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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~  References
 ~  Article Figures

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  Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 30  |  Issue : 2  |  Page : 239-241
 

Use of John Cunningham virus polymerase chain reaction in the diagnosis of progressive multifocal leucoencephalopathy - A rare presenting manifestation in an HIV-positive patient


1 Department of Clinical Microbiology and Immunology, Sir Ganga Ram Hospital, New Delhi, India
2 Department of Neurology, Sir Ganga Ram Hospital, New Delhi, India
3 Department of CT Scan and MRI, Sir Ganga Ram Hospital, New Delhi, India
4 Department of Histopathology, Sir Ganga Ram Hospital, New Delhi, India

Date of Submission29-Oct-2011
Date of Acceptance02-Mar-2012
Date of Web Publication28-May-2012

Correspondence Address:
C Wattal
Department of Clinical Microbiology and Immunology, Sir Ganga Ram Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.96710

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 ~ Abstract 

John Cunningham virus infection is an important cause of progressive multifocal leucoencephalopathy (PML) in the context of advanced human immunodeficiency virus infection. Limited data are available regarding the true incidence of PML as a presenting manifestation of HIV. We report one such case and also highlight the effective use of polymerase chain reaction in confirming its diagnosis.


Keywords: John Cunningham virus, polymerase chain reaction, progressive multifocal leucoencephalopathy


How to cite this article:
Datta S, Wattal C, Sethi P K, Buxi T, Jain D. Use of John Cunningham virus polymerase chain reaction in the diagnosis of progressive multifocal leucoencephalopathy - A rare presenting manifestation in an HIV-positive patient. Indian J Med Microbiol 2012;30:239-41

How to cite this URL:
Datta S, Wattal C, Sethi P K, Buxi T, Jain D. Use of John Cunningham virus polymerase chain reaction in the diagnosis of progressive multifocal leucoencephalopathy - A rare presenting manifestation in an HIV-positive patient. Indian J Med Microbiol [serial online] 2012 [cited 2019 Sep 19];30:239-41. Available from: http://www.ijmm.org/text.asp?2012/30/2/239/96710



 ~ Introduction Top


Progressive multifocal leucoencephalopathy (PML) is a demyelinating disease of the central nervous system resulting from reactivation of John Cunningham virus (JCV) in immunocompromised patients. [1] Although the population of human immunodeficiency virus (HIV)/AIDS in India is estimated to be over 5 million, data on the true incidence of PML as a presenting manifestation of HIV is limited. [2] Diagnosis of PML may be difficult. Although imaging results help in presumptive diagnosis, they are often altered by associated immune reaction or cerebral atrophy. [3],[4] Though brain biopsy is confirmatory, it is an invasive procedure. Detecting JCV in cerebrospinal fluid (CSF) by polymerase chain reaction (PCR) is a definitive laboratory confirmation. We report a case of PML as a presenting manifestation of HIV/AIDS and the role of JCV PCR as an effective mode of diagnosis.


 ~ Case Report Top


A 52-year-old lady with a medical history of hypertension, diabetes and hypothyroidism on medication presented with progressive spastic weakness for past 4 months, resulting in paraplegia of the lower limbs and weakness of the right and left upper limb with dysarthria. There was no bladder and bowel involvement. She was diagnosed from outside as a case of motor neuron disease and was referred to our hospital for admission. On examination, the power in both her lower limbs was 0/5, 1/5 in the right upper limb and 3/5 in the left upper limb, with increased muscle tone in all the four limbs. She was further investigated on admission. A computed tomography-magnetic resonance imaging (CT-MRI) scan of the brain revealed symmetrical increased signal intensity areas in bilateral posterior parietal, frontoparietal, parasaggital cortex and underlying white matter region, and was reported as suggestive of ischemic insult in bilateral middle cerebral artery territories [Figure 1]. In view of the atypical presentation of progressive spastic quadriparesis and abnormal signal change in brain, possibility of PML versus lymphoma was kept in mind. She was screened for HIV and tested positive for HIV with a CD4 count of 84 cells/μl. Her laboratory CSF parameters were all within normal limits. Stereotactic brain biopsy was offered and CSF sample was sent for JCV PCR.
Figure 1: CT– MRI scan. (a) T2W Coronal: Subcortical white matter hyper-intensities in bi-parietal supra-ventricular regions. (b) T2W Saggital: Subcortical white matter hyper intensities involving the body
of corpus callosum. (c) FLAIR Axial: Reconfi rming the involvement of sub-cortical white matter. (d) T1W Axial: Lack of enhancement of lesions


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A real-time qualitative PCR was done to detect the presence of JCV. High pure viral nucleic acid kit (Roche Diagnostics, Germany) was used for extraction. A 172-bp fragment of the small t-antigen of JCV was amplified with specific primers and detected with probes labelled with lightcycler® Red 690 (detected in channel 705). An additional PCR product of 658 bp formed the internal control DNA (IC). The IC was labelled with the dye LC 640. Detection was recorded in channel 640 with lightcycler® 2.0 instrument. The PCR was positive for JCV. A repeat PCR with fresh CSF sample was also positive for JCV.

The histopathological examination [Figure 2] revealed prominent pallor of the white matter. In these areas, there was admixture of large atypical hyperplastic reactive astrocytes and abnormal appearing oligodendrocytes. The features were consistent with PML.
Figure 2: Histopathological slide. The oligodendroglial cells exhibited marked nuclear swelling with homogenous dense chromatin (ground glass appearance) due to intra-nuclear viral inclusions (a nd b). Focally micro glial proliferation was evident (c). On special staining foci of de-myelination with relative preservation of axon was noted (d)

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The MRI images including the T2W sagittal, axial and coronal, FLAIR axial and post-contrast T1W axial were reviewed again keeping in mind the laboratory confirmation of PML. Classical subcortical white matter involvement was seen along with involvement of the body of corpus callosum suggestive of demyelination as typically seen in PML [Figure 1].

