PMC7461937_01
From left to right: sagittal, axial MRI T2-weighted sequences and axial gadolinium contrast T1-weighted sequences. (A) On the day of admission. (B) Three days after admission. (C) Forty-one days after admission.
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F1
The MRI scan of the brain on the day of admission showed bihemispheric confluent T2 white matter lesions without changes, typical for PML (Figure 1A). MRI scan of the brain at that time showed progressive bihemispheric confluent white matter lesions (Figure 1B). T2 lesion load; however, the regression of gadolinium enhancement suggested remission of acute inflammation (Figure 1C). The neurological status remained severely impaired: the tetraplegia slightly improved by developing into a severe tetraparesis of 2/5 at the upper and persisting plegia of lower limbs (EDSS 8.5).
Histology showed an active demyelinating multiple sclerosis (MS) lesion corresponding to immunopathological pattern II. Arrows indicate the sharply demarcated inflammatory subcortical plaque on the left; the cerebral cortex is present on the right [H&E stain, x10 (A)]. Axons were preserved within the lesion [Bielschowsky silver stain, x10 (B)], whereas myelin was lost [proteolipid protein, x10 (C); cyclic nucleotide phosphodiesterase stain, x40 (D)]. The lesion showed early active demyelination as indicated by the presence of major (C) and minor myelin proteins (D) within the macrophages. Complement [c9neo complement stain, x40 (E)] and immunoglobulin G [IgG; IgG stain x40 (F)] were found within the macrophages, suggesting a complement and immunoglobulin-mediated demyelination (pattern II).
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F2
Inflammatory infiltrates within the lesion consisted of CD3 dominated by CD8-positive T cells as well as CD138-positive plasma cells (Figure 2).