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(A, B) Axial Inversion Recovery MR images (TR/TE/TI=9000 ms/81 ms/2500 ms) demonstrate cortical hyperintensity of the limbic system involving the mesial temporal lobes, hippocampi, amygdalae, left cingulate and orbitofrontal gyri and left insular cortex (arrows), note the minimal white matter involvement disproportional to cortical involvement with loss of gray-white matter interfaces. (C, D) Axial Apparent Diffusion Coefficient maps (TR/TE=7200 ms/104 ms) show hyperintense signal indicating facilitated diffusion on corresponding inversion recovery cortical hyperintensity from T2 shine-through effect involving the limbic system (arrows) without diffusion restriction indicating absence of acute infarction, acute hyponatremic encephalopathy or pyogenic encephalitis. (E, F) Axial susceptibility-weighted MR images (TR/TE=27 ms/20 ms) demonstrate no evidence for hemorrhage, excluding hemorrhagic encephalitides. (G, H) Axial contrast-enhanced T1-weighted MR images (TR/TE=650 ms/8.4 ms) show no abnormal enhancement of the limbic structures.
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Work-up included brain computerized tomography (CT) and magnetic resonance imaging (MRI), which suggested a diagnosis of encephalitis - viral encephalitis or limbic encephalitis (Figure 1).