title: A Difficult Decision: Atypical JC Polyomavirus Encephalopathy in a Kidney Transplant Recipient.
abstract: A number of cerebral manifestations are associated with JC polyomavirus (JCPyV) which are diagnosed by detection of JCPyV in cerebrospinal fluid (CSF), often with the support of cerebral imaging. Here we present an unusual case of a kidney transplant patient presenting with progressive neurological deterioration attributed to JCPyV encephalopathy.
  
  
  
  Quantitative polymerase chain reaction JCPyV was used prospectively and retrospectively to track the viral load within the patient blood, urine, CSF, and kidney sections. A JCPyV VP1 enzyme-linked immunosorbent assay was used to measure patient and donor antibody titers. Immunohistochemical staining was used to identify active JCPyV infection within the kidney allograft.
  
  
  
  JC polyomavirus was detected in the CSF at the time of presentation. JC polyomavirus was not detected in pretransplant serum, however viral loads increased with time, peaking during the height of the neurological symptoms (1.5E copies/mL). No parenchymal brain lesions were evident on imaging, but transient cerebral venous sinus thrombosis was present. Progressive decline in neurological function necessitated immunotherapy cessation and allograft removal, which led to decreasing serum viral loads and resolution of neurological symptoms. JC polyomavirus was detected within the graft's collecting duct cells using quantitative polymerase chain reaction and immunohistochemical staining. The patient was JCPyV naive pretransplant, but showed high antibody titers during the neurological symptoms, with the IgM decrease paralleling the viral load after graft removal.
  
  
  
  We report a case of atypical JCPyV encephalopathy associated with cerebral venous sinus thrombosis and disseminated primary JCPyV infection originating from the kidney allograft. Clinical improvement followed removal of the allograft and cessation of immunosuppression.
authors.affiliation: 1 Queensland Paediatric Infectious Diseases Laboratory, The University of Queensland, Brisbane, Australia. 2 Department of Renal Medicine, Princess Alexandra Hospital, The University of Queensland, Brisbane, Australia. 3 Department of Anatomical Pathology, Princess Alexandra Hospital, Brisbane, Australia. 4 Division of Neuro Immunology and Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. 5 Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Seweryn
authors.initials: S
authors.lastname: Bialasiewicz
authors.forename: Gareth
authors.initials: G
authors.lastname: Hart
authors.forename: Kimberly
authors.initials: K
authors.lastname: Oliver
authors.forename: Shruti P
authors.initials: SP
authors.lastname: Agnihotri
authors.forename: Igor J
authors.initials: IJ
authors.lastname: Koralnik
authors.forename: Raphael
authors.initials: R
authors.lastname: Viscidi
authors.forename: Michael D
authors.initials: MD
authors.lastname: Nissen
authors.forename: Theo P
authors.initials: TP
authors.lastname: Sloots
authors.forename: Michael T
authors.initials: MT
authors.lastname: Burke
authors.forename: Nicole M
authors.initials: NM
authors.lastname: Isbel
authors.forename: John
authors.initials: J
authors.lastname: Burke
mesh_terms: D000328:Adult; D000914:Antibodies, Viral / Q000097:blood; D001706:Biopsy; D002533:Cerebral Angiography / Q000379:methods; D004334:Drug Administration Schedule; D006801:Humans; D016867:Immunocompromised Host; D007150:Immunohistochemistry; D007166:Immunosuppressive Agents / Q000008:administration & dosage / Q000009:adverse effects; D007577:JC Virus / Q000235:genetics / Q000276:immunology / Q000302:isolation & purification*; D007668:Kidney / Q000601:surgery / Q000821:virology*; D016030:Kidney Transplantation / Q000009:adverse effects*; D007968:Leukoencephalopathy, Progressive Multifocal / Q000175:diagnosis / Q000276:immunology / Q000628:therapy / Q000821:virology*; D018810:Magnetic Resonance Angiography; D008297:Male; D009392:Nephrectomy; D010690:Phlebography / Q000379:methods; D027601:Polyomavirus Infections / Q000175:diagnosis / Q000276:immunology / Q000628:therapy / Q000821:virology*; D012086:Reoperation; D016896:Treatment Outcome; D019562:Viral Load
chemical_list: D000914:Antibodies, Viral; D007166:Immunosuppressive Agents