PMC8422457_01
Fluorodeoxyglucose-positron emission tomography imaging demonstrates areas of hypermetabolism in the right subaxillary lymph nodes (a), left lingual tonsil (b), and T3 region of the spinal cord (c).
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F1
Follow-up positron emission tomography (PET) imaging revealed low-grade metabolic activity in mesenteric, aortocaval, internal mammary, abdominal wall, and axillary nodes as well as heterogeneous uptake in the spleen consistent with "low-grade lymphoproliferative disease." Additional hypermetabolic lesions were observed in the left lingual tonsil and within the spinal cord at the level of the third thoracic vertebra [Figure 1a-c].
Initial magnetic resonance imaging of the thoracic spine demonstrates a 9-mm homogeneously-enhancing intramedullary spinal cord lesion with significant edema within the spinal cord above and below the lesion. Sagittal T2-weighted image (a), sagittal T1-weighted image without contrast (b), and sagittal T1-weighted image without contrast (c) are shown.
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F2
Magnetic resonance imaging (MRI) of the spine demonstrated a 9-mm expansile homogeneously enhancing intramedullary spinal cord mass at the T3 level with significant edema within the spinal cord above and below the lesion [Figure 2a-c].
Follow up serial sagittal T1-weighted magnetic resonance imaging of the thoracic spine with contrast - 3 months (a), 6 months (b), and 10 months (c) from initial imaging [Figure 2c] - demonstrate interval regression and ultimate resolution of the enhancing intramedullary spinal cord lesion.
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F3
A repeat MRI was performed to follow the thoracic lesion, which showed significant improvement [Figure 3a]. Follow-up MRI of the thoracic lesion again showed significant reduction in size and patient reported continued improvement in strength and sensation of his left leg [Figure 3b]. MRI of the spine 4 weeks after discharge demonstrated complete resolution of the spine mass [Figure 3c] and significant improvement in the edema within the spinal cord [Figure 4].
Follow-up sagittal T2-weighted MRI of the thoracic spine at 10 months. Significant improvement in spinal cord edema compared to initial imaging [Figure 2a].
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F4
MRI of the spine 4 weeks after discharge demonstrated complete resolution of the spine mass [Figure 3c] and significant improvement in the edema within the spinal cord [Figure 4].
Hematoxylin and eosin (H&E) (a) and Grocott methenamine silver (GMS) special stain (b) (x400) of the necrotizing granuloma in the left tonsil. H&E (c) and GMS special stain (d) (x400) of the non-necrotizing granuloma in the abdominal wall. A few GMS-positive fungal microorganisms are identified that are morphologically consistent with histoplasma.
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F5
Repeat tissue sectioning demonstrated rare fungal elements in the previous colonic, abdominal wall, cervical lymph node, and tonsil specimens [Figure 5a-d], implying that indolent disseminated histoplasmosis was the cause of his systemic and gastrointestinal symptoms from the outset.