Endgames Picture Quiz

Cerebral mass in HIV infection

BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f6314 (Published 24 October 2013) Cite this as: BMJ 2013;347:f6314

This article has a correction. Please see:

  1. H Taha, speciality registrar, genitourinary and HIV medicine,
  2. S Das, consultant, genitourinary and HIV medicine
  1. 1Coventry and Warwickshire Partnership NHS Trust, Coventry CV1 4FS, UK
  1. Correspondence to: H Taha Huda.taha{at}covwarkpt.nhs.uk

A 34 year old woman from the Republic of Congo with known HIV infection presented with a one day history of sudden weakness of the right arm and mild headache. She had a history of cardiomyopathy, hypertension, and epilepsy. She had not travelled abroad since she had moved to the United Kingdom 10 years ago. Other than weakness in the extensor muscles of the right arm grade 4/5 on the Medical Research Council scale, the physical examination was unremarkable.

Her CD4 lymphocyte count was 750×106 cells/L and her differential white cell count and C reactive protein concentration were normal, as was the chest radiograph. Cultures for blood, urine, stool, and sputum were negative. She regularly took atazanavir, ritonavir, phenytoin, carbamazepine, carvedilol, and a fixed dose combination of tenofovir and emtricitabine. Magnetic resonance imaging (MRI) of the brain was performed (fig 1)

Fig 1 Sagittal T1 weighted enhanced magnetic resonance image of the brain, with contrast

Questions

  • 1 Describe the findings on MRI

  • 2 What are the differential diagnoses?

  • 3 What other tests might help pinpoint the differential diagnoses?

  • 4 How would you manage and follow up this patient?

Answers

1 Describe the findings on MRI

Short answer

The image shows a 13 mm diameter ring enhancing lesion in the left superior frontal gyrus with peri-lesional oedema. Two similar lesions, with some enhancement in their walls but no surrounding oedema, are also seen in the left occipital and left parietal lobes.

Long answer

The sagittal T1 weighted MRI scan shows a cystic ring enhancing lesion in the left superior frontal gyrus and two similar lesions in the left occipital and left parietal lobes, both of which show some enhancement in their wall but no surrounding oedema (fig 2). A coronal T2 weighted FLAIR (fluid attenuated inversion recovery) image without contrast showed a cystic lesion within the left superior frontal …

Sign in

Free trial

Register for a free trial to thebmj.com to receive unlimited access to all content on thebmj.com for 14 days.
Sign up for a free trial

Subscribe