(Kiosk 3) Acute Rehabilitation for Immune Reconstitution Inflammatory Syndrome: A Case Report

Case Diagnosis: A man in his 30’s with recent human immunodeficiency virus (HIV) diagnosis and progressive multifocal leukoencephalopathy (PML) with immune reconstitution inflammatory syndrome (IRIS).

Case Description or Program Description: A man in his 30’s was diagnosed with HIV (CD4 < 50, viral load ~4 million) and PML after presenting with mild subacute expressive aphasia. MRI showed hyperintensities through the bilateral cerebral and cerebellar hemispheres. He started ART treatment with bictegravir, emtricitabine, and tenofovir. After 5 weeks, he presented with 2 days of worsening expressive aphasia, left sided apraxia, neglect, Babinski’s reflex, bilateral Hoffman’s reflex, and cognitive slowing. His CD4 counts had tripled and viral load decreased (~200). Repeat MRI showed new areas of enhancement throughout cerebral and cerebellar hemispheres, primarily in the right parietal and cerebellar areas. He was diagnosed with PML-IRIS with worsening of PML inflammation after initiation of ART. He started a prednisone taper, inpatient PT, OT, and SLP, with minimal improvement in speech and gait. To assist recovery, the patient was sent to acute rehabilitation. At 2 weeks into corticosteroid therapy and 1 week into rehabilitation, the patient was slowly improving.

Setting: Acute Rehabilitation at University Hospital

Assessment/Results: After 14 days in acute rehab, the patient’s functional mobility improved, and his speech, while still slow and halting, had improved. He was more easily able to overcome neglect. Babinski's reflex improved to negative bilaterally.

Discussion (relevance): This is the first reported case, to our knowledge, of acute inpatient rehabilitation for a case of HIV ART associated PML-IRIS. Clinical management of ART induced PML-IRIS initiation is often tapered corticosteroids, but prognosis is uncertain. This case is notable in that it provides an adjunctive therapy plan with medical management for PML-IRIS.

Conclusions: In conjunction with medical management with steroid taper, acute rehabilitation can be considered for PML-IRIS recovery.