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 35 ICNS Innovations in Clinical Neuroscience • January–February 2018 • Volume 15 • Number 1–2 oligodendrocytes, and is associated with HIV infection in 55 to 85 percent of all PML cases. 1 The lysis of oligodendrocytes, which are the myelin-producing cells of the CNS, results in subsequent mono- and/or multifocal demyelination of the white matter, which is the macroscopic and microscopic hallmark of PML, and atrophy of affected structures. 4,5 The heterogeneous involvement of the white matter leads to a wide range of clinical presentations, with behavioral and cognitive impairment seen in one-third to one-half of the affected patients. 4 Before the introduction of HAART, PML in HIV-positive patients had an associated one- year mortality of nearly 100 percent; however, mortality drops to 40 percent if treatment is initiated with the onset of PML. 1 In-vitro studies have shown that JCV infection of oligodendrocytes is serotonin 5HT 2A receptor- dependent and researchers have postulated that 5HT 2A antagonists like mirtazapine might be beneficial in the treatment of PML by preventing the spread of the virus. 6 Our case supports emerging literature that reports clinical improvement attributable to an empirical off-label use of mirtazapine in the treatment of HIV-positive patients with PML. Comparable beneficial effects of mirtazapine have been reported in HIV-negative patients with PML who are under immunosuppressive treatment for dermatomyositis, sarcoidosis, or polycythemia vera as underlying diseases. 7–9 Our case not only highlights the significance of immune reconstitution in both HIV-positive and HIV-negative patients with PML, but also the possible benefit of adding mirtazapine to their treatment plan. Our case also underlines the importance of HAART in the treatment of HIV and illustrates the synergic effect of combining HAART with mirtazapine, which can lead to quantifiable clinical improvement and interval resolution of MRI findings even if the symptoms are severe. Our patient was younger than cases reported in the literature and showed marked clinical improvement, which was visible in MRI scans, within a few months. This suggests that the plasticity of the brain in a young adult might impact the course of the disease. REFERENCES 1. Cettomai D, McArthur JC. Mirtazapine use in human immunodeficiency virus-infected patients with progressive multifocal leukoencephalopathy. Arch Neurol. 2009;66(2):255–258. 2. Lanzafame M, Ferrari S, Lattuada E, et al. Mirtazapine in an HIV-1 infected patient with progressive multifocal leukoencephalopathy. Infez Med. 2009;17(1):35–37. 3. Mahncke HW, Bronstone A, Merzenich MM. Brain plasticity and functional losses in the aged: scientific bases for a novel intervention. Prog Brain Res. 2006;157:81–109. 4. Berger JR, Aksamit AJ, Clifford DB, et al. PML diagnostic criteria: consensus statement from the AAN Neuroinfectious Disease Section. Neurology. 2013;80(15):1430–1438. 5. Mark AS, Atlas SW. Progressive multifocal leukoencephalopathy in patients with AIDS: appearance on MR images. Radiology. 1989;173(2):517–520. 6. Elphick GF, Querbes W, Jordan JA, et al. The human polyomavirus, JCV, uses serotonin receptors to infect cells. Science. 2004;306(5700):1380–1383. 7. Vulliemoz S, Lurati-Ruiz F, Borruat FX, et al. Favourable outcome of progressive multifocal leucoencephalopathy in two patients with dermatomyositis. J Neurol Neurosurg Psychiatry. 2006;77(9):1079–1082. 8. Owczarczyk K, Hilker R, Brunn A, et al. Progressive multifocal leucoencephalopathy in a patient with sarcoidosis—successful treatment with cidofovir and mirtazapine. Rheumatology (Oxford). Vol 46. England2007:888–890. 9. Verma S, Cikurel K, Koralnik IJ, et al. Mirtazapine in progressive multifocal leukoencephalopathy associated with polycythemia vera. J Infect Dis. 2007;196(5):709–711. ICNS

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