"Lack of knowledge is no excuse" HIV positive patient with progressive multifocal leukoencephalopathy. Case report from Kenya.

Progressive multifocal leukoencephalopathy (PML) is a severe demyelinating disease that affects the central nervous system, which has high morbidity and mortality and no effective, targeted therapies are available. According to the data from developing countries, it affects about 3 to 5% patients who are HIV positive. We present a case of a 27-year-old patient, who got infected with the HIV virus from his mother. The patient had poor compliance to the therapy since its initiation. Due to poor compliance and immunological and virological failure of the first line ARVs, the patient developed PML. Despite confirmed diagnosis of PML and change of the regimen to the second line ARVs, due to progression of the condition, he sought care of an unknown physician, who prescribed therapy with azathioprine 150 mg twice daily, which the patient used for more than 2 weeks. Despite immediate virological suppression, the condition significantly worsened, until the patient developed paraparesis, postural tremor, head tremor, severe dysarthria; he was not able to walk, eat or express himself. The major roadblocks to diagnosis of PML include poor access to health care in general, as well as poor knowledge of the rare condition among the health care professionals. Therapy with azathioprine has been proved to be associated with the development of PML. Thus, in resource limited settings, there is an urgent need for improved access to health care and imaging and laboratory diagnostic means, which would decrease the economic and social burden of severe conditions, such as PML.