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26th February 2025
A 45-year-old female presents to the medical take with difficulty walking.
A 45-year-old female presents to the medical take with difficulty walking. She has a past medical history of SLE, which is treated with rituximab 6 monthly. Her husband is concerned that she has been more forgetful recently, and her speech has become less clear. On examination you note that she has proximal muscle weakness of the right leg and an ataxic gait. She has no rash, no joint inflammation, no alopecia and no mouth ulcers.
Blood tests are performed as below:
| Normal range | ||
|---|---|---|
| Hb | 135 | (135-170) |
| WCC | 7.9 | (3.5-11.0) |
| Plt | 175 | (140-400) |
| Neut | 3.1 | (1.7-7.5) |
| Na | 137 | (135-145) |
| K | 4.1 | (3.5-5.1) |
| Urea | 3.4 | (2.9-8.2) |
| Creat | 61 | (66-112) |
| eGFR | >90 | |
| CRP | <1 | (0-5) |
| ESR | 10 | |
| ANA | Positive, titre 1:1280 | |
| ENA | Positive | |
| Anti-Sm | Positive | |
| dsDNA | Negative | |
| C3 | 1.3 | (0.9-1.8) |
| C4 | 1.2 | (0.1-0.4) |
| HIV-1 and 2 | Negative | (0.1-0.4) |
MRI head is performed and shows multifocal asymmetric periventricular T2 hyperintense lesions.
Lumbar puncture is performed with results as below:
| Normal Range | ||
| Appearance | Clear, colourless | |
| Microscopy | No organisms seen. No growth after 24h | |
| WCC | 15 cells/uL | (0-5 cells/uL) |
| Protein | 60 mg/dL | (0.15-0.45g/L) |
| Glucose | 3.2 mmol/L | (2.8-4.2 mmol/L) |
| JC virus DNA | Detected |
What is the most likely diagnosis?
Select the SINGLE most appropriate option from the list below. Select ONE option only.
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