Abstract Details

Title PML presenting as an isolated vertigo: a diagnositic challange

Topic Infectious Disease

Presentation(s) P4 - Poster Session 4 (5:30 PM-6:30 PM)

Poster/Presentation
Number 4-012

Objective NA

Background Progressive multifocal leukoencephalopathy (PML) is a devastating demyelinating disease of the central nervous system caused by human polyomavirus (JCV) in immunocompromised patients. It presents with focal neurological deficits that vary depending on lesion localization. We report a case of PML in a newly diagnosed AIDS patient who presented with unremitting vertigo and headache.

Design/Methods 35-year-old male presenting with 2 weeks of vertigo and persistent headaches. Four weeks prior to symptoms onset, patient had a shingles infection treated with valacyclovir. Subsequent to treatment completion, patient noted left temporal headache associated with vertigo. Initial neurological examination was normal. Dix-hallpike maneuver resulted in worsening of vertigo. Initial serum lab values were normal. MRI brain with and without gadolinium showed multiple high signal intensity lesions seen on FLAIR and T2-weighted images in subcortical white matter of bilateral cerebral hemispheres, also right thalamus, pons, medulla, bilateral cerebellar hemispheres, and bilateral middle cerebellar peduncles. Patient noted on further discussion that he could have been exposed recently to HIV infection. Basic CSF analysis was unrevealing. JCV in CSF was sent. HIV was positive with a viral load of 387,000 and CD4+ count of 27. Subsequently JCV was detected in the CSF. Patient was started on HAART. Neurological examination deteriorated throughout his hospitalization. Currently, patient is aphasic with left-sided hemiplegia. Symptoms are stable and he is receiving rehabilitation.

Results NA

Conclusions This is an atypical case of PML presenting with persistent headache and vertigo for 2 weeks with normal examination despite the heavy burden of demyelinating lesions on MRI. Prior to completion of work up, initial differential diagnosis included VZV encephalitis given his persistent headaches or valacyclovir neurotoxicity which can present with ataxia. Detailed history revealing that patient was at high risk for HIV was a key. In conclusion, PML can be an exceedingly difficult diagnosis in some circumstances.

Authors/Disclosures
Bayan Moustafa, DO PRESENTER	Dr. Moustafa has nothing to disclose.
Sushant Puri, MBBS (Oregon Health & Science University (OHSU))	Dr. Puri has nothing to disclose.

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