PMC6546850_01
MR examination showing typical findings of PML with white matter FLAIR- (A) and T2 weighted- (B) hyperintensities without mass effect. T2-signal elevations (B) are in part spot-like and resemble the milky-way-appearance typical for PML. The area affected by the JC-virus infection does have a typical rim with reduced ADC values (C, white arrow) indicating the inflammatory border zone with acute demyelination combined with swelling of astrocytes and oligodendrocytes.
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F1
The MRI had displayed a massive enlargement of parietooccipital lesions in both hemispheres predominantly affecting the left white matter (Figure 1).
Tomograms of 18F-FDG uptake (A) as well as the result of SPM analysis (B, using an uncorrected p < 0.001 for statistical inferences) revealed distinct bilateral hypo-metabolism pronounced on the left side in parietotemporal and occipital areas. Note, unlike in tomograms the left side appears left in the SPM images.
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F2
The metabolism in the frontal cortex, basal ganglia, and cerebellar regions appeared to be normal (Figure 2).
MR examination showing the progress of the PML-related FLAIR-hyperintensities (A). The new multifocal and strong contrast enhancement (B) indicates the PML-IRIS. The zone of active inflammation and demyelination is again indicated also by the low ADC-rim surrounding the area affected by the JC-virus (C, white arrow).
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F3
The MRI showed a further expansion of the lesions with a new peripheral contrast enhancement (Figure 3) as a sign of a PML-related immune reconstitution inflammatory syndrome (PML-IRIS).