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PML Prognosis CD4 Recovery — SCE Infectious Diseases MCQ

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ModerateCNS InfectionPML Prognosis CD4 RecoverySCE Infectious Diseases

A 40-year-old man with HIV (CD4 30) develops progressive multifocal leukoencephalopathy. CSF JC virus PCR is positive. MRI shows extensive bilateral white matter disease. He is started on ART urgently. What is the single most important prognostic factor?

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Correct answer: B — CD4 count recovery on ART — patients who achieve CD4 >100 cells/µL have significantly better survival than those who do not achieve immune reconstitution

PML prognosis in HIV depends primarily on the ability to achieve immune reconstitution with ART. Patients who achieve CD4 >100 cells/µL have 1-year survival >50%, compared to <10% in those who fail to reconstitute. There is no direct anti-JC virus therapy — immune reconstitution is the only treatment. Paradoxically, rapid immune reconstitution can trigger PML-IRIS (inflammatory worsening in ~20%), which requires corticosteroids. The balance between achieving rapid immune recovery (good for PML) and triggering IRIS (potentially harmful) is a key management challenge.

Reference: BHIVA 2022 – OI guidelines; Lancet Neurol 2020 – PML prognosis