CLINICAL REPORT Multiple Sclerosis–Like Clinical and Magnetic Resonance Imaging Findings in Human Immunodeficiency Virus Positive-Case Arzu Coban, MD,* Gulsen Akman-Demir, MD,* Halit Ozsut, MD,† and Mef kure Eraksoy, MD* Objective: Neurologic complications may develop during the course of acquired immunodeficiency syndrome. Differential diagnosis of the chronic progressive myelopathy related to human immunodeficiency virus must include multiple sclerosis. Case Report: We report a human immunodeficiency virus–positive case with progressive myelopathy who showed multiple sclerosis– like white matter lesions on cranial magnetic resonance imaging. Viral screening revealed positive serology for human immunodefi- ciency virus. Conclusion: This case suggests that in a patient who presents with a multiple sclerosis–like clinical course and cerebral white matter lesions, a human immunodeficiency virus–related clinical picture should be taken into consideration in the differential diagnosis. Key Words: cerebral white matter lesions, chronic progressive myelopathy, human immunodeficiency virus, multiple sclerosis (The Neurologist 2007;13: 154 –157) N eurologic disease associated with human immunodefi- ciency virus (HIV) infection is a relatively common and frequently life-threatening condition. 1 In large series of pa- tients with acquired immunodeficiency syndrome (AIDS), the incidence of neurologic disease varies between 40% and 70%. 1–3 The spectrum of neurologic disease is quite broad and includes those neurologic complications that are believed to occur as a direct consequence of the HIV-1 infection and those that are chiefly related to the immunosuppression that accompanies the infection or drug-related neurologic compli- cations. 4–6 Another rare category of neurologic disorder, man- ifesting as a multiple sclerosis (MS)–like illness, has occasion- ally been reported in patients with HIV-1 infection. 5 However, in those case reports it was stated that it was difficult to prove a causal relationship between the 2 diseases. 5 In this report, we present a case of progressive myelop- athy with a MS-like clinical course and cerebral white matter lesions who was found to be seropositive for HIV. CASE REPORT A 56-year-old man, a restaurant owner, complained of weakness in 4 extremities, most prominent in the legs. Weakness started in the right leg about 3 years ago. After 1 year, marked right-upper-extremity weakness had developed. Six months ago, he developed increasing weakness in his left upper and lower extremities. He became unable to stand without any aid within the last month. The patient had pulmonary tuberculosis 10 years ago. Additionally, he had an inguinal hernia repair 5 years ago. There was no history of disease in the family. He had a history of alcohol abuse approximately for 40 years. He did not have any specific risk factor for HIV disease. Physical examination revealed mild hepatomegaly. Neurologic examination revealed bilateral pyramidal quadri- paresis most prominent in the right side (muscle strength: right upper extremity 3/5– 4/5, right lower extremity 2/5–3/5, left lower extremity 4+/5), moderately diminished vibration sensation in the lower extremities, diminished deep tendon reflexes, minimal dysmetria on the right upper extremity, bilateral Babinski signs, and a spastic-ataxic gait disturbance. There were no bladder and bowel symptoms. With a cane, he could walk about 150 –200 m. Routine blood count was normal except for a mild thrombocytopenia (116,000/mm 3 ). There was a mild decrease in the total lymphocyte count (800/mm 3 ). Erythrocyte sedimentation rate was 40 mm/h. Other laboratory tests were unremarkable other than a mild increase of the hepatic enzymes (AST: 74 U/L; ALT: 76 U/L; GGT: 194 U/L). Brain magnetic resonance imaging (MRI) examinations revealed a few small (3–5 mm in diameter), hyperintense, white-matter lesions on T2- and FLAIR-weighted images in the periventricular areas and deep white matter, which were not contrast-enhancing (Fig. 1A, B). Cervical MRI exam- ination revealed multiple hyperintense lesions on T2- and FLAIR-weighted images (Fig. 2). Magnetic resonance spectros- copy (MRS) suggested demyelinating lesions. Electromyogra- phy showed mild upper motor neuron involvement. Cerebrospi- nal fluid (CSF) examination revealed a protein level of 56 mg/dL (normal, 15– 45 mg/dL), and the glucose was normal. There was no cellular response in the CSF. Cytologic examination and IgG From the *Departments of Neurology and †Infectious Diseases, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey. This work was presented as a poster at the 40th National Congress of Neurology, Antalya, Turkey, September 2004. Reprints: Arzu Coban, MD, Istanbul University, Istanbul Faculty of Medi- cine, Department of Neurology, Millet Cad. Istanbul, 34390, Turkey. E-mail: arzucoban2002@yahoo.com. Copyright © 2007 by Lippincott Williams & Wilkins ISSN: 1074-7931/07/1303-0154 DOI: 10.1097/01.nrl.0000252948.82865.58 The Neurologist • Volume 13, Number 3, May 2007 154