427 - Atypical Thalamic and Brainstem Lesions in a Patient with Progressive Multifocal Leukoencephalopathy: A Case Report

Thursday, February 22, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

KN

Kevin J. Noorda, BS

Medical Student
Kirk Kerkorian School of Medicine at UNLV
North Las Vegas, Nevada, United States

Co-Author(s)

JL

Junjia Liu, PhD

Medical Student
Albert Einstein College of Medicine
Bronx, New York, United States
MJ

Mihir Jani, MD

Resident Physician
Montefiore
New York, New York, United States
MS

Michelle Stern, MD

Department Chair of PM&R
Jacobi Medical Center & North Central Bronx Hospital, Albert Einstein College of Medicine
Bronx, New York, United States

Case Diagnosis: PML induced left sided Abducens nerve palsy with right sided neurological deficits.

Case Description: A 58-year-old female with HIV and medication noncompliance presented with diplopia, medial deviation of the right eye, left sided Abducens nerve palsy, right sided facial droop, bilateral lower extremity weakness, and right sided facial and upper extremity numbness. CT head, MRI brain, and head MR angiogram suggested an infectious rather than vascular etiology. Lesions found on the bilateral medulla, pons, left thalamus, and brainstem indicated PML with atypical lesion distribution. CSF analysis was JC virus positive but otherwise negative. Blood culture was negative.

After five days, the patient was transferred to acute inpatient rehabilitation for daily physical, occupational, and speech-language therapy with alternate eye patching for diplopia relief. The patient was discharged fifteen days later to subacute rehabilitation with improvements in strength, activities of daily living, ambulation, and functional capacity.

Discussions: This case highlights the diverse presentation of PML. It demonstrates the significance of imaging techniques and cultures in identifying the cause of neurological deficits for appropriate treatment. PML typically causes lesions in the frontal and/or parieto-occipital lobes, but can occur rarely in the brainstem. PML commonly presents with subacute neurologic deficits including altered mental status, motor deficits, and visual symptoms like hemianopia and diplopia, but symptoms depend on lesion location(s).

PML is treated with supportive therapy and immediate antiretroviral therapy, whereas other HIV-associated infections require additional antifungal, antibiotic, or antiparasitic treatment. This case emphasizes the need for multidisciplinary cohesion in treating patients with PML in an acute rehabilitation setting to achieve maximum functional recovery.

Conclusions: Patients with HIV receiving inadequate medical management or high viral load presenting with neurological and extraocular impairments should be assessed for PML. Imaging and CSF analysis can aid in diagnosis. Immediate HIV treatment and functional therapy are crucial for optimizing patient outcomes.