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. 2021 May 18;14:17562864211006503. doi: 10.1177/17562864211006503

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© The Author(s), 2021

This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).

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Figure 5. — A paradigm of successfully treated TDL with rituximab in a patient with MS during chronic treatment with natalizumab. (a) and (b) The patient presented for the first time TDL-like lesion (non-PML) in the right precental gyrus with no Gd+ during natalizumab treatment. (c) and (d) After natalizumab withdrawal and IVMP course, a significant MRI activity with enlargement of the TDL (non-PML) and multiple bilateral hemispheric punctuate Gd+ lesions were noted. (e) and (f) Further increase in size of the TDL with a little reduction of the punctuate Gd+ lesions following three monthly cycles of cyclophosphamide (cyclophosphamide failure, 9 months after TDL-like lesion appearance). (g) and (h) Remarkable reduction of the TDL (non-PML) with slight remaining Gd+ post-rituximab initiation.

FLAIR images: (a), (c), (e), (g). T1-weighted contrast-enhanced images: (b), (d), (f), (h).

Gd+, gadolinium enhancement; IVMP, intravenous methylprednisolone; MRI, magnetic resonance imaging; MS, multiple sclerosis; PML, progressive multifocal leukoencephalopathy; TDL, tumefactive demyelinating lesion.