# Progressive Multifocal Leukoencephalopathy as the Initial Presentation of Undiagnosed HIV Infection: A Case Report

## TL;DR

A case report describes a patient with undiagnosed HIV who developed PML, highlighting the challenges of diagnosing these conditions in resource-limited settings.

## Contribution

This case report adds to the understanding of PML as an initial HIV presentation and emphasizes diagnostic challenges in low-resource settings.

## Key findings

- PML was diagnosed in a patient with newly identified HIV, showing the importance of considering PML in differential diagnoses.
- The patient's poor outcome highlights the limitations of delayed diagnosis and resource constraints in managing PML and HIV.
- Early ART initiation is critical but may not improve outcomes in severe immunosuppression cases.

## Abstract

Progressive multifocal leukoencephalopathy (PML) is a rare and often fatal complication associated with advanced HIV infection, caused by the reactivation of the John Cunningham (JC) virus in immunocompromised individuals. Diagnosis is challenging due to nonspecific symptoms and the need for specialized diagnostic tools, which may not be readily available in resource-limited settings. Early initiation of antiretroviral therapy (ART) is critical for managing the condition, though prognosis remains poor in advanced cases.

We present the case of a 30-year-old male with newly diagnosed HIV who presented with a two-week history of fever, headache, hiccups, and unconsciousness. Initially suspected to have encephalitis, the patient was empirically treated with ceftriaxone, acyclovir, and later vancomycin. HIV testing, performed with an independent kit, confirmed a positive diagnosis, and ART was started. A CSF analysis revealed findings suggestive of tuberculous meningitis, and treatment for tuberculosis was initiated. However, subsequent re-evaluation of MRI images raised suspicion of PML, which was confirmed radiologically. Due to resource constraints, JC virus polymerase chain reaction testing was not conducted, and further diagnostic tests were unavailable. The patient’s condition continued to deteriorate despite supportive care, and he succumbed to complications of immunosuppression on the 13th day of admission.

This case highlights the diagnostic challenges of PML in patients with HIV, especially in settings with limited resources. The patient's initial presentation with nonspecific neurological symptoms and delayed diagnosis of HIV and PML contributed to poor outcomes. Early ART initiation remains essential, though its efficacy may be limited in cases of severe immunosuppression.

PML should be considered in the differential diagnosis of neurological symptoms in patients with newly diagnosed or advanced HIV. Early ART initiation is crucial, though the prognosis remains poor in severe cases. This case emphasizes the importance of comprehensive neurological assessment and vigilance in individuals with HIV presenting with new-onset neurological symptoms.