PMC4813061_01
Axial (A) and sagittal (B) unenhanced CT head done in case 1 shows ill-defined hyperdense ring configuration lesion in the left frontoparietal region with surrounding vasogenic edema
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F1
Computed tomography (CT) head without contrast revealed a subtle, ill defined, hyperdense ring configuration lesion in the left frontoparietal region with surrounding vasogenic edema [Figure 1A and B].
Su bsequent MRI brain with and without contrast in case 1 shows a ring configuration with perilesional edema expanding the left post central gyrus on T2 and FLAIR images (A and B). Small area of restricted diffusion (C and D; white arrow in C) and T1 shortening (E) is seen within this lesion. Post contrast T1 image shows an irregular crenated thick-walled round rim enhancement (F)
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F2
Subsequent magnetic resonance imaging (MRI) brain with and without contrast revealed an irregular, crenated, thick walled, round rim-enhancing lesion in the left postcentral gyrus [Figure 2F]. There was perilesional edema expanding the postcentral gyrus [Figure 2A and B]. Small area of restricted diffusion [Figure 2C and D; white arrow in C] and T1 shortening [Figure 2E] was seen within the lesion.
Single voxel short TE (left) and long TE (right) MR spectroscopy through the lesion in case 1 show a peak between 3.5 to 3.8 (white arrow) may represent trehalose peak. Choline-to-NAA ratio did not meet the criteria for neoplasm. Multiple peaks at 0.9-1.3 ppm represent lipid/lactate
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F3
Choline-to-N-acetylaspartate (NAA) ratio did not meet the criteria for neoplasm on either the short or long TE images [Figure 3A and B].
Follow up MRI brain performed 12 months after treatment in case 1 shows complete resolution of edema (A) and enhancing lesion (B)
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Follow-up after 9 months of treatment revealed marked reduction in the size of the lesion and perilesional edema (image not shown) with complete resolution after 12 months [Figure 4A and B].
Axial contrast enhanced CT chest images in case 1 show consolidation in the right lower lobe (A and B). Blastomycosis was confirmed at bronchoalveolar lavage
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PMC4813061_02
MRI brain with contrast in case 2 shows vasogenic edema (A) in left cerebellar hemishphere surrounding an ill-defined altered signal intensity mass lesion demonstrating small focal areas of restricted diffusion (B and C). The mass lesion shows heterogeneous conglomerate ring enhancement (D and E). Contrast enhanced dynamic susceptibility imaging (DSC) MR perfusion with contrast (F) shows no evidence of increased perfusion/neoangiogenesis
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MRI brain showed a heterogeneous conglomerate ring-enhancing left cerebellar mass and extensive surrounding edema with mass effect on the brainstem and adjacent ventricular system [Figure 6A, E and F]focal tentorial enhancement. Laterally, the mass was contacting the dural surface with focal tentorial enhancement [Figure 6D and E; pre-contrast and post-contrast respectively]. MR perfusion with contrast showed no evidence of increased perfusion/neoangiogenesis within the mass [Figure 6F]. MRS (short and long
Single voxel short TE (left) and long TE (right) MR spectroscopy through the lesion in case 2 shows increased lipid/lactate, decreased N-acetyl aspartate, and increased choline peaks. Peak between 3.5 to 3.8 (white arrow) may represent trehalose peak
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TE) showed increased lipid/lactate, decreased N-acetyl aspartate, and increased choline peaks, which were typical for a neoplasm [Figure 7].
Hematoxylin and eosin (H and E) stained section at x400 magnification (A) in case 2 show large round thick-walled yeast cells. Grocott's methenamine silver (GMS) stain section at x400 magnification (B) demonstrates broad based budding yeast cells
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F8
Hematoxylin and Eosin (H and E) stained section at x400 magnification showed large, round, thick-walled yeast cells [Figure 8A]. Grocott's methenamine silver (GMS) stain section at x400 magnification highlighted the yeast cells with broad-based budding [Figure 8B].
PMC4813061_03
MRI brain without contrast in case 3 shows scattered small scalp lesions showing restricted diffusion (A and B; white arrow in A). The lesions appear hypointense on T1 (C) and hyperintense on FLAIR (D)
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F9
MRI brain without contrast revealed scattered multiple small scalp lesions showing restricted diffusion [Figure 9A and B; arrow in A]. The lesions were hypointense on T1 and hyperintense on fluid attenuation inversion recovery (FLAIR) images [Figure 9C and D].
Pre-treatment CT chest in case 3 (A and B) shows multiple scattered nodules and areas of ground glass opacity (A) with consolidation in the superior segment of the left lower lobe (B). CT chest after two weeks of antifungal treatment (C and D) shows remarkable clearance of the lesions
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F10
CT chest before treatment showed multiple scattered nodules and areas of ground glass opacity [Figure 10A] with consolidation in the superior segment of the left lower lobe [Figure 10B]. B for 2 weeks and oral itraconazole for 1 year showed remarkable clearance of the lesions in the skin and lungs [Figure 10C and D]. Biopsy of the skin lesions revealed focal dense collections of polymorphs admixed with fibrin and multiple round to oval yeast with occasional budding on H and E stain [Figure 11A].
H and E stained section at x400 magnification in case 3 from the biopsied skin lesions show collections of polymorphs admixed with fibrin and multiple round to oval yeast with occasional budding (A). Broad based budding yeasts are seen on GMS stain (B)
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F11
B for 2 weeks and oral itraconazole for 1 year showed remarkable clearance of the lesions in the skin and lungs [Figure 10C and D]. Biopsy of the skin lesions revealed focal dense collections of polymorphs admixed with fibrin and multiple round to oval yeast with occasional budding on H and E stain [Figure 11A]. GMS positive with negative mucicarmine. GMS stain showed broad based budding yeasts [Figure 11B].