PMC10423447_01
Sagittal T2-weighted MRI of the cervical spinal cord (A) demonstrates longitudinally extensive transverse myelitis (LETM) involving most of the cervical and upper thoracic cord from C2-T4 (arrow). Dorsal subpial enhancement associated with neurosarcoidosis-related LETM as shown on sagittal T1-weighted and axial T1-weighted MRI with gadolinium (B, C respectively; arrows). Spinal cord biopsy showed non-caseating granulomas (D; black arrow) on hematoxylin and eosin staining in a background of a mixed inflammatory infiltrate composed of lymphocytes, macrophages, and occasional plasma cells. Sagittal T2-weighted MRI of the cervical spinal cord two months after combination therapy with infliximab and methotrexate showed resolution of the spinal cord signal abnormality (E). Scale and magnification (D) 100 mum, 10x.
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He was found to have a multi-focal enhancing and longitudinally extensive lesion with dorsal subpial enhancement on MRI of the cervical and thoracic spine extending from C2 to mid T4 level (Figure 1).
Axial T2/FLAIR MRI showing multiple brain parenchymal lesions most prominently in the right frontal lobe (A) and simultaneous enhancing lesions on axial T1-weighted MRI with gadolinium (B). Follow up at 3 months (C), (D), 6 months (E), (F), 12 months (G), (H) and 24 months (I), (J) showed significantly reduced but persistent enhancement despite treatment with voriconazole for two years.
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Repeat brain and orbital MRI showed innumerable ring-enhancing lesions in the brain, right endophthalmitis, episcleritis and orbital cellulitis extending from adjacent frontal lesions with surrounding edema concerning for infection (Figure 2).
External examination of right eye showed severe chemosis, periorbital edema and proptosis (A). Pathological examination of the enucleated eye showed fungal hyphae on hematoxylin and eosin stain (B), (C) on a background of extensive acute and chronic inflammation, edema, necrosis, and abscess formation. Grocott-Gomori methenamine silver stain of the left lower lung biopsy specimen showed septate hyphae with acute angle branching, with a morphology consistent with Aspergillus (D). Scale and magnification (B) 100 mum, 10x; (C) 20 mum, 40x; (D) 200 mum, 40x.
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Unfortunately, he lost all vision in the right eye and underwent enucleation, which substantiated the diagnosis of aspergillosis on histological analysis (Figure 3).