Photo Quiz

Intracranial Lesion with Fever and Headaches

 

Am Fam Physician. 2013 Jun 15;87(12):877-879.

A 32-year-old woman presented to the emergency department with headaches and fevers that had persisted for the previous six weeks. The headaches were generalized and associated with nausea and photophobia. She had no focal weakness, numbness, or seizure activity. Her medical history was significant for AIDS, which was diagnosed three years earlier. She had not been taking antiretroviral drugs. Her last CD4 cell count was 282 per mm3 (0.28 × 109 per L), which was measured three months earlier.

On examination, she had a temperature of 102°F (38.9°C) and marked wasting. She had no focal neurologic deficits. Magnetic resonance imaging of the brain showed multiple ring-enhancing lesions in the basal ganglia and cerebral hemispheres (see accompanying figure).

Question

Based on the patient's history, physical examination, and imaging findings, which one of the following is the most likely diagnosis?

A. Human immunodeficiency virus encephalopathy.

B. Primary central nervous system lymphoma.

C. Progressive multifocal leukoencephalopathy.

D. Toxoplasmic encephalitis.

E. Tuberculoma.

Discussion

The correct answer is D: toxoplasmic encephalitis. Toxoplasmic encephalitis is the reactivation of disease from a prior parasitic infection. Patients may present with fevers, headaches, seizures, confusion, dementia, or focal neurologic deficits. Laboratory findings include polymerase chain reaction testing that is positive for Toxoplasma antigen in the cerebrospinal fluid, the presence of Toxoplasma antibodies indicative of past exposure, and a CD4 cell count less than 100 per mm3 (0.10 × 109 per L).

In this patient, a brain biopsy was positive for toxoplasmosis. Lesions are often multiple and localized to the parietal or frontal lobes, basal ganglia, or corticomedullary border.1 Magnetic resonance imaging demonstrates abscesses that are generally isodense or hypodense lesions, enhancing in a ring or nodular pattern with perifocal vasogenic edema and mass effect.2 Standard treatment is sulfadiazine and pyrimethamine (Daraprim), with leucovorin as needed, for a minimum of four to six weeks. Resumption of antiretroviral therapy is indicated to raise CD4 counts to more than 200 per mm3 (0.20 × 109 per L). If the lesions do not decrease in size within two weeks of initiating treatment, a brain biopsy is needed to exclude lymphoma.3

Human immunodeficiency virus encephalopathy presents with the triad of dementia, depression, and movement disorders. The most common finding on magnetic resonance imaging is cerebral atrophy. Multiple hyperintense lesions are nonenhancing, poorly demarcated, and localized bilaterally to the subcortical white matter.2 Lesions are usually symmetrical.

Primary central nervous system lymphoma is an extranodal non-Hodgkin lymphoma that can involve the brain, leptomeninges, eyes, or spinal cord without evidence of systemic disease. Patients present with confusion, memory loss, hemiparesis, aphasia, and seizures. Most patients have constitutional symptoms such as fever, night sweats, and weight loss. Epstein-Barr virus DNA may be found in the cerebrospinal fluid. The median CD4 cell count at the time of diagnosis is 50 per mm3 (0.50 × 109 per L). Lesions exhibit homogeneous contrast enhancement with edema and mass effect. Lesions that involve the corpus callosum, or the periventricular or periependymal area, and those larger than 3 cm are more likely to be caused by this condition.3,4 Brain biopsy is needed for definitive diagnosis.

Progressive multifocal leukoencephalopathy is a fatal demyelinating disease caused by reactivation of the JC virus in patients with severe immunosuppression. Patients present with rapidly progressive focal neurologic deficits and cognitive impairment. There are multifocal areas of demyelination, particularly in the periventricular areas and the subcortical white matter. On imaging, these lesions appear as bilateral, asymmetrical, hypodense, patchy or confluent white matter lesions.5 The lesions are nonenhancing without edema or mass effect. Diagnosis is made in patients with appropriate clinical features who have polymerase chain reaction testing positive for JC virus DNA in the cerebrospinal fluid.

