Background Progressive multifocal leukoencephalopathy (PML) is an opportunistic infection caused by reactivation of the JC polyomavirus (JCV). It is characterised by severe demyelination of the central nervous system, which is invariably fatal. PML mainly occurs in immunosuppressed individuals. Within the context of HIV infection, the prognosis with highly active antiretroviral therapy (HAART) is of only 50 percent of patients with PML surviving longer than one year.

No specific treatment exists for JCV infection. The main treatment approach involves HAART to reverse the immunosuppression. Cidofovir has been used in patients with HIV infection as treatment for PML, but the largest clinical studies have reported no benefit.

Purpose To describe and evaluate the efficacy of cidofovir for the treatment of PML in HAART-treated HIV patients.

Material and methods A 43-year-old man was diagnosed with HIV infection for 10 years without treatment. In June 2011 the patient began treatment with tenofovir/emtricitabine/efavirenz (11 cells/mm3 CD4, HIV-RNA 111,560 copies/mL). After three months the patient presented aphasia, hemiparesis and visual field deficits (almost blind).

His medical record was reviewed with a focus on drug treatments, laboratory results and clinical evolution.

Results On admission he had 68 cells/mm³ CD4, HIV-RNA undetectable, JCV PCR of the CSF was 5,417,063 copies/mL. Toxoplasma gondii and BK virus were negative. He was diagnosed with PML, with magnetic resonance imaging supporting the disease. Treatment started with cidofovir 325 mg bi-weekly and optimised HAART (abacavir/lamivudine/efavirenz).

Cidofovir was withdrawn after 2 months; the result showed an improvement in his motor deficit. However dysphasia and visual loss continued. Three years after infection the patient is still alive with neurological deficits.

Conclusion In patients with HIV and PML, the main treatment approach should be the restoration of the host adaptive immune response by optimising the effective HAART. Cidofovir can be useful to help reduce the progression of PML.

Reference

1. De Luca A, Ammassari A, Pezzotti P, et al. Cidofovir in addition to antiretroviral treatment is not effective for AIDS-associated progressive multifocal leukoencephalopathy: a multicohort analysis. AIDS 2008;22(14):1759–67

ReferenceNo conflict of interest.