LAUSR

A 66-year-old Chinese woman presented with progressive cognitive decline, difficulty for calculating and dizziness for 2 years. She complained of bilateral limb weakness and gait disturbance which was characterized by small steps without falling for 1 month. No headache, nausea, vomiting, dysphagia, dysarthria, urinary incontinence, seizure attack, fever. Neurological examination showed an apathetic patient with severe cognitive decline (MMSE score was 14/30) and decreased muscle strength with limb spasm bilaterally. No hepatosplenomegaly and lymphadenopathy. Lumbar puncture showed normal pressure with mild lymphocytosis, glucose of 36 mg/dl, and protein of 60 mg/dl. PCR of CSF HSV and CMV returned negative. CSF was also negative for IgG oligoclonal bands. Serum EBV IgG was positive. EEG showed slowing of the normal background diffusely. Cranial MRI exhibited diffuse white matter changes, involving periventricular area, frontoparietal white matter, without mass effect (Figure 1A,B). Repeated MRI revealed progressive leukoencephalopathy involving brainstem and cerebellar peduncle (Figure 1C,D) with mild periventricular enhancement 5 months later (Figure 1E). Brain biopsy targeting periventricular deep white matter was therefore performed.