PMC4410509_01
Gadolinium-enhanced T1 MRI shows left medullary enhancement (arrow, a) as extensive nodular circumferential leptomeningeal enhancement (arrows, b). Findings correlate with axial T2 FLAIR images also showing lateral brainstem hyperintensity (arrows, c) as well as a patchy involvement of the bilateral midbrain (arrows, d) and the pituitary infundibulum (arrowhead, d).
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F1
A brain MRI confirmed extensive nodular leptomeningeal enhancement along the left ventral medulla, and pons becoming more circumferential around the midbrain with disease extension into the left Sylvian fissure and along the pituitary infundibulum (fig. 1).
Intraoperative photograph shows the direct swab of a mycotic-appearing mass which resulted in negative smear and culture. Also seen are a number of small colonies (arrowheads), one of which resulted in the positive identification of blastomyces dermatitidis on culture.
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F2
An example of an intraoperative mycotic mass is shown in figure 2.