Innovations In Clinical Neuroscience

JAN-FEB 2018

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

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C A S E R E P O R T 33 ICNS Innovations in Clinical Neuroscience • January–February 2018 • Volume 15 • Number 1–2 P Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system caused by the human John Cunningham (JC) virus. JC virus is usually identified in immunosuppressed patients (e.g., patients with human immunodeficiency virus [HIV]/acquired immunodeficiency syndrome [AIDS]). Previous case reports have claimed a favorable outcome by adding the serotonergic 5-hydroxytriptamine 2A (5HT 2A ) receptor antagonist mirtazapine to the highly active antiretroviral therapy (HAART) of HIV-positive patients with PML, with improvement or stabilization of symptoms in 41- to 52-year- old patients with or without changes in the corresponding images. 1,2 We questioned if adding mirtazapine to HAART in a young patient would have similar positive results. We report a 20-year-old HIV-positive patient who showed progressive neurocognitive decline due to PML. The patient had been nonadherent with HIV treatment for several years, so HAART was reinitiated and mirtazapine was added to the patient's therapy regimen. The patient showed significant, quantifiable neurocognitive improvement after adding mirtazapine to the HAART therapy. Magnetic resonance imaging (MRI) demonstrated improvement in the subcortical white matter, an area that is commonly involved in PML. The results fall in line with in-vitro study results and the emerging literature claiming the benefit of adding mirtazapine to HAART, and illustrate how the combination of these therapies can have a synergistic effect. This case further illustrates that the age of the patient might positively impact clinical outcome, possibly due to different age-related brain plasticity. 3 CASE REPORT A 20-year-old Hispanic woman presented to the emergency department reporting suprapubic pain and was admitted to the United States/Mexico border hospital for treatment of a urinary tract infection. Review of her past medical history revealed that she had been diagnosed with HIV at the age of 11 and AIDS at the age of 16. Throughout her hospital stay, the patient appeared confused and increasingly anxious. A psychiatric consultation found her to be disorientated to date, place, and location, along with poor concentration, executive function, insight, and judgment. Risperidone 0.5mg was prescribed to treat symptoms of delirium. The patient had been nonadherent with HIV treatment for several years and was at an increased risk for opportunistic infections with A B S T R A C T Highly active antiretroviral therapy is well-established in the treatment of human immunodeficiency virus (HIV)-positive patients. Nonadherence with therapy regimens often leads to the occurrence of opportunistic infections that further complicate treatment and challenge the treating physician. We report a young HIV-positive patient who suffered from progressive multifocal leukoencephalopathy caused by the human John Cunningham virus and showed objective clinical improvement after adding mirtazapine to the treatment regimen, an observation that is supported by the emerging literature. Keywords: Progressive multifocal leukoencephalopathy (PML), acquired immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV), mirtazapine, highly active antiretroviral therapy (HAART) The Benefit of Mirtazapine in the Treatment of Progressive Multifocal Leukoencephalopathy in a Young HIV-positive Patient: A Case Report by CAROLA MULLINS, MD; JORGE MIRANDA, MS; HUGO SANDOVAL, PhD; LUIS RAMOS-DURAN, MD; and SILVINA B. TONARELLI, MD Drs. Mullins , Sandoval, and Ramos-Duran are with the Department of Radiology, Dr. Miranda is with the Paul Foster School of Medicine, and Dr. Tonarelli is with the Department of Psychiatry— all with Texas Tech University Health Sciences Center in El Paso, Texas. Innov Clin Neurosci. 2017;15(1–2):33–35 FUNDING: No funding was provided for the preparation of this article. DISCLOSURES: The authors report no conflict of interest relevant to the content of this article. CORRESPONDENCE: Carola Mullins, MD; Email: carola.mullins@ttuhsc.edu

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