Double Trouble! Concomitant PML and Neurosyphilis Infection in Patient with Progressive Dysarthria with History of CVA and AIDS: A Case Report
Emma Streveler1, Ryan Crane1, Hannah Bray1, Talawnda Bragg1, Gordana Simeunovic1
1Corewell Health Grand Rapids/Michigan State University College of Human Medicine
Background:
Progressive multifocal leukoencephalopathy (PML) is a rare, progressive, and often fatal white matter disease caused by JC virus re-activation that occurs in immunocompromised patients, particularly those with AIDS. Neurosyphilis is the most common non-AIDS-defining central nervous system (CNS) infection, caused by untreated syphilis involving the CNS. Both diseases can present as focal neurologic deficits that may mimic ischemic stroke. We report a case of PML and neurosyphilis co-infection in a patient with prior ischemic stroke with known residual dysarthria, who presented to the hospital as a stroke code activation.
Design/Methods:
Case Report
Results:
49-year-old male with past medical history of HIV/AIDs not on any antiretroviral therapy, and prior ischemic stroke with residual dysarthria presented to the emergency department for acute worsening of his dysarthria and new paresthesia. A stroke code was activated. A non-contrast CT head revealed subcortical edema in the posterior left frontal and left parietal temporal regions. Brain MRI demonstrated T2 FLAIR hyper-intensities within these regions consistent with white matter disease. Blood work showed a CD4+ count of 135 cells/uL, HIV viral load 43000 copies/mL, and serum RPR 1:32. Cerebrospinal fluid testing revealed JC virus level of 700 copies/ml and VDRL 1:1. Antiretroviral therapy with bictegravir/emtricitabine/tenofovir alafenamide (Biktarvy) was reinitiated along with a 14-day course of intravenous Penicillin G for neurosyphilis, resulting in improvement in mental status and dysarthria.
Conclusions:
This case describes PML and neurosyphilis co-infection presenting with stroke-like symptoms in a patient with a history of prior ischemic stroke and HIV/AIDS. Given the severity of PML, clinicians should consider this diagnosis in HIV-positive patients presenting with new neurological deficits, even in those with traditional stroke risk factors, to avoid delays in antiretroviral therapy initiation. Furthermore, confirmation of one CNS infection does not exclude others, a comprehensive CNS infectious workup is warranted in all HIV-positive patients with neurological manifestations.
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