Figure 3. PML-IRIS in an HIV+ patient.

A 40 yo man with HIV infection, who presented with progressive onset of word finding difficulties and right hemiparesis followed by seizure, 4 days after starting cART. PCR was positive for JCV in the CSF peripheral CD4 count was 468 cells/ul. MRI performed at another hospital reported a 3 cm focus of abnormal increased signal on FLAIR sequences in the left frontal subcortical white matter, surrounded by linear and punctate foci of enhancement at the margins of the lesion. This lesion extended into the left corona radiata, the corpus callosum and the right frontal white matter. MRI performed at our hospital 3 week after the initial one showed lesions in FLAIR (A, arrows) and contrast enhancement in T1-weighted image post gadolinium injection (B, arrowheads). His aphasia improved progressively with addition of ritonavir to his cART regimen. His CD4 count increased to 558 cells/ul and his HIV plasma viral load was undetectable. He then presented with worsening aphasia. MRI performed 2 and a half month after onset of initial symptoms showed enlargement of the lesions in the left hemispheric white matter and the corpus callosum in FLAIR (C, arrows) which displayed intense contrast enhancement in T1-weighted images (D, arrowheads) as well as mass effect, right to left shift and subfalcine herniation. He was treated with dexamethasone 6 mg three times a day, tapered over 2 weeks, and cART was discontinued for two weeks. All neurological symptoms progressively improved and 2 and a half year later, he has no residual weakness and only minor word finding difficulties. MRI showed leukomalacia and atrophy of the left frontal lobe with dilatation of the left lateral ventricule in FLAIR (E, arrows) and absence of contrast enhancement in T1-weighted image (F, arrowheads). His CD4 count was 669/ul and HIV plasma viral load continue to be undetectable.