Simultaneous Development of Progressive Multifocal Leukoencephalopathy and Cryptococcal Meningitis during Methotrexate and Infliximab Treatment

Abstract

Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system caused by reactivation of the JC virus under an immunosuppressed state. This condition carries a high risk of cryptococcal meningitis. We herein report a 65-year-old woman who simultaneously developed PML and cryptococcal meningitis and presented with bilateral sixth nerve palsy. She had been treated with methotrexate and infliximab for rheumatoid arthritis. Her symptoms improved with antifungal drug treatment and discontinuation of immunosuppression therapy. Although concurrent PML and cryptococcal meningitis is rare, it should be considered in immunosuppressed patients.

Keywords: JC virus; cryptococcal meningitis; infliximab; methotrexate; progressive multifocal leukoencephalopathy.

Figure 1.

Changes in brain magnetic resonance imaging (MRI) over time. Fluid-attenuated inversion recovery (FLAIR) scans at first admission (A) and two months (B), three months (C), and six months (D) after the first admission. (A) shows nonspecific changes. (B) shows focal lesions in the white matter of the bilateral frontal and temporal lobes. (C) shows that the lesions in the white matter on FLAIR grew. (D) shows that the lesions gradually disappeared, and no new lesions developed.

Figure 2.

Summary of the clinical course. Methotrexate and infliximab were discontinued, and antifungal therapy was initiated at readmission. The patient symptoms improved over 10 weeks, and there was no recurrence >24 weeks after the first admission.