We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Clinical Pathologic Conference |

Rapid Multifocal Neurologic Decline in an Immunocompromised Patient

Julie Anne Kromm, MD, FRCPC1,2; Christopher Power, MD, FRCPC1; Gregg Blevins, MD1; Loree Larratt, MD3; F. K. H. van Landeghem, MD4; Jeremy Rempel, MD5
[+] Author Affiliations
1Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
2Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
3Division of Hematology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
4Neuropathology Specialty Group, Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
5Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
JAMA Neurol. 2016;73(2):226-231. doi:10.1001/jamaneurol.2015.2658.
Text Size: A A A
Published online

A man in his early 70s with a diagnosis of chronic lymphocytic leukemia and being treated with prednisone, fludarabine, cyclophosphamide, and rituximab presented with progressive multifocal neurologic decline. The patient died 2 months after the onset of this decline despite extensive clinical and laboratory investigation and a trial of methylprednisolone therapy. The approach to the immunosuppressed patient with progressive neurologic decline, neuropathologic findings, and final diagnosis are discussed.

Figures in this Article


Place holder to copy figure label and caption
Figure 1.
Magnetic Resonance Imaging

Magnetic resonance image at 5 weeks after the onset of neurologic symptoms in the patient described in this report. Hyperintensities (arrowheads) on fluid-attenuated inversion recovery involving the left cerebellar hemisphere (A), bilateral pons (B), bilateral midbrain peduncles (C), and extending up into the thalami bilaterally (D).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Pathologic Characteristics

A, Luxol fast blue-periodic acid–Schiff and hematoxylin-eosin staining of the central pons showing bilaterally symmetric areas of demyelination (original magnification ×10). B, Optic nerve tissue immunostained for myelin basic protein, showing reduced immunoreactivity and disruption of myelin structure (arrowheads) (original magnification ×40). C, CD68-immunoreactive macrophages infiltrating the optic nerve (original magnification ×20). D, High-power magnification showing macrophages with phagocytosed myelin (arrowheads). E, Neurofilament immunostaining of the pons showing myelin phagocytosis by macrophages (arrowhead) (original magnification ×40). F, Neurofilament immunostaining of the optic nerve showing occasional axonal retraction bulbs (arrowhead) (original magnification ×40).

Graphic Jump Location




Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.


Some tools below are only available to our subscribers or users with an online account.

0 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles

Care at the Close of Life: Evidence and Experience
What Is the Diagnosis?

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis