30     SA JOURNAL OF RADIOLOGY  •  March 2011  

QUIZ CASE

Neurological case: Cognitive decline and 
depressed level of consciousness in AIDS
Hein Els, MB ChB, MFamMed, CCFP
Department of Diagnostic Radiology, Tygerberg Academic Hospital, Tygerberg

Savvas Andronikou, MB ChB, FCRad, FRCR (Lond), PhD
Department of Radiology, University of the Witwatersrand, Johannesburg

Presentation
A 39-year-old man was referred from a rural hospital. On examination, he had a new onset left hemiplegia, left gaze palsy and decreased level of 
consciousness. Prior to the acute deterioration, he had shown progressive decline in his cognitive functioning. He was known to be HIV-positive with 
a CD4 count of 19. He was not on anti-retroviral therapy (ART) at the time of admission. Two years earlier, he had been diagnosed with pulmonary 
tuberculosis and had completed his prescribed treatment.

What is the most likely diagnosis according to the imaging? Select the diagnosis from one of the following options, and provide a justification.
• HIV encephalitis (HIVE)
• toxoplasma encephalitis
• progressive multifocal leucoencephalopathy (PML)
• primary central nervous system lymphoma (PCNSL).

Please submit your response to els.hein@gmail.com or docsav@mweb.co.za by 29 April 2011. The winning respondent will receive a R1 000 prize from 
the RSSA. A detailed diagnosis and discussion will appear in the next issue of the SAJR.

Fig.1a. Unenhanced CT image reveals a focal white matter 
hypodensity involving the right frontoparietal area and right 
basal ganglia. A smaller left-sided lesion was noted in the 
anterior capsula externa.

Fig. 1b. No enhancement was demonstrated on post-contrast 
imaging.

Fig. 2. T2WI shows hyperintense signal in white matter right 
parietal lobe with involvement of the subcortical U-fibres and 
mild mass effect. The right basal ganglia and left anterior capsula 
externa lesions are again demonstrated.

Fig. 3. Follow-up CT 2 months later demonstrates significant 
progression of the disease.