PMC6027819_01
The clinical course and treatments.. Abbreviations: mPSL, methylprednisolone; PSL, prednisolone; CsA, cyclosporine-A; IVCY, intravenous cyclophosphamide; RTX, rituximab; MMF, mycophenolate mofetil; HLH, hemophagocytic lymphohistiocytosis; IL-6, interleukin-6; CSF, cerebrospinal fluid.
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The final administration of RTX was 5 months before PML onset (Figure 1).
Changes in brain magnetic resonance imaging (FLAIR images).. Notes: (A) At the time of the PML onset. (B) A month and half after PML onset before starting treatment by mefloquine and mirtazapine. (C) Two months after the start of treatment by mefloquine and mirtazapine. (D) Eight months after the onset of PML and 6 months after the start of treatment by mefloquine and mirtazapine.. Abbreviations: FLAIR, fluid-attenuated inversion recovery; PML, progressive multifocal leukoencephalopathy.
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Brain magnetic resonance imaging (MRI) showed an abnormal focal lesion in the white matter of the temporal lobe (left lobe dominant) (Figure 2A). White matter lesions gradually extended (Figure 2B). Two months after starting mefloquine and mirtazapine administration, white matter lesions further extended (Figure 2C). Although MRI findings revealed improvement of white matter lesions in the brain and the load of JC virus DNA in the CSF was drastically decreased (7,492 copies/muL), extensive atrophy of the brain parenchyma was observed (Figure 2D).