Download Case Study 71

Clayton Wiley MD/PhD
38-year-old male with progressive weakness of upper and
lower extremities, in addition to confusion.
Describe the MRI findings (location, enhancement, mass
effect).
MRI T2 FLAIR images
MRI T1 pre and post contrast
MRI side-by-side FLAIR and postcontrast images
Question 1
What additional clinical
information would you like to
know?
Answer
Is there any significant past medical history?
signs/symptoms of infection
previous malignancy (Fam Hx)
Previous treatments
PE- evidence of peripheral lesions or infections?
Lab- Blood and CSF analysis
Question 2
Give a differential diagnosis based on MRI.
Answer
• Infectious disease (Toxoplasmosis, Amebic encephalitis,
Viral, PML)
• Lymphoma
• Demyelinating lesion (Multiple sclerosis)
• Metastasis
• Gliomatosis cerebri
• Multiple infarcts (Embolic / Vasculopathy)
Question 3
The surgeon tells you that a full body CT showed no masses,
an HIV test was positive and the CSF showed
lymphocytes. You receive 2 cores of tissue in consultation for
intraoperative guidance. Describe the cytologic features of the
touch prep and smear.
Click here to view slides.
Question 4
What is your intraoperative diagnosis?
Question 5
What can a neuropathologist do to
validate their diagnosis?
Answer
LCA, CD20/L26 & CD3. Other hematopoietic markers (ie
CD79a, kappa, lambda, CD10, MUM-1, etc) and
vimentin/GFAP (to highlight gliosis) might also be helpful in
certain cases.
Question 6
Review the permanent section and describe the microscopic
features.
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Question 7
What is your final diagnosis?
Question 8
Secondary involvement by lymphoma is most common in what
part of the CNS?
Answer
Dura / leptomeninges
Question 9
What are some diseases associated with PCNSL?
Answer
•
•
•
•
•
HIV infection
Immunosuppressive therapy (post transplantation)
Hodgkin's disease
Epstein-Barr virus
Primary immunodeficiency syndromes: Wiskott-Aldrich, Xlinked lymphoproliferative, Severe combined
immunodeficiency, Ataxia-telangiectasia