Distinguishing Progressive Multifocal Leukoencephalopathy From Cerebral Toxoplasmosis in HIV: A Case Report

Progressive multifocal leukoencephalopathy and cerebral toxoplasmosis are serious opportunistic infections in patients with advanced HIV infection. Diagnosis is often challenging due to overlapping clinical and radiological features. We present the case of a 40-year-old woman with a three-week history of expressive dysphasia, headache, and right arm weakness. Imaging revealed multiple enhancing brain lesions, initially raising concern for metastatic cancer. An extensive malignancy workup was unrevealing. Lumbar puncture confirmed JC virus in the CSF, and further testing identified previously undiagnosed HIV with a CD4 count of 39 cells/μL, positive Toxoplasma IgG, and hepatitis C coinfection. Treatment with antiretroviral therapy, co-trimoxazole, and corticosteroids was initiated. The patient subsequently developed suspected immune reconstitution inflammatory syndrome and new-onset seizures.