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Sakizadeh J, Davis MJ, Fontana L. Progressive multifocal leukoencephalopathy in a lung transplant recipient. Clin Case Rep 2024; 12:e8626. [PMID: 38464572 PMCID: PMC10923696 DOI: 10.1002/ccr3.8626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/23/2024] [Accepted: 02/08/2024] [Indexed: 03/12/2024] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare and fatal demyelinating disease of the central nervous system (CNS). The case we describe highlights the importance of considering a diagnosis of PML early (<1 year) after lung transplant.
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Affiliation(s)
- Jason Sakizadeh
- University of Minnesota Medical School Twin Cities CampusMinneapolisMNUSA
| | - Michael J. Davis
- Division of Infectious Diseases and International MedicineUniversity of Minnesota Medical School Twin Cities Campus, Infectious DiseaseMinneapolisMNUSA
| | - Lauren Fontana
- Division of Infectious Diseases and International MedicineUniversity of Minnesota Medical School Twin Cities Campus, Infectious DiseaseMinneapolisMNUSA
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Polastri M, Pérez IC, Pehlivan E, Paganelli GM, Dell'Amore A. Postoperative foot drop in patients receiving lung transplantation: increasing awareness and preventing risks. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2021. [DOI: 10.12968/ijtr.2021.0168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Massimiliano Polastri
- Department of Continuity of Care and Disability, Physical Medicine and Rehabilitation, St Orsola University Hospital, Bologna, Italy
| | - Isabel Cerdá Pérez
- Department of Clinical, Integrated and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Esra Pehlivan
- Department of Physical Therapy and Rehabilitation, University of Health Sciences Turkey, School of Health Sciences, Istanbul, Turkey
| | - Gian Maria Paganelli
- Department of Cardiac-Thoracic-Vascular Diseases, Unit of Pneumonology, St Orsola University Hospital, Bologna, Italy
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Lippa AM, Ocwieja KE, Iglesias J, Fawaz R, Elisofon S, Lee C, Sharma TS. Progressive multifocal leukoencephalopathy presenting with acute sensorineural hearing loss in an intestinal transplant recipient. Transpl Infect Dis 2020; 22:e13304. [PMID: 32367644 DOI: 10.1111/tid.13304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/12/2020] [Accepted: 04/25/2020] [Indexed: 02/06/2023]
Abstract
A 20-year-old male presented 3.5 years after intestinal transplantation with rapidly progressive sensorineural hearing loss. Initial brain imaging was consistent with inflammation and/or demyelination. Lumbar puncture was initially non-diagnostic and a broad infectious workup was unrevealing. Three months after presentation, a repeat LP detected JC virus for which tests had not earlier been conducted. He continued to deteriorate despite withdrawal of prior immunosuppression and addition of mirtazapine, maraviroc, and steroids. He died of progressive neurologic decompensation 5 months after his initial presentation. This case highlights progressive multifocal leukoencephalopathy (PML) as a rare complication after solid organ transplantation and acute sensorineural hearing loss as an unusual first presenting symptom of PML. JC virus should be considered in the differential diagnosis of acute sensorineural hearing loss in any immunocompromised patient.
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Affiliation(s)
- Andrew M Lippa
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, USA
| | - Karen E Ocwieja
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, USA
| | - Julie Iglesias
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Rima Fawaz
- Division of Gastroenterology and Hepatology, Yale New Haven Children's Hospital, New Haven, CT, USA
| | - Scott Elisofon
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Christine Lee
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Tanvi S Sharma
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, USA
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Crowhurst T, Koszyca B, Holmes M, Holmes-Liew CL. Progressive multifocal leukoencephalopathy in a lung transplant recipient presenting with memory impairment: Case report and literature review. Transpl Infect Dis 2020; 22:e13293. [PMID: 32291834 DOI: 10.1111/tid.13293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 03/31/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating disease of the central nervous system caused by JC virus (JCV). The disease occurs in the setting of significant immunocompromise and has now been reported in many different settings, although only very rarely after lung transplantation. The mortality rate is high and therapeutic options are limited. CASE PRESENTATION We report a case of a 66-year-old man who presented with non-specific memory disturbance at 19 months after lung transplantation for chronic hypersensitivity pneumonitis. He had required methylprednisolone for acute allograft rejection but achieved good graft function. Physical examination was unremarkable. CT revealed hypodensity in the left frontal lobe. MR demonstrated significant hyperintense white-matter abnormalities on T2-weighted and fluid-attenuated inversion recovery (FLAIR) sequences, mainly focused on the periventricular region adjacent the frontal horn of the left lateral ventricle. Brain biopsy confirmed PML. The patient had his immunosuppression reduced but then developed antibody-mediated rejection four months later. Despite re-escalation of immunosuppression, he remains neurologically stable on mirtazapine at eight months post-diagnosis. CONCLUSIONS This very rare case highlights the challenges presented by PML, especially in the lung transplant population. It reveals the difficult balance between reducing immunosuppression to protect the brain versus prevention of lung allograft rejection. It clearly highlights the need for improved therapeutic modalities.
