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Is progressive multifocal leukoencephalopathy a chronic disease because of defective interfering particles or temperature-sensitive mutants of JC virus?

JC virus was examined for temperature sensitivity and for evidence of defective interfering particles as a means of explaining the slow chronic nature of progressive multifocal leukoencephalopathy (PML). JC virus direct from the brain tissue of seven persons with PML was not temperature sensitive as indicated by in vitro assay at 37 and 39 degrees C. In fact, more cells contained viral antigen at 39 than at 37 degrees C. The amount of infectious virus also was increased at 39 degrees C. Virions isolated directly from diseased brain tissue had a higher buoyant density than did virus from the same PML patient passaged in culture and containing genomic deletions. In contrast to DNA from culture-passed virus, DNA extracted from virions direct from brain tissue was homogeneous in length. In 13 separate cases examined, the viral DNA direct from the brain was homogeneous although variations in length were noted among DNAs from different cases. Restriction enzyme cleavage patterns identified all as JC virus DNA. It was concluded that neither temperature sensitivity nor DI particles can be used to explain the slow, progressive nature of PML.

Adult↗

Detection of JC virus by anti-VP1 immunohistochemistry in brains with progressive multifocal leukoencephalopathy.

We have assessed the diagnostic efficacy of a novel polyclonal rabbit antiserum directed to the recombinant major capsid protein VP1 of JC virus (JCV). Immunohistochemistry for VP1 was compared to non-radioactive JCV DNA in situ hybridization (ISH) in ten cases of progressive multifocal leukoencephalopathy (PML). Tissue sections from postmortem brains were studied from PML patients suffering from immunodeficient conditions of various causes: immunodeficiency syndrome (AIDS, n = 7), severe combined immune deficiency due to adenosine deaminase deficiency (n = 1), sarcoidosis (n = 1) and leukemia (n = 1). VP1 immunohistochemistry demonstrated the presence of JCV in lesional oligodendrocytes of all PML patients, whereas ISH was able to detect JCV in nine out of ten cases. We conclude that VP1 immunohistochemistry is a specific, sensitive and rapid method for confirming the diagnosis of PML.

Adult↗

Progressive multifocal leukoencephalopathy in an adult patient with ICF syndrome.

We report on a patient affected by ICF syndrome (immunodeficiency, centromeric instability of chromosomes 1, 9 and 16 and facial dysmorphism), who presented with slowing in mentation, mild right hemiparesis and focal motor seizures. MRI study of the brain suggested a diagnosis of progressive multifocal leukoencephalopathy (PML), which was confirmed by JC virus DNA detection on CSF by polymerase chain reaction (PCR). This is a unique case of adult infective neurological complication described in ICF Syndrome.

Acquired Immunodeficiency Syndrome↗

Progressive multifocal leukoencephalopathy after initiation of highly active antiretroviral therapy in a child with advanced human immunodeficiency virus infection: a case of immune reconstitution inflammatory syndrome.

Five weeks after commencing highly active antiretroviral therapy, a 12-year-old boy with advanced human immunodeficiency virus infection presented with acute cerebellar dysfunction and hemiparesis. Progressive multifocal leukoencephalopathy was diagnosed by cerebrospinal fluid polymerase chain reaction for JC virus and magnetic resonance imaging of the brain. Rapid and sustained improvement followed a prolonged course of glucocorticosteroid therapy while continuing antiretrovirals.

Antiretroviral Therapy, Highly Active↗

Diagnosis of progressive multifocal leukoencephalopathy by brain biopsy with biotin labeled DNA:DNA in situ hybridization.

DNA:DNA in situ hybridization using a cloned JC virus (JCV) DNA probe labeled with biotin confirmed the presence of JCV DNA in formalin-fixed, paraffin-embedded brain biopsies from four cases of progressive multifocal leukoencephalopathy (PML). Only small pieces of tissue were available in each case. Detection of the JC DNA:DNA hybrids was carried out by affinity cytochemistry. JCV DNA was identified predominantly in the nuclei of interfascicular oligodendrocytes in demyelinated areas of the biopsies. JC virus was isolated from one case, and the diagnosis of PML was substantiated in all cases by electron microscopic identification or immunocytochemical labeling of JC viral antigen. In situ hybridization using a biotin labeled JCV DNA probe is a specific, sensitive and convenient method for confirming the diagnosis of PML in suspected cases evaluated by brain biopsy.

Adult↗

Progressive multifocal leukoencephalopathy with detection of JC virus in a patient with chronic lymphocytic leukemia parallel to onset of fludarabine therapy.

