of a patient with immune reconstitution syndrome associated with progressive multifocal leukoencephalopathy (PML) in human immunodeficiency virus (HIV) and to review the literature.
  
  
  METHODS
  A 38-year-old man was presented with a rapidly evolving brainstem syndrome. Serology for HIV was positive with an initial CD4 count of 130 cells/mL3. Magnetic resonance imaging showed widespread high signal changes within the brainstem bilaterally, the cerebellum, inferior cerebellar peduncle, and the frontal lobe on the right. Opportunistic infections were excluded from blood and cerebrospinal fluid samples. Despite treatment with antiretrovirals, he continued to deteriorate neurologically, and a repeat magnetic resonance imaging scan showed progression of his lesions. Cortical wedge frontal lobe brain biopsy showed features characteristic of PML, but was associated with an exaggerated inflammatory response. Polymerase chain reaction analysis of the specimen demonstrated the presence of JC virus (JCV) DNA, confirming the pathologic impression of PML.
  
  
  RESULTS
  The patient made a rapid (within 24 hours) improvement with pulsed methylprednisolone and has maintained a clinical response 7 months later. These features clinically, radiologically, and histopathologically suggest an added component in the form of immune reconstitution syndrome to PML.
  
  
  CONCLUSIONS
  This report highlights the need to carefully evaluate the clinical syndrome in patients with HIV-associated leukoencephalopathy. It also substantiates the role of corticosteroids in carefully considered cases of HIV with leukoencephalopathy secondary to immune reconstitution.
authors.affiliation: Monsall Unit, Department of Infectious Diseases and Tropical Medicine, North Manchester General Hospital, Crumpsall, Manchester, UK. jennytravis@doctors.org.uk
authors.forename: Jennifer
authors.initials: J
authors.lastname: Travis
authors.forename: Anoop
authors.initials: A
authors.lastname: Varma
authors.forename: Daniel
authors.initials: D
authors.lastname: duPlessis
authors.forename: Ian
authors.initials: I
authors.lastname: Turnbull
authors.forename: F Javier
authors.initials: FJ
authors.lastname: Vilar
mesh_terms: D000163:Acquired Immunodeficiency Syndrome / Q000150:complications*; D000328:Adult; D015704:CD4 Antigens / Q000378:metabolism; D006801:Humans; D007968:Leukoencephalopathy, Progressive Multifocal / Q000209:etiology* / Q000276:immunology* / Q000473:pathology / Q000821:virology*; D008279:Magnetic Resonance Imaging; D008297:Male
chemical_list: D015704:CD4 Antigens