PMC5445650_01
Chest X-ray from posteroanterior projections (a) and left lateral (b) showing discrete perihilar opacities poorly defined at right
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F1
The patient was submitted to computed tomography (CT) in a 16-row multidetector scanner, which revealed, after iodinated contrast infusion, a nodular hypodense lesion with ring enhancement and associated perilesional edema in the left cerebellar hemisphere [Figure 1].
Protocol for high-resolution CT scanning of the chest, axial sections showing lesions with excavated walls, sometimes thin and smooth (a), sometimes thicker and asymmetric (b), and peripheral nodular solid lesions (c and d) in lung parenchyma, as well as area of lowest vascularity and not well defined in both upper and lower regions of the lungs
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F2
Chest radiography [Figure 2] showed reticular opacities, perihilar and poorly defined in the right hemithorax.
Axial sections of computed tomography before (a) and after (b) the infusion of iodinated contrast agent, revealing nodular hypodense lesion with ring- enhancement, in the left cerebellar hemisphere. Reformation in the coronal (c) and sagittal (d) confirmed the lesion was located in the posterior cranial fossa
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F3
The CT in a 16-row multidetector scanner [Figure 3] and high-resolution chest protocol were done, showing pulmonary nodules in the right, some of them with excavated wall, sometimes thin and smooth, sometimes asymmetrical, and occasionally associated with perilesional ground-glass opacities.
Brain MRI. (a) T1W nodular lesion with peripheral hyperintense rim surrounding a hypointense white matter in the left cerebellar hemisphere. Axial images in (b) T2W sequences and (c) FLAIR-perilesional edema, heterogeneity with peripheral hypointense white matter, center hyperintense. (d) T1W revealed ring-enhancement after intravenous infusion of paramagnetic contrast (gadolinium) in axial section. Axial image of diffusion- DWI sequences (e) lesion hyperintense center; and apparent diffusion coefficient (f), hypointense lesion with restricted diffusion of water molecules
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F4
T1-weighted sequences [Figure 4a], showed peripheral hyperintense rim surrounding a hypointense center and ring enhancement after intravenous infusion of paramagnetic contrast [Figure 4d]. T2-weigthted sequences and fluid-attenuated inversion recovery (FLAIR) [Figure 4b and c] showed perilesional edema in the left cerebellar hemisphere and peripheral hypointense in the center of the respective lesion. The diffusion-weighted (DWI) sequences and apparent diffusion coefficient (ADC), respectively, showed hyperintense and hypointense lesions with restricted diffusion of water molecules [Figure 4e and f]. The proton spectroscopy curves for MR of cerebellar lesions showed an increase in lactate and lipids peaks and reduction of N-acetyl-aspartate (NAA) peak, without increase in choline peak [Figure 5].
Proton spectroscopy curvs for magnetic resonance of cerebellar lesions showing increased peaks of lactate and lipids and reduction of N-acetyl-aspartate (NAA) peak, without increasing of choline peak
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F5
T2-weigthted sequences and fluid-attenuated inversion recovery (FLAIR) [Figure 4b and c] showed perilesional edema in the left cerebellar hemisphere and peripheral hypointense in the center of the respective lesion. The diffusion-weighted (DWI) sequences and apparent diffusion coefficient (ADC), respectively, showed hyperintense and hypointense lesions with restricted diffusion of water molecules [Figure 4e and f]. The proton spectroscopy curves for MR of cerebellar lesions showed an increase in lactate and lipids peaks and reduction of N-acetyl-aspartate (NAA) peak, without increase in choline peak [Figure 5].
(a) Cerebellar lesion fragment Grocott-Gomori staining revealing the typical histological findings of paracoccidioidomycosis forms: "ship's steering wheel" (arrow in a) and "Mickey Mouse" (arrow in b)
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F6
Microsurgery biopsy of cerebellar lesion was performed, and the histological analysis concluded that it was paracoccidioidomycosis without neoplasia signals [Figure 6].