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A 38-year-old HIV-infected patient presenting with seizures

Posted Jun 29 2010 11:27am
The "best case" award winner at the Diagnostic Slide Session at the recent American Association of Neuropathologists annual meeting in Philadelphia was presented by Dr. Sandra Camelo-Piragua, Ronald A. Goerss, and David N. Lewis of Massachusetts General Hospital . The case is that of a 38-year-old AIDS patient who had been only intermittently compliant with his HAART therapy. He presented to the hospital with seizures in 2009 after a year of fluctuating neurological symptoms. Imaging studies showed the following white matter changes
Macrophages were also present
The following stains for organisms were all NEGATIVE: AFB, GMS, HSV1, HSV2, CMV, HHV8, and toxoplasma. An H&E/LFB stain demonstrated that this was a leukoencephalopathic process

Immunohistochemistry of one of the lymphoid follicles indicated that the lymphoid infiltrate was a reactive, rather a neoplastic process
Polyoma virus immunohistochemistry for the SV40 (a surrogate marker for JC virus due to cross-reactivity) was found to be positiveSo, the final diagnosis rendered was Progressive Multifocal Leukoencephalopathy (PML) with concomitant Immune Reconstitution Inflammatory Syndrome (IRIS). IRIS is an inflammatory response in HIV-infected individuals upon initiation of HAART therapy. The immune response can be so robust as to cause morbidity, particularly with the brain is involved. Thanks to Dr. Camelo-Piragua for providing the images associated with this interesting case, and I wish her the best of luck in her upcoming move to Ann Arbor where she will take a position on the faculty at the University of Michigan !
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