Dados do Trabalho

Título

Progressive multifocal leukoencephalopathy. A hidden and quickly deadly entity.

Descrição sucinta do(s) objetivo(s)

To present a case of progressive multifocal leukoencephalopathy in an immunosuppressed patient.
Review the pathophysiological concepts and radiological findings associated with this disease.

História clínica

46-year-old female patient with a history of cerebral toxoplasmosis and HIV with poor adherence to treatment.
She consulted with a clinical picture of 6 hours of evolution characterized by a feeling of dizziness, associated with repeated emetic episodes, alteration in visual acuity, paresis of lower limbs and instability in walking, for which she consulted the emergency room.
- Diffuse asymmetric FLAIR hyperintensities in bi-hemispheric white matter, with involvement of subcortical U fibers, marginal restriction on DWI, without reinforcement after the administration of intravenous contrast. Other areas with similar signal involve the brain stem and both cerebellar hemispheres, mainly on the left side.

Discussão e diagnóstico

Progressive multifocal leukoencephalopathy (PML) is an opportunistic infection in the central nervous system caused by the reactivation of the JC virus that destroys myelin-producing cells in the context of deficient cellular immunity (CD4 < 100). It is rapidly fatal in the absence of adequate therapeutic intervention.
Its clinical presentation is nonspecific, including mental deterioration, vision loss, speech disturbances, ataxia, paralysis, brain lesions, and finally, coma.
In relation to its diagnosis, CT showed a focal, asymmetric lesion, with low attenuation and no enhancement after the administration of intravenous contrast. On the other hand, in brain MRI, the visualization of multiple irregular and hyperintense lesions in T2-weighted sequences, with asymmetric distribution, located in the periventricular and subcortical white matter (subcortical U fibers), the latter also evident in our patient is characteristic of the disease. in FLAIR sequences, without mass effect and non-contrast enhancement. Likewise, a ring diffusion restriction pattern can be seen in DWI. Finally, our patient concluded with findings suggestive of PML and sequelae toxoplasmosis. Unfortunately, she presented an unfavorable clinical course, with deterioration of the sensorium, which progressed to a comatose state and subsequent death.

Conclusões

The LMP is an opportunistic infection that, without timely treatment, can progress rapidly and be fatal. It is essential for the radiologist to recognize early the typical patterns of this condition, given its impact on reducing morbidity and mortality for patients.

Palavras Chave

HIV; leucoencefalopathy

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