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Neurology Resident and Fellow Section

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1 Neurology Resident and Fellow Section
A 62-year-old man with progressive headache and right-sided weakness Teaching NeuroImages Neurology Resident and Fellow Section © 2016 American Academy of Neurology

2 Vignette A 62-year-old man presented with 7 days-history of progressive headache and right-sided weakness. The patient was a kidney transplant recipient, 16 years ago, due to diabetic nephropathy. Medications included prednisone and mycophenolate mofetil. Examination showed right hemiparesis. Brain MRI is attached (Figure 1). Marussi VHR et al. © 2016 American Academy of Neurology

3 Imaging Marussi VHR et al.
Axial FLAIR (A) and Axial T2 (B) brain MRI disclose a large brain mass in left frontal lobe. Axial post-contrast T1 (C) showed marked peripheral enchancement by gadolinium. Axial SWI (D) depicted hemorrhagic component. Axial diffusion (E) and corresponding ADC maps (not shown) demonstrated restriction diffusion (b=1000 image). A brain tumor was suspected, but axial arterial spin labeling perfusion (F) revealed with low perfusion. Marussi VHR et al. © 2016 American Academy of Neurology

4 Imaging Marussi VHR et al.
Pathological findings after excision of the brain mass: cytopathic effects with intranuclear basophilic inclusion (curved arrow) and inflammatory infiltrate with necrosis (straight arrow) - HEX200 (A and B). Immunohistochemistry shows cytomegalovirus CCH2+DDG9 Clone (Dako) - IHCX40 e IHCX100 (C and D). Marussi VHR et al. © 2016 American Academy of Neurology

5 Final diagnosis: Cytomegalovirus infection mimicking a brain tumor in a kidney transplant patient CMV infection of the nervous system in adults usually affects immunosuppressed patients. Common neurological manifestation includes: polyradiculoneuropathy, myelitis and encephalitis. Neuroimaging features include periventricular abnormalities1. Rarely CMV may present as pseudotumoral lesions2. References: Maschke M, Kastrup O, Diener HC. CNS manifestations of cytomegalovirus infections: diagnosis and treatment. CNS Drugs. 2002;16(5): Huang PP, McMeeking AA, Stempien MJ, Zagzag D. Cytomegalovirus disease presenting as a focal brain mass: report of two cases. Neurosurgery. 1997 May;40(5): Marussi VHR et al. © 2016 American Academy of Neurology

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