Focal haemorrhage as atypical feature on MRI in progressive multifocal leukoencephalopathy

Progressive multifocal leukoencephalopathy (PML) is a severe progressive demyelinating disorder caused by the suppression of cell-mediated immunity and is diagnosed by typical imaging features on MRI and confirmed by the identification of the JC virus on CSF. We present a case of HIV positive adult male who presented with progressive hemiparesis and spastic dysarthria over 3 months duration, and MRI showed white matter T2 hyper, T1 isointense and peripherally diffusion restricting lesion in the right frontoparietal region with an additional focal haemorrhage within the lesion, which misled us away from considering PML. However, repeat imaging showed progression of the lesion and CSF analysis showed John Cunningham (JC) virus, confirming the diagnosis.