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Affiliation(s)
- Thomas Crowhurst
- Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia.,SA Lung Transplant Service, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Barbara Koszyca
- SA Pathology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Mark Holmes
- Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia.,SA Lung Transplant Service, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Chien-Li Holmes-Liew
- Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia.,SA Lung Transplant Service, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
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Lokhandwala S, Sendowski M, Grafe M, Rakita RM, Kapnadak SG. Progressive Behavior Changes and Brain Lesions in a Lung Transplant Recipient. Clin Infect Dis 2020; 68:887-889. [PMID: 30766993 DOI: 10.1093/cid/ciy404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sharukh Lokhandwala
- Divison of Pulmonary, Critical Care and Sleep Medicine, University of Washington School of Medicine, Seattle.,Divison of Epidemiology, University of Washington School of Public Health, Seattle
| | | | - Marjorie Grafe
- Division of Neuropathology, Oregon Health and Science University, Portland
| | - Robert M Rakita
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle
| | - Siddhartha G Kapnadak
- Divison of Pulmonary, Critical Care and Sleep Medicine, University of Washington School of Medicine, Seattle
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Ishii K, Yamamoto F, Homma S, Okada Y, Nakamichi K, Saijo M, Tamaoka A. Probable progressive multifocal leukoencephalopathy-immune reconstitution inflammatory syndrome with immunosuppressant dose reduction following lung transplantation: a case report and literature review. BMC Neurol 2019; 19:263. [PMID: 31672142 PMCID: PMC6822459 DOI: 10.1186/s12883-019-1493-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 10/09/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Progressive multifocal leukoencephalopathy (PML) is a rapidly developing demyelinating disease in the cerebral white matter and is often caused by JC polyomavirus (JCV). PML after lung transplantation is rare and has a poor prognosis, with no established therapies. Reducing the patient's immunosuppressant doses, thereby restoring immunity, could be used to treat PML. However, some patients develop immune reconstitution inflammatory syndrome (IRIS) with this treatment, an immune-induced inflammatory response to JCV that results in serious neuronal damage. We herein report a case of a 60-year-old female who suffered from PML 5 years after lung transplantation, had worsened brain lesions thought to be related to PML-IRIS at the time of immunosuppressant reduction, and missed treatment opportunities. CASE PRESENTATION A 60-year-old female developed PML 5 years after lung transplantation. Fluid-attenuated inversion recovery and diffusion-weighted brain magnetic resonance imaging (MRI) revealed multiple high-signal lesions, mainly in the cerebral white matter. Polymerase chain reaction found 0.32 million copies/mL of JCV in the cerebrospinal fluid. Thus, she was given a diagnosis of PML. Mycophenolate mofetil and tacrolimus dosages were reduced, and CD4-positive cell counts and the blood concentration of each immunosuppressant were monitored. Mefloquine was also orally administered at a daily dose of 275 mg for 3 days and was then administered at a dose of 275 mg per week. Although the patient's CD4-positive cell counts increased and her immune system recovered, her symptoms and brain MRI findings worsened. We suspected PML progression or a transition to PML-IRIS. Steroid pulse therapy to suppress the inflammatory lesions was not possible but was retrospectively indicated. The patient rapidly began to exhibit akinetic mutism and died 4 months after the onset of neurologic symptoms. CONCLUSIONS When neurologic symptoms and abnormal brain MRI findings are noted during immune recovery, it is often difficult to distinguish between progressed PML and PML-IRIS. However, the pathogenesis of brain lesions usually involves inflammation and immune-reactive mechanisms for JCV. Steroid pulse therapy, which can reduce inflammation, should thus be administered in organ transplantation cases with differential diagnoses including PML-IRIS.
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Affiliation(s)
- Kazuhiro Ishii
- Department of Neurology, Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Ten'noudai, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Fumiko Yamamoto
- Department of Neurology, Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Ten'noudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Shinsuke Homma
- Department of Pulmonology, Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Ten'noudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yoshinori Okada
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, 4-1 Seiryomachi, Aoba-ku Sendai, 980-8575, Japan
| | - Kazuo Nakamichi
- Department of Virology 1, National Institute of Infectious Diseases, Toyama 1-23-1, Shinjuku-ku, Tokyo, 162-8640, Japan
| | - Masayuki Saijo
- Department of Virology 1, National Institute of Infectious Diseases, Toyama 1-23-1, Shinjuku-ku, Tokyo, 162-8640, Japan
| | - Akira Tamaoka
- Department of Neurology, Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Ten'noudai, Tsukuba, Ibaraki, 305-8575, Japan
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