(Kiosk 7) A Case of Suspected Post-covid Progressive Multifocal Leukoencephalopathy (PML)

Case Diagnosis: A Case of Suspected Post-COVID Progressive Multifocal Leukoencephalopathy (PML)

Case Description or Program Description: A 74 year old female with a past history of recent COVID infection in January 2022, seizures who presented with acute on chronic left sided weakness and altered mental status. The weakness began a couple days after being diagnosed with a COVID infection and continued for 5 months. Her weakness waxes and wanes, but is more prominent when fatigued.

Setting: Tertiary Care Hospital

Assessment/Results: Patient underwent a comprehensive neurological workup over a 5 month period including a stroke workup and extensive neuroimaging. Pertinent negatives from workup John Cunningham Virus (JCV) negative, L-spine MRI showed central canal stenosis and no oligoclonal bands in CSF. Pertinent positives Brain MRI showed infiltrative T2 hyperintense white matter process in bilateral frontal lobes and body of corpus callosum and CSF showed elevated myelin basic protein.

Discussion (relevance): PML is a rare demyelinating disorder of the central nervous system that primarily affects the brain. This disease process has been typically recognized after treatment of an autoimmune condition with monoclonal antibodies. The diagnosis of PML is made based on the combination of subacute neurological changes, supportive MRI findings, and presence of JCV DNA in the CSF or brain tissue. Despite a negative history for immunosuppression and JCV not being detectable in the CSF the suspicion for PML was still raised. The presence and location of the brain lesions, clinically visible neurological changes and elevated markers of demyelination are all contributing factors. Additionally, failure to detect JCV in the CSF or brain tissue biopsy doesn’t necessarily rule out PML.

Conclusions: There is scant literature regarding the association of SARS-CoV-2 infection and PML, and existing case reports focus on patients with pre-existing Multiple Sclerosis managed with immunomodulatory therapies. It is possible that the immunological changes due to COVID-19 infection initiated an autoimmune cascade leading to PML.