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.