Progressive neurological deficit in an HIV patient.

To cite: Nwankwo N, Yeddula K, Vogel J. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013009985 DESCRIPTION A 57-year-old man with a history of HIV presented to the hospital with generalised weakness, slurred speech and an unsteady gait. CT scan showed hypodensity in the left cerebellar hemisphere and middle cerebellar peduncle and an MRI of the brain was consistent with the left middle peduncle subacute ischaemic infarct. He was started on aspirin 325 mg daily and transferred to the skilled nursing facility for physical therapy. Two months after the initial event, he was readmitted for worsening slurred speech, unsteady gait, dysphagia and left-sided facial droop. A repeat MRI did not show any new cerebrovascular accident while anMR angiogram of the brain showed no evidence of stenosis or aneurysmal dilation; however, the patient’s condition continued to deteriorate. Three weeks later, he was much worse in terms of his dysarthria as his speech was incomprehensible, his dysphagia prompted percutaneous endoscopic gastrostomy tube placement and became bed ridden. Repeat MRI showed pure posterior fossa changes with bilateral T2 fluid attenuated inversion recovery prolongation of signal within the pons, bilateral middle cerebellar peduncles and medulla without significant mass effect. The lesion was highly suspicious of progessive multifocal leucoencephalopathy (PML) considering his CD4 count and viral load were 8 and 2267, respectively. He was started on highly active antiretroviral therapy , as he was initially non-compliant owing to dysphagia. The patient agreed to a lumbar puncture and the cerebrospinal fluid sample showed the presence of polyoma/JC virus. The patient expired a month after diagnosis.