PMC7332495_01
Computed tomography scan before (a and b) and after (c-f) contrast injection. Significant perilesional edema and isodense peripheral aspect of multinodular subcortical left parietal lesion with hypodense content to normal parenchyma with moderate mass effect to the left lateral ventricle (a and b). Ring peripheral postcontrast enhancement in axial, coronal, and sagittal views (d-f).
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F1
Three months later, the patient returned with an increase in the frequency of focal seizures and an increase in the remnant lesion, observed by a CT and MRI performed on readmission [Figures 1 and 2], this time with a length of over 3 cm.
Magnetic resonance imaging findings: perilesional edema, iso/hyperintense periphery with hypointense content on T1WI (a), hypointense periphery with hyperintense content on T2WI (b), postcontrast periphery enhancement (c), restricted diffusion (d), and lipid peak at 1.3 ppm in spectroscopy (e).
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F2
Three months later, the patient returned with an increase in the frequency of focal seizures and an increase in the remnant lesion, observed by a CT and MRI performed on readmission [Figures 1 and 2], this time with a length of over 3 cm.
Intraoperative findings of the lesion. (a) Firm capsulated lesion. (b) Microdissection in the cleavage plane between the capsule and with matter tissue. (c) Break of the capsule with liquefactive necrotic material leakage. (d) Final aspect with resection cavity lined by fibrillar hemostatic.
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F3
Antibiotic therapy was restarted and a new surgical approach was employed, this time with complete resection of the lesion [Figure 3].
Histological study: (a-c) brain parenchyma with reactive infiltrate of lymphocytes and giant cells with central necrosis gliosis (red arrows) (Hematoxylin and Eosin); (d) presence of characteristic helm-shaped yeasts (multiple budding) compatible with paracoccidioidomycosis (Gomori's methenamine silver stain).
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F4
In the middle of the process and, sometimes, in the giant cells, histological examination using the Grocott-Gomori's methenamine silver nitrate stain method showed highly specific signs of cerebral PCM similar to a ship's wheel or Mickey Mouse ears [Figure 4].