PMC5437433_01
Brain magnetic resonance imaging on day 1 after presentation. a T1 + gadolinium showing a discrete area of contrast enhancement. b Fluid attenuation inversion recovery consistent with significant cerebral oedema. c Susceptibility-weighted imaging demonstrates multiple petechial haemorrhages.
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F1
There was central homogeneous enhancement after contrast (Fig. 1).
Photomicrographs demonstrating the features of the second biopsy. a Perivascular haemorrhage, haemosiderin, and oedema (black arrowhead). There were plentiful foamy macrophages and a mild lymphocytic inflammatory response (haematoxylin and eosin. Original magnification x100). b Immunohistochemical staining for the macrophage marker CD163, highlighting foamy macrophages as the dominant cell type (CD163 immunoperoxidase, original magnification x40). c Evidence of early white matter cavitation (asterisk in white space) with a cystic space lined by foamy macrophages. More marked perivascular inflammation present at the biopsy edge (haematoxylin and eosin. Original magnification x40). d Adjacent gliosis in surrounding white matter containing plump, reactive gemistocytic astrocytes. Scattered astrocytes had fragmented nuclei typical of Creutzfeldt-Peters cells (black arrowheads; haematoxylin and eosin. Original magnification x400). e, f Serial sections stained with histochemical stain Luxol Fast Blue(LBF)/Cresyl Violet (CV) and immunohistochemical stain for neurofilament (NF), respectively. There was perivascular loss of blue-staining myelin with an irregular margin (black arrowheads). Neurofilament highlighted variable numbers of preserved axons within the areas of myelin loss. At higher magnification occasional axonal spheroids were demonstrated. There was patchy loss of axons within the areas of cystic degeneration (LFB/CV and NF immunoperoxidase, original magnification x40).
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F2
Special stains and microbiological cultures for organisms were negative (Fig. 2).
Progress magnetic resonance imaging. a T2. b Susceptibility-weighted imaging. Three weeks after presentation, showing a cystic lesion and ongoing surrounding mass effect, consistent with multiple areas of haemorrhagic necrosis. This may represent the natural progression of the disease, though it is difficult to evaluate how much is secondary to postoperative changes. c T2. d Susceptibility-weighted imaging. Five weeks after presentation, showing improving oedema and resolving haemorrhagic cysts. e T2. f Susceptibility-weighted imaging. Two months after presentation, showing significant reduction in the areas of cystic necrosis.
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F3
Serial MRIs showed stable appearance of the right frontoparietal lesion (Fig. 3).