Viral break through during dolutegravir-based antiretroviral therapy after excessive consumption of fruit juices

Abstract

infusion with new partial seizure activity, a dense rightsided spastic hemiplegia (power 0/5), complete aphasia, and inability to follow commands. The swallow also deteriorated, resulting in aspiration pneumonia, so a feeding tube was placed. MRI showed further progression with new lesional enhancement and increased midline shift. There was a mild elevation of CSF protein (0.62 g/l) and white cells (7 cells/ml).Although there was an ongoing decline following the first infusion, the trajectory of rapid deterioration slowed and a gradual improvement was observed following the second infusion of pembrolizumab. The patient began to speak again using short phrases, her right-sided weakness improved (power 2/5), and she regained her swallow sufficiently to allow a normal oral diet. The steroids were weaned then stopped. She continued to improve, and by the time of the fourth pembrolizumab infusion at 25 weeks, she was able to use a wheelchair, speak in short sentences, and use a low-tech communication board. This coincided with further radiological improvement. JCV DNA remained detectable at a low level in the CSF. Her CD4 þ cell count improved to 72 cells/ml (8%) after 1 year of ART.