Tuberculomas are granulomatous lesions that develop after recent or remote tuberculosis infection of the central nervous system. Patients present with focal neurologic symptoms and signs of an intracranial lesion, usually without evidence of systemic illness or meningeal inflammation. Tuberculomas may be solitary or multiple, and may show nodular enhancement.2

View/Print Table

Summary Table

ConditionRadiologic characteristicsDiagnosis

Human immunodeficiency virus encephalopathy

Nonenhancing, poorly demarcated, bilateral and symmetrical subcortical white matter lesions; cerebral atrophy

Clinical triad of dementia, depression, and movement disorder

Primary central nervous system lymphoma

Solitary or multiple lesions exhibit homogeneous contrast enhancement with mass effect; involve corpus callosum, or periventricular or periependymal areas

Brain biopsy shows diffuse B-cell lymphoma (rarely T-cell lymphoma)

Progressive multifocal leukoencephalopathy

Bilateral, asymmetrical, hypodense, patchy or confluent white matter lesions; nonenhancing without edema or mass effect; more common in periventricular areas and the subcortical white matter

PCR testing shows JC virus DNA in cerebrospinal fluid

Toxoplasmic encephalitis

Multiple ring-enhancing lesions with perifocal vasogenic edema and mass effect; more common in parietal basal ganglia, or corticomedullary border

PCR testing shows Toxoplasma antigen in cerebrospinal fluid

Tuberculoma

Solitary or multiple lesions are isointense, with a hyperintense ring on T1-weighted imaging and hypointense ring on T2-weighted imaging (but hyperintense lesions if there is liquefactive necrosis)

Recent or remote tuberculosis infection


PCR = polymerase chain reaction.

Summary Table

ConditionRadiologic characteristicsDiagnosis

Human immunodeficiency virus encephalopathy

Nonenhancing, poorly demarcated, bilateral and symmetrical subcortical white matter lesions; cerebral atrophy

Clinical triad of dementia, depression, and movement disorder

Primary central nervous system lymphoma

Solitary or multiple lesions exhibit homogeneous contrast enhancement with mass effect; involve corpus callosum, or periventricular or periependymal areas

Brain biopsy shows diffuse B-cell lymphoma (rarely T-cell lymphoma)

Progressive multifocal leukoencephalopathy

Bilateral, asymmetrical, hypodense, patchy or confluent white matter lesions; nonenhancing without edema or mass effect; more common in periventricular areas and the subcortical white matter

PCR testing shows JC virus DNA in cerebrospinal fluid

Toxoplasmic encephalitis

Multiple ring-enhancing lesions with perifocal vasogenic edema and mass effect; more common in parietal basal ganglia, or corticomedullary border

PCR testing shows Toxoplasma antigen in cerebrospinal fluid

Tuberculoma

Solitary or multiple lesions are isointense, with a hyperintense ring on T1-weighted imaging and hypointense ring on T2-weighted imaging (but hyperintense lesions if there is liquefactive necrosis)

Recent or remote tuberculosis infection


PCR = polymerase chain reaction.

Author disclosure: No relevant financial affiliations.

Address correspondence to Abhishek Agarwal, MD, at aagarwal@uams.edu. Reprints are not available from the authors.

REFERENCES

show all references

1. Miller RF, Hall-Craggs MA, Costa DC, et al. Magnetic resonance imaging, thallium-201 SPET scanning, and laboratory analyses for discrimination of cerebral lymphoma and toxoplasmosis in AIDS. Sex Transm Infect. 1998;74(4):258–264....

2. Senocak E, Oğuz KK, Ozgen B, et al. Imaging features of CNS involvement in AIDS. Diagn Interv Radiol. 2010;16(3):193–200.

3. Thurnher MM, Thurnher SA, Schindler E. CNS involvement in AIDS: spectrum of CT and MR findings. Eur Radiol. 1997;7(7):1091–1097.

4. Gill PS, Graham RA, Boswell W, Meyer P, Krailo M, Levine AM. A comparison of imaging, clinical, and pathologic aspects of space-occupying lesions within the brain in patients with acquired immune deficiency syndrome. Am J Physiol Imaging. 1986;1(3):134–141.

5. Whiteman ML, Post MJ, Berger JR, Tate LG, Bell MD, Limonte LP. Progressive multifocal leukoencephalopathy in 47 HIV-seropositive patients: neuroimaging with clinical and pathologic correlation. Radiology. 1993;187(1):233–240.

Contributing editor for Photo Quiz is John E. Delzell, Jr., MD, MSPH.

A collection of Photo Quizzes published in AFP is available at http://www.aafp.org/afp/photoquiz.

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at http://www.aafp.org/afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. E-mail submissions to afpphoto@aafp.org.


 

Copyright © 2013 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Dec 1, 2016

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article