Progressive multifocal leukoencephalopathy
HIV positive without antiretroviral therapy for 8 years. Four months ago with numbness in the left arm and two months ago with left motor deficit and visual and speech impairment.
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Extensive right frontoparietal white matter signal abnormality is seen involving the pre and post central gyrus. Signal abnormality also extends just into the occipital lobe on the right and is seen on left parietal and occipital lobes. Small foci are also identified in the region of the basal ganglia, splenium of corpus callosum, brain stem and cerebellar peduncles. This is associated with no mass effect or abnormal enhancement. No evidence of hemorrhage.
Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease which results from the JC virus infecting oligodendrocytes. It is considered the most common clinical manifestation of JC virus infection in the brain.
The main differential diagnosis of this image pattern within the clinical context is the HIV encephalopathy. PML usually presents asymmetric lesions, predominantly in the parietal lobes, which start in the juxtacortical white matter and cross to the contralateral hemisphere through the corpus callosum.