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Progressive multifocal leukoencephalopathy 10 years following transplant: 5HT receptor antagonism as an adjunct to immune reconstitution
  1. Shaun Chandler1 and
  2. Nicole Isbel2,3
  1. 1Metro North Kidney Health Service, Queensland Health, Brisbane, Queensland, Australia
  2. 2Metro South Integrated Nephrology and Transplant Services, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
  3. 3The University of Queensland Faculty of Medicine, Herston, Queensland, Australia
  1. Correspondence to Dr Shaun Chandler; shaun.chandler{at}


We report a case of a patient presenting with subacute neurological symptoms 10 years postkidney transplant. Cognitive deficits included acalculia and left upper limb dysesthesia, progressing to hemiplegic upper motor neuron weakness. Investigations included an MRI with multiple FLAIR hyperintensities, while a lumbar puncture was sterile with negative flow cytometry. Ultimately, PCR testing for John Cunningham virus was positive on cerebrospinal fluid. The diagnosis of progressive multifocal leukoencephalopathy (PML) was confirmed on the basis of the above.

Initially, the patient was managed with withdrawal of immunosuppressants and close observation. Mirtazapine was commenced based on case reports of successful use in non-transplant patients; the patient’s recovery was temporally related to withdrawal of immunosuppression and increasing mirtazapine dosage. The patient is currently maintained on prednisolone and mirtazapine with stable graft function and improved mobility and cognitive function.

  • Renal transplantation
  • Infection (neurology)

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  • Contributors SC and NI contributed equally to the concept and design of the work. All authors contributed to the draft and revisions of the manuscript as well as reviewing for important intellectual content.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.