The patient was put on highly active anti-retroviral therapy (HAART), but the neurologic condition continued to deteriorate. Subsequently, the patient was discharged against medical advice as requested by the relatives.


 ~ Discussion Top


PML was first diagnosed by a German neuropathologist, Hallervorden, in 1930. It was described as a syndrome in 1958 by Astrom and Richardson and identified as a viral disease in 1965 by Zu-Rhein. The JCV was isolated in 1971 by Padgett and Walker, which is a DNA containing polyomavirus. [5] JCV is a ubiquitous human pathogen. Inhalation and ingestion of contaminated water have been suggested as major modes of transmission. It is harboured in kidneys and is shed in urine. [5] More than 80% of the human adults are seropositive for JCV-specific antibodies. [6]

Suppression of cellular immunity secondary to HIV is a major cause of JCV reactivation leading to PML. [7] In PML, the JCV targets the oligodendrocyte, the cell that forms and maintains the myelin sheath of the CNS. The neurological signs and symptoms of PML result from viral destruction of the myelin producing oligodendrocytes in the CNS. The main pathological features are due to alterations in oligodendroglia with intranuclear inclusions that contain JCV viral particles. [8] Motor weakness may not be present early, but eventually occurs in 75% of the cases. [9] Though PML progresses relentlessly, early diagnosis and confirmation has shown dramatic improvement following institution of HAART. [10]

HAART has also led to the emergence of an entity of leucoencephalopathy associated with immune reconstitution which often resembles PML neuroradiologically. [2],[3] Hence, laboratory confirmation of PML is mandatory. [3] Recently published diagnostic criteria classify PML as "definite PML" or "presumptive PML." [10] When the clinical and imaging findings are consistent with PML with evidence of JCV DNA in CSF or consistent histopathological changes, then the diagnosis of definite PML is considered and the same without laboratory confirmation is presumptive PML. [8],[10]

In our case study, the diagnosis of definite PML was made with laboratory confirmation of JCV both by PCR and histopathological examination. Brain biopsy is an invasive procedure and is not an option with debilitated or unwilling patients or with inaccessible lesions. Moreover, though the sensitivity and specificity of this procedure are 64-96% and 100% respectively, the estimated associated procedural complication rate is 2.9% with a morbidity of 8.4%. [10] Virological confirmation by JCV PCR is a better alternative for a definitive diagnosis. In patients not on HAART therapy, PCR for JCV DNA has a sensitivity of 92% and specificity of 92-100% in the diagnosis of PML. Thus, a high degree of clinical suspicion substantiated by imaging and rapid laboratory evidence by help of CSF PCR for JCV can ensure an early diagnosis and better management and outcome of such cases.

 
 ~ References Top

1.Koralnik IJ. Progressive multifocal leucoencephalopathy revisited: Has the disease outgrown its name? Ann Neurol 2006;60:162-73.  Back to cited text no. 1
    
2.Shankar SK, Satishchandra P, Mahadevan A, Yasha TC, Nagaraja D, Taly AB, et al. Low prevalence of progressive multifocal leukoencephalopathy in India and Africa: Is there a biological explanation? J Neurovirol 2003;9:59-67.  Back to cited text no. 2
    
3.Thurnher MM, Post MJ, Rieger A, Kleibl-Popov C, Loewe C, Schindler E. Initial and follow up MR imaging findings in AIDS-related PML treated with HAART. Am J Neuroradiol 2001;22:977-84.  Back to cited text no. 3
    
4.Giambenedetto D, Vago S, Pompucci G, Scoppetuolo G, Cingolani A, Marzocchetti A, et al. fatal inflammatory AIDS associated PML with high CD4 counts on HAART: A new clinical entity? J Neurol 2004;63:2452-3.  Back to cited text no. 4
    
5.Hurley RA, Ernest T, Khalil K, Valle LD, Simone IL, Taber KH. Identification of HIV associated progressive multifocal leucoencephalopathy. J Neuropsychiatry Clin Neurosci 2003;15:1-6.  Back to cited text no. 5
    
6.Gheuens S, Pierone G, Peeters P, Koralnik IJ. Progressive multi-focal leucoencephalopathy in individuals with minimal or occult immunosuppression. J Neurol Neurosurg Psychiatry 2010;81:247-54.  Back to cited text no. 6
    
7.Raina S, Kaushal SS, Gupta D, Himral P, Sawal N, Sood V, et al. Progressive Multifocal Leukoencephalopathy - As a Presenting Manifestation of AIDS. Neurol India 2010;58:118-21.  Back to cited text no. 7
    
8.Cinque P, Koralnik IJ, Gerevini S, Miro JM, Price RW. Progressive multifocal leucoencephalopathy in HIV-1 infection. Lancet Infect Dis 2009;9:625-36.  Back to cited text no. 8
    
9.Dworkin MS. A review of progressive multifocal leucoencephalopathy in persons with and without AIDS. Curr Clin Top Infect Dis 2002;22:181-95.  Back to cited text no. 9
    
10.Bag AK, Cure JK, Chapman PR, Roberson GH, Shah R. JC virus infection of brain. Am J Neuroradiol 2010;31:1564-76.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]

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