Along with the establishment of more intense chemotherapeutic regimens including fludarabine for the treatment of indolent lymphoproliferative diseases like chronic lymphocytic leukemia (CLL), an increasing amount of cases with progressive multifocal leukoencephalopathy (PML) due to JC virus have been observed. We report a patient with CLL who developed PML parallel to the onset of fludarabine therapy. Spinal fluid was tested positive for JC virus. Despite virostatic treatment with cidofovir, neurologic symptoms were progressive and the disease ultimately fatal. The present case suggests that immunosuppression caused by chronic lymphoproliferative malignancies alone may be a factor in the development of PML. Chemotherapy with fludarabine may act as an additional trigger. The question remains whether serologic screening for JC virus in patients with chronic lymphoproliferative disease undergoing intense chemotherapy might be valuable once sufficient antiviral treatment has been established.

Antineoplastic Agents↗

Progressive multifocal leukoencephalopathy in a patient with Hodgkin's disease.

This is a report on a 78-year-old patient with Hodgkin's disease of mixed cell type in stage III B, who, because of his age, underwent only mild cytostatic therapy. Two months after beginning of treatment, cerebellar neurological symptoms developed. He died of bronchopneumonia 3 months later. At autopsy progressive multifocal leukoencephalopathy with multiple demyelinated areas in the cerebellum was established. Paracristallinic structures within nuclei of glial cells resembling papovavirus formations were detected by electron microscopy.

Aged↗

Progressive multifocal leukoencephalopathy demonstrating contrast enhancement on MRI and uptake of thallium-201: a case report.

We describe a patient with AIDS who presented with focal neurological symptoms, and who had contrast-enhancing brain lesions on MRI which demonstrated increased thallium-201 uptake on SPECT. These findings were consistent with lymphoma; however, brain biopsy established a diagnosis of progressive multifocal leukoencephalopathy (PML). To our knowledge, this is the first reported case of PML with increased thallium-201 uptake on brain SPECT.

AIDS-Related Opportunistic Infections↗

Low prevalence of progressive multifocal leukoencephalopathy in India and Africa: is there a biological explanation?

Infection with human immunodeficiency virus (HIV) clade C virus is the most common form of HIV infection in the world. It largely infects populations in Africa and Asia and not much is known about the neurological complications associated with the virus. Cases of progressive multifocal leukoencephalopathy (PML) have been rarely reported in the literature in the acquired immunodeficiency syndrome (AIDS) or non-AIDS populations from these regions. In this article, the authors present three recently diagnosed patients with AIDS and PML from one neurological center in India, review the diagnostic challenges faced, and speculate on the possible biological reasons, including viral strain differences as well as HIV and JC virus interactions, that may account for the low incidence.

Acquired Immunodeficiency Syndrome↗

[Pure alexia secondary to progressive multifocal leukoencephalopathy as first manifestation of HIV infection].

INTRODUCTION: Pure alexia, or alexia without agraphia, is usually caused by disconnection between the gyrus angularis and visual areas of both hemispheres. Cerebrovascular disease is the most frequent cause of this syndrome. CLINICAL CASE: We report the first case of a patient with pure alexia secondary to progressive multifocal leukoencephalopathy (PML) as the first manifestation of Human Immunodeficiency Virus (HIV) infection. Polymerase chain reaction in cerebrospinal fluid was positive for JC virus. Despite favorable immunological and virological response to highly active antiretroviral therapy, neurological symptoms and demyelinating lesions progressed during the first months, and right homonyous hemianopsia, acalculia, and color anomia were noted. In magnetic resonance imaging (MRI) demyelinating lesions involved white matter of both occipital lobes, with left predominance, forceps major and splenium of the corpus callosum, together with white matter of the left temporal lobe and both hippocampal regions. During the following months, coinciding cidofovir treatment, the patient had partial clinical improvement, but neurological deficits persisted. The size of MRI lesions significantly improved. CONCLUSIONS: PML is frequently the first manifestation of AIDS (acquired immunodeficiency syndrome). It should be considered as a possible diagnosis of pure alexia.

Alexia, Pure↗

Complete genome of a JC virus genotype type 6 from the brain of an African American with progressive multifocal leukoencephalopathy.

