PATIENT 2
A 9-year-old male with KMT2A-rearranged relapsed refractory acute myeloid leukemia developed respiratory syncytial virus (RSV) infection and was admitted for neutropenic fever.
Shortly after admission he developed altered mental status, including periods of agitation and confusion alternating with being overly sedated. Head CT showed cerebral volume loss. EEG showed diffuse slowing consistent with encephalopathy. CSF evaluation showed negative bacterial and fungal cultures. PCR panel was negative for micro-organisms, and cytology showed no leukemia involvement (Supplemental Table 1). He was treated with broad spectrum antibiotics for neutropenic fever, acyclovir for presumed herpes simplex virus encephalitis and PO ribavirin for RSV infection. He received IVIG (1g/kg/dose x 2 days) for presumed autoimmune encephalitis with no benefit. CSF m-NGS was positive for HAstV-VA1.
Because of his incurable leukemia, he remained inpatient for palliative care. Treatment for astrovirus infection was aligned with his goals of care with IVIG (1 g/kg/dose thrice weekly for one week then weekly thereafter) and oral nitazoxanide (250 mg orally twice daily). He had progressive neurologic deterioration, developed renal and respiratory failure and died 7 weeks after diagnosis. Family refused autopsy.