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Abstract: This case is a 56-year-old male patient with a history of chronic kidney disease, combined with diabetes mellitus, hypertension, and hyperlipidemia, etc. He underwent kidney transplantation 1 year ago. Recently, he came to the clinic with sudden onset of limb immobility and blurred consciousness. After admission, cerebrospinal fluid examination and blood sampling were further improved, and progressive multifocal leukoencephalopathy was considered. He was given medication and symptomatic supportive treatment, and the lesion was reduced and stabilized.
Basic information】Male, 56 years old
Disease Type】Progressive multifocal leukoencephalopathy
Hospital】Shandong Provincial Third Hospital
Date of consultation】March 2019
Treatment plan】Medication (recombinant human interferon α1b+ for injection and cytarabine for injection)
Treatment period】Inpatient treatment for 14 days, followed up by telephone after 1 month
Treatment effect] The disease was controlled, the lesions were reduced, and the disease was stable
I. Initial consultation
A patient with a long history of chronic kidney disease, combined with diabetes mellitus, hypertension and hyperlipidemia, etc. One year ago, the patient found a suitable kidney source and underwent kidney transplantation, and then took immunosuppressive drugs for a long time, and his condition was relatively stable. Recently, the patient was sent to the hospital by his family when he suddenly became unconscious and had difficulty moving his limbs. After examination, the patient was found to be in a blurred state of consciousness, and the occurrence of an acute cerebrovascular event was considered. An emergency cranial MRI was given, suggesting multiple abnormal signals in the bilateral cerebral hemispheres, suggesting white matter encephalopathy. The patient’s current condition was serious and might be on the verge of aggravation, so hospitalization was recommended. The family expressed understanding and actively cooperated with the hospitalization.
II. Treatment history
After admission to the hospital, no significant abnormalities were found in the blood tests; the cranial magnetic resonance examination suggested abnormal signal shadows in the bilateral cerebral hemispheres, with a tendency to worsen. Complete lumbar puncture of cerebrospinal fluid suggested positive viral infection and high intracerebral pressure. Neurological examination suggested that the patient was drowsy, with grade 2 muscle strength of the right limb and grade 4 muscle strength of the left limb. Combined with the previous history of renal transplantation and long-term immunosuppressive drugs, intermittent multifocal leukoencephalopathy was considered a high possibility, and there were difficulties with the current brain histopathological biopsy. The nephrology department was consulted and recommended to reduce the use of immunosuppressive drugs, and injectable recombinant human interferon α1b and injectable cytarabine could be given for experimental treatment. 7 days later, the cranial MRI was repeated again, and the abnormal intracranial type of lesion was reduced compared with the previous one.
III. Treatment effect
Progressive multifocal leukoencephalopathy is an intracerebral demyelinating disease due to viral infection, commonly seen in immunocompromised patients with progressive exacerbation, which can lead to severe neurological dysfunction or even death, and has a poor prognosis. After 14 days of treatment with recombinant human interferon α1b for injection and cytarabine for injection, the patient’s family requested to be discharged from the hospital after a review of cranial MRI and imaging showed that the intracerebral lesions were less severe than before and that the lesions did not expand further.
IV. Notes
This patient’s condition was initially controlled with relatively good results, and we are happy for the patient and family. If the patient’s hemiplegia, aphasia, and impaired consciousness continue to worsen after discharge from the hospital, he should be alert to the progression of the disease and seek timely medical follow-up; if there is no abnormal condition, he should also be reviewed within the prescribed time. In addition, daily attention should be paid to proper nutrition, eating foods that are easy to digest and absorb; avoid straining, and monitor blood pressure, body temperature and other vital signs. During immunosuppressive treatment, you should actively exercise to improve immunity, reduce the occurrence of infection and avoid the possibility of simultaneous combination of the disease. Family members should pay high attention to the family care work.
V. Personal insight
Progressive multifocal leukoencephalopathy is a rare clinical condition commonly seen in immunocompromised patients, such as AIDS patients, hematologic patients or organ transplant patients, with demyelinating changes in the brain due to viral infection. Progressive multifocal leukoencephalopathy is a rare and difficult disease that is difficult to treat and has a relatively poor prognosis. It needs to be differentiated from other diseases in the brain, such as cerebral infarction, cerebral hemorrhage, and encephalitis. Patients with immune deficiency and signs of neurological dysfunction should have cranial magnetic resonance examination completed and should be actively seen in the hospital once signs of neurological dysfunction appear to avoid delaying the disease. Usually, as in the case of this patient, after treatment, the initial control can be obtained, but it is recommended that after treatment to ensure good sleep patterns, diet, and active exercise to avoid colds, diarrhea and other infectious diseases, aggravating or causing a relapse of the disease.