OBJECTIVES: The major genotypes of the human polyomavirus JC (JCV) include type 1 (European), type 2 (Asian), type 3 (African), and type 4 (United States). Here we report characterization of the complete genome of a genotype obtained from the brain of an African American with systemic lupus erythematosus (SLE) and progressive multifocal leukoencephalopathy (PML). STUDY DESIGN/METHODS: DNA extracted from JCV-infected brain tissue was subjected to whole-genome polymerase chain reaction (PCR) amplification and direct cycle sequencing. Relations to other JCV genotypes and the predicted amino acid sequence were analyzed. RESULTS: This African-American type 6 strain (#601) differs from strains of all other genotypes in about 2% of its DNA sequence. The length of the total coding region of strain #601 is increased to 4855 bp by the insertion of a single nucleotide in the large T-antigen intron. This strain, originally placed with the type 2 group on the basis of its sequence in the VT-intergenic region, is very closely related to strains recently identified in the urine of individuals from Ghana, West Africa. CONCLUSIONS: This is the first example of an African JCV genotype identified in the brain of an African-American PML patient. The extent of sequence divergence of JCV type 6 suggests a split of type 6 strains before the separation of types 2 and 3. These findings confirm that distinctive African genotypes of JCV have been maintained in the African-American population and that they are capable of causing PML.

Adult↗

Progressive multifocal leukoencephalopathy: investigation of three cases using in situ hybridization with JC virus biotinylated DNA probe.

Using the technique of in situ DNA-to-DNA hybridization, a JC virus biotinylated DNA probe was developed and applied to formalin-fixed, paraffin-embedded, or fixed, frozen sections of brain tissue from three subjects with progressive multifocal leukoencephalopathy (PML). Light microscopy was carried out to correlate the presence of JC virus DNA with the selective infection of oligodendrocytes and astrocytes in PML. Oligodendrocytes (lytically infected) showed the greatest evidence of viral DNA. More astrocytes showing bizarre morphological changes had evidence of viral DNA than did astrocytes that were simply reactive. Viral DNA was not evident in vascular endothelial cells using this technique. Viral DNA replication may be an important initial step which produces the bizarre "transformed" astrocytes of PML. Findings in this study do not support the hypothesis that vascular endothelial replication is important in the pathogenesis of JC virus-induced PML. In situ hybridization with biotinylated JC virus probe may be useful in the diagnosis of PML on brain biopsy specimens.

Adult↗

[Progressive multifocal leukoencephalopathy mimicking multiple sclerosis as the sole clinical manifestation of acquired immunodeficiency syndrome].

A 38 year-old wife, of belgian origin and residency, suffered from a left retrobulbar optic neuritis in 1973, with as only sequel dyschromatopsia and central scotoma enlargement. In 1985, 12 years later, she complained of a progressive weakness of the right hand, and developed a spastic tetraplegia within four months. The C.T. Scan showed white matter hypodensities, without mass effect or contrast enhancement, first limited to the left centrum semiovale and later on with multifocal character. Somatosensory evoked potentials after stimulation of the right median nerve demonstrated only lemniscus medialis response. Multiple sclerosis was initially suspected. Analysis of lymphocytes subsets however showed a markedly reduced helper population with as a result a very low H/S ratio, and the serology was found positive for HTLV-III-LAV, thus demonstrating the diagnosis of acquired immune deficiency syndrome (AIDS). Visceral autopsy demonstrated only a CMV pneumonia. Autopsy of the brain showed typical lesions of progressive multifocal leukoencephalopathy (PML). This case is compared with 20 previously published observations of PML associated with AIDS and appears rather unusual due to the association of unfrequent clinical peculiarities: previous, probably coincidental, retrobulbar optic neuritis, female patient, lack of risk factor and clinical symptoms of AIDS. The diagnostic difficulties in the present case are emphasized.

Acquired Immunodeficiency Syndrome↗

Segmentation of progressive multifocal leukoencephalopathy lesions in fluid-attenuated inversion recovery magnetic resonance imaging.

BACKGROUND AND PURPOSE: The authors compared the reproducibility of a manual and a semiautomated technique for the quantitation of white-matter lesions in magnetic resonance imaging (MRI). METHODS: Volumes of white-matter lesions were determined using fluid-attenuated inversion recovery MRI in 23 AIDS patients with progressive multifocal leukoencephalopathy. Manual outlining was compared to an automated method based on region growing and adaptive thresholding. RESULTS: Lesion volumes from the 2 methods correlated well (61 lesions, r = 0.99, P < 10(-4)), although the volumes differed substantially (12.8% +/- 13.7%). Interscan, intrasubject reproducibility was better for the automated than the manual method (2.9% +/- 3.2% vs 12.4% +/- 16.2% volume difference, P = .02). CONCLUSION: The automated algorithm appeared more reproducible, which renders it superior to the manual method for longitudinal studies.

AIDS-Related Opportunistic Infections↗

Overexpression of Ki-67 and cyclins A and B1 in JC virus-infected cells of progressive multifocal leukoencephalopathy.

