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MRI Findings in a 38-Year-Old Male with Progressive Weakness and Confusion

This article discusses the MRI findings in a 38-year-old male with progressive weakness of upper and lower extremities and confusion. It also explores the additional clinical information, the cytologic features, intraoperative diagnosis, and final diagnosis. Additionally, it provides information about lymphoma and diseases associated with primary central nervous system lymphoma (PCNSL).

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MRI Findings in a 38-Year-Old Male with Progressive Weakness and Confusion

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  1. Clayton Wiley MD/PhD

  2. 38-year-old male with progressive weakness of upper and lower extremities, in addition to confusion. Describe the MRI findings (location, enhancement, mass effect).

  3. MRI T2 FLAIR images

  4. MRI T1 pre and post contrast

  5. MRI side-by-side FLAIR and postcontrast images

  6. Question 1 What additional clinical information would you like to know?

  7. 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

  8. Question 2 Give a differential diagnosis based on MRI.

  9. Answer • Infectious disease (Toxoplasmosis, Amebic encephalitis, Viral, PML) • Lymphoma • Demyelinating lesion (Multiple sclerosis) • Metastasis • Gliomatosis cerebri • Multiple infarcts (Embolic / Vasculopathy)

  10. 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.

  11. Question 4 What is your intraoperative diagnosis?

  12. Question 5 What can a neuropathologist do to validate their diagnosis?

  13. 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.

  14. Question 6 Review the permanent section and describe the microscopic features. Click here to view slide.

  15. Question 7 What is your final diagnosis?

  16. Question 8 Secondary involvement by lymphoma is most common in what part of the CNS?

  17. Answer Dura / leptomeninges

  18. Question 9 What are some diseases associated with PCNSL?

  19. Answer • HIV infection • Immunosuppressive therapy (post transplantation) • Hodgkin's disease • Epstein-Barr virus • Primary immunodeficiency syndromes: Wiskott-Aldrich, X-linked lymphoproliferative, Severe combined immunodeficiency, Ataxia-telangiectasia

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