A "progressive" visual loss

maintenance therapy with interferon-α injections 3 times weekly. On examination she was alert and collaborative, was not feverish, was fully conscious, had no dizziness or systemic symptoms and her heart rate and arterial pressure were normal. Physical examination of the heart, thorax and abdomen was unremarkable and the carotid pulses were present with no bruits. No neck stiffness was elicited. The patient was unsteady on her feet but there was no postural drift of the upper and lower limbs; the tendon reflexes were symmetrical and normal and the plantar reflex was flexor bilaterally. The pupils were equal and reactive with no ptosis. The extraocular movements were intact, without nystagmus. The hematocrit was 0.43, the white cell count was 85 u 109/L with 0.82 lymphocytes (CD4 2.75 u 109/L; CD8 3.53 u 109/L; CD4/CD8 ratio 0.78) and 0.11 neutrophils; her hemoglobin level was 143 g/L, the platelet count was 83 u 109/L, the blood glucose was 11 766 mmol/L. The level of total serum IgG was 2.38 g/L (n.v. 8.0-18.0 g/L), IgA < 0.26 g/L (n.v. 0.07-3.0 g/L), and that of IgM was < 0.19 g/L (n.v. 0.05-2.5 g/L). A bone marrow biopsy showed a lymphocytic infiltrate with nodular and trabecular patterns and hypocellularity of myeloid lineage. An accurate visual field examination revealed a left homonymous hemianopsia and a cranial computed tomographic scan without injection of contrast material showed hypodensity of the white matter of the occipital lobes. Fluid-attenuated inversion recovery (FLAIR) and gadolinium-enhanced magnetic resonance imaging (MRI) of the brain showed hypointense signals in T1-weighted and hyperintense signals in T2-weighted images in the white matter of the right and left occipital lobes without any mass effect (Fig. 1). Dipartimento di Emergenza e Accettazione (Direttore: Prof. Rodolfo Proietti), *Istituto di Medicina Interna e Geriatria (Direttore: Prof. Giovanni Gasbarrini), **Istituto di Malattie Infettive (Direttore: Prof. Roberto Cauda), Universita Cattolica del Sacro Cuore, Policlinico “A. Gemelli” di Roma © 2004 CEPI Srl An unusual cause of acute-onset and progressively worsening visual loss is presented. A 60-yearold woman was referred for left homonymous hemianopsia to our Emergency Medicine Department because of a suspected vascular accident. Ten years earlier she had been diagnosed as having chronic lymphocytic leukemia. Brain computed tomography and magnetic resonance imaging revealed “bilateral foci of white matter abnormalities in the occipital regions, compatible with a diagnosis of progressive multifocal leukoencephalopathy”. Her cerebrospinal fluid was positive for papovavirus JC. Progressive multifocal leukoencephalopathy due to papovavirus JC, a typical complication in AIDS patients, is a rare complication in patients with other immunosuppressive conditions, such as chronic lymphocytic leukemia. (Ann Ital Med Int 2004; 19: 118-121)