Both SV40 and JC virus (JCV) appropriate the host cell replicative machinery to attend to their own reproductive needs. SV40 large T antigen is able to induce the expression of cyclins A, B1, and E (but not of cylin D1) in transfected diploid cells. Whether JCV infection influences cyclin expression in a similar fashion in the setting of progressive multifocal leukoencephalopathy (PML) remains unknown. Brain lesions from 7 PML cases (4 autopsies and 3 biopsies) were immunohistochemically investigated for the expression of Ki-67 and cyclins A, B1, and D1. All 7 cases showed strong positivity for Ki-67 and cyclins A and B1 in JCV-infected oligodendrocytes and astrocytes, the nuclear immunolocalization of cyclin A being in strong contrast to the cytoplasmic distribution of cyclin B1. No immunostaining for cyclin D1 was obtained in any of the 7 cases. These findings suggest that JCV infection is associated with overexpression of Ki-67 and cyclins A and B1 in PML host glial cells. Since cyclin changes in JCV-infected cells recapitulate SV40 T antigen-associated cyclin fluctuations, it appears reasonable to think that JCV T antigen shares some of the previously described capabilities of SV40 T antigen to alter cyclin expression for the sake of viral replication.

Acquired Immunodeficiency Syndrome↗

The association of progressive multifocal leukoencephalopathy and sarcoidosis.

A 59-year-old woman had a right homonymous hemianopsia, memory impairment for five months, a nonenhancing area in the left parieto-occipital region on CT scan, and bilateral reticulonodular infiltrates on chest x-ray film. Lung biopsy findings were consistent with sarcoidosis, a clinical diagnosis of CNS sarcoidosis made, and prednisone therapy begun. She deteriorated neurologically and died. At autopsy characteristic histologic and electron microscopic features of progressive multifocal leukoencephalopathy (PML) were found. We conclude that this and other cases demonstrate an association of PML and sarcoidosis and that steroid treatment is not a precondition. We also suggest an aggressive diagnostic approach in evaluating sarcoidosis with atypical neurologic deficits.

Central Nervous System Diseases↗

Progressive multifocal leukoencephalopathy and oligodendroglioma in a monkey co-infected by simian immunodeficiency virus and simian virus 40.

A rhesus monkey experimentally inoculated with simian immunodeficiency virus (SIV) mac251 was killed 42 months later because of poor general condition. CD4 lymphocyte count which was 3,430/mm3 before inoculation, had decreased to 638/mm3 2 months before death. Neuropathological examination revealed changes characteristic of progressive multifocal leukoencephalopathy (PML) in the white matter of the cerebral hemispheres and brain stem. In situ hybridization was negative for JC virus but markedly positive for simian virus 40 (SV40) in the nuclei of many oligodendrocytes. Many oligodendrocytes also expressed p53. Within an area involved by PML, there was a densely cellular tumor with honeycomb appearance and elongated vessels characteristic of oligodendrogliomas. Within the tumor in situ hybridization for SV40 and immunocytochemistry for p53 were negative. Opportunistic infection by SV40 has been occasionally reported in experimentally SIV-infected monkeys resulting in PML or malignant astrocytoma. Association of JC virus-induced PML and astrocytomas has been reported in three human cases without AIDS. In those cases, as in our monkey, polyomaviruses (SV40 or JC virus) were expressed in the areas with PML but not in the glial tumor. Association of PML and oligodendroglioma has not been reported previously to our knowledge. The relationship between oligodendrocyte proliferation and polyomavirus infection of oligodendrocytes is unclear. Our findings suggest that binding of the viral protein to p53 may result in inactivation of the pro-apoptotic protein favoring the proliferation of a randomly occurring tumoral clone of oligodendrocytes.

Animals↗

Progressive multifocal leukoencephalopathy mimicking cerebral vasculitis in systemic granulomatosis.

We describe the case of a 69-year-old man with systemic granulomatosis who presented with left-sided hemiplegia. Initial diagnosis concerning the neurological troubles was cerebral vasculitis. Corticosteroids associated with antituberculosis therapy showed a rapid but transient amelioration followed by neurological aggravation. Two weeks later, JC virus was detected in cerebrospinal fluid by PCR and the diagnosis of progressive multifocal leukoencephalopathy (PML) was made. Treatment with cytarabine and cidofovir was initiated but the patient died three months after the first neurological signs. In the presence of central neurological symptoms occurring during systemic granulomatosis before specific therapy, PML should be evoked.

Adrenal Cortex Hormones↗