Clinical Reasoning: Progressive Hemiparesis and White Matter Abnormalities in a HIV-Negative Patient.

A 61-year-old man from India was admitted to the hospital after being found unresponsive by the roadside. He was treated with dual-antiplatelet therapy for an acute coronary syndrome. Ten days into admission he was noted to have mild left sided face, arm and leg weakness which progressed significantly over the next two months in association with progressive white matter abnormalities on MRI of the brain. Here we review the approach and clinical reasoning that led to the detection of a rare underlying cause of a devastating neurological disease. We also present a novel treatment approach which achieved a sustained clinical and radiological response.