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Progressive Multifocal Leukoencephalopathy Background Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating disease of the central nervous system (CNS) to which immunocompromised hosts are vulnerable. It is caused by the JC virus, a polyomavirus that infects and lyses oligodendrocytes. Disease is thought to result from reactivation of latent infection. Among HIV-infected patients, PML occurs most frequently in those with CD4 counts of
6–94 | Clinical Manual for Management of the HIV-Infected Adult/2006 Radiographic studies CNS imaging may reveal changes typical of PML, but is nonspecific. Magnetic resonance imaging (MRI) is more sensitive than computed tomography (CT) for detecting PML. PML presents as single or multiple hypodense lesions in the subcortical white matter, with no surrounding edema. On MRI, lesions show increased T2 signal and little or no enhancement with gadolinium. On CT, PML lesions typically are nonenhancing. In some patients, and particularly in patients taking ART, PML lesions may show inflammatory changes, such as enhancement. CSF evaluation ♦ CSF cell count, protein level, and glucose level generally are normal or show mild pleocytosis and slightly elevated protein. ♦ A JC virus polymerase chain reaction (PCR) assay is approximately 75-85% sensitive; detection of JC virus in a patient whose clinical presentation and radiographic imaging results are consistent with PML is adequate to make a diagnosis. A negative result with JC virus PCR does not rule out PML. Other studies ♦ Other diagnostic tests should be performed as indicated to rule out other potential causes of the patient’s symptoms. ♦ A brain biopsy should be considered if the diagnosis is unclear. Treatment ♦ ♦ ♦ There is no specific treatment for JC virus. Potent ART with effective immune reconstitution is the only treatment that may be effective for patients with PML. Even with ART, however, mortality rates approach 50%, and neurologic deficits are unlikely to be reversible. Initiate ART for patients who are not already receiving treatment. It is not clear whether antiretroviral agents with good CNS penetration are more effective than those that are less likely to cross the blood-brain barrier. For patients who are taking ART with incomplete virologic suppression, change the ART regimen appropriately to achieve virologic suppression, if possible. For patients on ART with poor immunologic response, consider changing or intensifying therapy with the goal of improved immunologic recovery. (See chapter Antiretroviral Therapy.) ♦ ♦ ♦ If symptoms are caused by immune reconstitution, consider adding corticosteroids (eg, dexamethasone) to help decrease inflammation. Depending on the patient’s cognitive and physical status, he or she may need a care provider in the home to assure that medications are taken on schedule. The patient is likely to need supportive care for personal hygiene, nutrition, safety, and prevention of accidents or injury; refer as indicated. Patient Education ♦ ♦ When a diagnosis of PML has been established or suspected, the clinician should initiate a discussion of plans for terminal care (including wills, advanced directives, and supportive care and services) with the patient and family members or caregivers. Supportive treatment will be necessary for an undetermined period of time, and hospice referral should be considered if the patient does not show clinical improvement in response to ART. If the patient is receiving ART, the clinician should be sure that family members or friends are taught about the medications and are able to help the patient with adherence. References ♦ ♦ ♦ ♦ ♦ Aksamit AJ. Review of progressive multifocal leukoencephalopathy and natalizumab. Neurologist. 2006 Nov;12(6):293-8. Centers for Disease Control and Prevention, National Institutes of Health, HIV Medicine Association/Infectious Diseases Society of America. Treating Opportunistic Infections Among HIV- Infected Adults and Adolescents. MMWR Recomm Rep. 2004 Dec 17; 53(RR15);1-112. Available at: http://aidsinfo.nih.gov/Guidelines/GuidelineDetail. aspx?GuidelineID=14. Koralnik IJ. New insights into progressive multifocal leukoencephalopathy. Curr Opin Neurol. 2004 Jun;17(3):365-70. Ragland J. Progressive multifocal leukoencephalopathy. AIDS Clin Care. 1993 Mar;5(3):17-19. Wyen C, Lehmann C, Fatkenheuer G, et al. AIDSrelated progressive multifocal leukoencephalopathy in the era of HAART: report of two cases and review of the literature. AIDS Patient Care STDS. 2005 Aug;19(8):486-94.
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Clinical Manual for Management of t
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Table of Contents Clinical Manual f
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Clinical Manual for Management of t
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Preface—About this Manual | Clini
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Previous Editions Atlanta Contribut
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♦ ♦ ♦ ♦ ♦ | Clinical Manu
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1-2 | Clinical Manual for Managemen
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Initial Physical Examination Backgr
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Genitals/Rectum • Inspect the gen
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Initial and Interim Laboratory and
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Section 1—Testing and Assessment
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Patient Education ♦ ♦ ♦ ♦ D
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Section 2—Health Maintenance and
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References ♦ ♦ ♦ ♦ ♦ ♦
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Occupational Postexposure Prophylax
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P: Plan Laboratory Testing Provide
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For hepatitis C, no recommended pro
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as hepatitis C or another sexually
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for treatment is appropriate, and b
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contact with the patient. Patients
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tablet daily of trimethoprim-sulfam
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Opportunistic Infection Prophylaxis
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Discontinuing Primary Prophylaxis P
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Latent Tuberculosis Background Late
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INH may cause liver toxicity and it
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Patient Education ♦ ♦ ♦ ♦
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Reducing Maternal-Infant HIV Transm
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Some states require written informe
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contraindicated during pregnancy be
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Section 3—Antiretroviral Therapy
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Nelfinavir (Viracept) Adequate drug
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Section 4—Complications of Antire
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♦ ♦ ♦ Toronto General Hospita
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Adverse Reactions to HIV Medication
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♦ ♦ ♦ ♦ ♦ Vital signs: No
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egimen, symptoms of fatigue could i
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Recreational Drugs and Antiretrovir
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Section 4—Complications of Antire
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LSD, Mescaline, Psilocin, and Methy
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Immune Reconstitution Syndrome Back
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A: Assessment In the appropriate cl
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♦ ♦ ♦ ♦ ♦ Navas E, Martin
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Eye Problems Background The immunos
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of
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Fever Background Although fever may
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Headache Background Headache may ha
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Lymphadenopathy Background Lymphade
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Treatment Treatment will depend on
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Neurologic Symptoms Background The
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♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦
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Pulmonary Symptoms Background Short
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Treatment Once the diagnosis is mad
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Candidiasis, Oral and Esophageal Ba
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Maintenance therapy Use caution whe
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Cervical Dysplasia Background Cervi
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Patient Education ♦ ♦ ♦ ♦ P
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Cryptosporidiosis Background Crypto
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Gonorrhea and Chlamydia Background
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Treatment of Gonorrhea Treatment op
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Hepatitis B Infection Background He
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♦ ♦ ♦ ♦ ♦ Some patients t
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Hepatitis C Infection Background He
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Page 288 and 289: Kaposi Sarcoma Background Kaposi sa
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Page 338 and 339: Toxoplasmosis Background Toxoplasma
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Page 346 and 347: Oral Health Background Examination
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Insomnia Background Insomnia is a c
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Suicidal Ideation Background Transi
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Section 8—Neuropsychiatric Disord
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P: Plan ♦ ♦ ♦ ♦ ♦ Check t
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Correctional Settings Background Ca
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Adherence Adherence is one of the m
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Karnofsky Performance Scale Backgro
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