Mirtazapine and mefloquine therapy for progressive multifocal leukoencephalopathy in a patient infected with human immunodeficiency virus

Purpose. A case of progressive multifocal leukoencephalopathy (PML) in a patient infected with human immunodeficiency virus (HIV) treated with mirtazapine and mefloquine is reported. Summary. A 49-year-old African-American man who was recently diagnosed with HIV infection was admitted to the hospital for progressive ataxia, dysarthria, and unsteady gait. Upon initial examination, the patient was fully oriented but appeared drowsy and uncooperative and was observed to be unsteady on his feet. Magnetic resonance imaging of the patient's brain revealed marked cerebellar and mild cerebral atrophy and moderate, nonspecific white matter disease. The results of a lumbar puncture revealed the presence of JC virus, and PML was diagnosed. As the patient's cognitive function began to worsen, mirtazapine and mefloquine were initiated. Treatment with mirtazapine 30 mg orally daily and mefloquine hydrochloride 250 mg orally for three days, then 250 mg weekly, was initiated. The dosing regimen was derived from a study currently underway at Washington University in St. Louis, Missouri. The patient also had pneumonia and, on day 7 of hospitalization, required intubation. The patient was extubated on day 11 and showed significant cognitive improvement; he was able to communicate his wish to enact a Do Not Intubate order. At this time, the patient began refusing all medications and ultimately died on hospital day 16 due to respiratory failure. Conclusion. A patient with HIV infection and PML was treated with mirtazapine and mefloquine. He tolerated the drugs well and exhibited functional and cognitive improvement, but the specific effects of mirtazapine and mefloquine were difficult to discern.