Table 1 Disease course from onset to the final outcome
Hospital course | Event | Clinical features | Disease evolution on MRI brain | Treatment | Outcomes |
|---|---|---|---|---|---|
Day 1 | Visual disturbance, leg weakness, pain, and unsteadiness | • Right-sided hip weakness • Ataxia • Diplopia and nystagmus | PMLx related changes in cerebellum | Methyl prednisolone 5 days, cidofovir, mirtazapine, probenecid | deterioration |
Day 16 | Headaches, worsening blurry vision, and diplopia | • Symptoms improved next 2 days • Mobility slightly improved | PML-related changes slightly more extensive | No changes made | Stable |
Day 48 | Prolonged generalized tonic-clonic seizure which lasted almost 50-min | • Decreased consciousness and right-sided Todd’s paresis. • Mechanical ventilation, ICU admission | Progression of PML | Loaded with phenobarbitone, methyl prednisolone 5 days, and oral taper over next 2 weeks | Deterioration |
Day 86 | Worsened swallow, weak cough reflex, and difficulty clearing secretions, requiring suctioning | • Significant dysarthria • Right hand weakness and impaired coordination • Gradually worsening swallow and gait, now using wheelchair • Bladder dysfunction | Progression of PML changes and features suggestive of worsening PML- and onset of IRISxx | Started on 5/7 course of IV immunoglobulins, antibiotics for recurrent aspirations, PEG tube inserted for feeding | Deterioration |
Day 125 | Seizure, eye flickering, and unresponsiveness, self-aborted less than a minute | • Nausea and vomiting • Dysarthria started improving • Truncal ataxia, completely wheel chair bound | Significant progression of PML and IRIS | IV methyl prednisolone 1 g for 5 days given followed by oral prednisolone taper over 2 weeks | Improvement |
Day 158 | Continued to improve mobility, still limited to wheelchair but sitting balance significantly improved | • Speech became clearer • Truncal ataxia improved • Swallowing improved | MRI not done | Transferred for long-term rehabilitation, stable at this point | Improvement |