2262. Not a Disease of the Past: A Case Series of Progressive Multifocal Leukoencephalopathy in the Established Antiretroviral Era

BACKGROUND: Progressive multifocal leukoencephalopathy (PML) and PML immune reconstitution inflammatory syndrome (PML-IRIS) can be a devastating neurologic process associated with HIV, but limited knowledge on their characteristics in the established antiretroviral (ART) era is available. We conducted a case series to evaluate the clinical course of PML and PML-IRIS at our urban safety-net hospital in Atlanta, GA. METHODS: All HIV-positive individuals with a positive JCV DNA PCR in the spinal fluid between May 1, 2013 to June 1, 2017 were identified through electronic medical records (EMR) query. Demographics, symptom presentation, laboratory data, imaging results, treatment, and outcomes were abstracted from the EMR. PML, and PML-IRIS were defined using the American Association of Neurology criteria. RESULTS: There were 26 patients included in this study, 15 (58%) HIV-positive patients with PML and 11 (42%) with PML-IRIS (2 with an unmasking presentation and 9 with a paradoxical presentation). The average age was 45 years, 23 (88%) were black, and 20 (77%) were male. Mean CD4 and HIV viral load were 65 cells/µL and 4.11 log(10) copies/mL, respectively. The most common presenting symptoms were motor weakness (18, 69%), cognitive deficits (15, 58%), and dysarthria (11, 42%). Twenty-four (92%) patients had white matter changes on magnetic resonance imaging (MRI). Enhancement on MRI and presentation with ataxia, dysarthria, or motor or visual deficits were found to be associated with PML-IRIS. Eleven (42%) patients were on ART at the time of diagnosis, and 24 (92%) of patients were on ART afterward. Corticosteroids were used in 9 patients with PML-IRIS and in 3 with PML. Maraviroc was used in 3 patients with PML-IRIS. Presenting with speech deficits or visual changes, having edema on MRI, and developing PML-IRIS were each positively associated with progression to hospice or withdrawal of care, although these values were not statistically significant. Outcomes were dismal with 7/15 (46.7%) patients with PML and 9/11 (81.8%) with PML-IRIS dying or being referred to hospice. CONCLUSION: Despite widespread access to ART, patients with PML continue to have poor outcomes, particularly among those who develop PML-IRIS. More research is needed to understand the risks for and prevention of PML-IRIS. DISCLOSURES: V. Marconi, ViiV: Investigator, Research support and salary. Bayer: Investigator, Research support. Gilead: Investigator, Research support.