By 2013 his CD4+ T cell count had been over 500 cells/μl for 7 years, and HIV RNA had been undetectable for a decade. Annual MRI brain scans since 2008 (Figs. 1, 2 and 3) showed progressive white matter atrophy, and since 2010 asymptomatic fluctuating contrast enhancement without mass effect, in both cortical grey and subcortical white matter.
Fig. 1 Case one, 2008: Fluid attenuated inversion recovery (FLAIR) MRI sequences showing multifocal hyperintensity in the subcortical U-fibres of the right basifrontal, right temporal, and left parieto-occipital regions (see arrows). The corresponding T1 post contrast images (lower row), demonstrate an absence of enhancement
Fig. 2 Case one, 2011: FLAIR MRI sequences from 2011 again show hyperintensity in the right basifrontal (see arrows) and left parieto-occipital regions, now with enhancement on corresponding post contrast T1 images (lower row) in the right basifrontal region only
Fig. 3 Case one, 2013: FLAIR hyperintensity has increased in the left parieto-occipital region (see arrows, top images), with new gyriform enhancement (see arrows, bottom images) on corresponding pre-contrast FLAIR sequences. The right basifrontal contrast enhancement has shown a complete resolution