For numerous reasons, it's been awhile since I posted a case... Here's a case that I had when I was a first year path resident. It's near and dear to my heart, so I held on to it for awhile.
This patient was a 46-year-old female with a several month history of rapidly-progressive cognitive decline. Neuroimaging demonstrated numerous foci of white-matter T2 and FLAIR signal abnormalities scattered throughout the cerebral hemispheres; gadolinium administration revealed numerous, ill-defined small foci of contrast enhancement. The antemortem clinical differential diagnosis included nearly all known causes of human disease, including infection, ADEM, AHLE, metastatic carcinoma (remote history of breast carcinoma). Despite aggressive clinical interventions, the patient expired after a several-week stay in the hospital.
Sectioning of the brain demonstrated (sadly, images not available) irregular, ill-defined areas of softening and hemorrhage in the hemispheric white matter. In areas, the gray-white junction was effaced.
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| Low power (H&E); frontal lobe |
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| Low power (LFB); frontal lobe, white matter |
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| High power (H&E); frontal lobe |
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| High power (H&E); frontal lobe |
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| High power (H&E); frontal lobe, neocortex |
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| High power (H&E); high power, frontal lobe leptomeninges |
No hints needed here. This case qualifies as an "Aunt Minnie". If you've seen it before, the diagnosis is unquestionable. If not, good luck...
Click here for the diagnosis...
I just finished a 2 week neuropath rotation and we had a case of intravascular lymphoma 2 days ago! Very puzzling clinical picture with 6 month history of various neurological symptoms and periventricular and frontal white matter lesions. An extensive work-up had been negative and worsening symptoms lead to biopsy. Infarct changes weren't really evident but the majority of vessels were filled with CD 20+ neoplastic cells with a cuff of mature lymphocytes.
ReplyDeleteThanks for sharing such interesting cases!