Mass Lesions In Patients Research Articles

Ventriculitis: a rare case of primary cerebral toxoplasmosis in AIDS patient and literature review

Cerebral toxoplasmosis remains the most important neurological opportunistic infection and the most common cause of intracerebral mass lesion in patients with acquired immunodeficiency syndrome (AIDS). We report a case of an adult AIDS patient with an atypical pattern of toxoplasma encephalitis, presenting with ventriculitis and obstructive hydrocephalus without any focal parenchymal lesion.

An algorithmic approach to intracranial mass lesions in HIV/AIDS

We developed a diagnostic and therapeutic algorithm for intracranial mass lesions in patients with HIV/AIDS that obviates the need for neurosurgical intervention. The approach is based upon CD4(+) lymphocyte count, serum toxoplasma immunoglobulin G (IgG) serology, chest X-ray, routine lumbar puncture studies, cerebrospinal fluid (CSF) cytology, CSF adenosine deaminase or Mycobacterium tuberculosis polymerase chain reaction testing, single positron emission-computed tomography (SPECT) scanning for intracranial enhancing lesions, and limited therapeutic trials. Over a 12-month period involving 26 patients, we found that the algorithm correctly identified the aetiology of focal intracranial lesions in all 23 evaluable patients. Costs for SPECT scanning for the entire study cohort were more than offset by the savings achieved by reduced hospital stays for the four patients with lymphoma alone. An algorithmic approach can accurately identify the cause(s) of central nervous system (CNS) mass lesions in HIV-infected patients, and SPECT scanning can replace stereotactic brain biopsy in most cases where opportunistic malignancy is suspected.

Abdominal desmoid in familial adenomatous polyposis presenting as a pancreatic cystic lesion

A 17-year-old male with familial adenomatous polyposis (FAP) presented with chest pain and significant weight loss. An abdominal CT scan detected a cystic pancreatic lesion of unknown etiology. The patient therefore underwent surgical resection of the distal pancreas, which included the lesion, because of the known association of pancreatic cancer with FAP. Histopathological examination of the resected specimen showed a benign pancreatic cyst and fibrous plaque with desmoid fibromatosis adherent to the surface of the pancreas, serosa of the stomach, and colon. The fibrous plaque was histologically identical to the fibrous mesenteric plaque known to occur in FAP and associated mesenteric fibromatosis. We present pathologic evidence that the pancreatic cyst formation was induced by FAP-associated desmoid invasion. Desmoid growth should be considered in the differential diagnosis of a pancreatic cystic mass lesion in patients with FAP or its Gardner syndrome variant. This case report provides the first pathologic evidence for benign epithelial cyst formation in the pancreas caused by fibromatosis invasion of that organ as a part of FAP.

HIV-related primary cerebral lymphoma: the role of stereotactic biopsy.

Primary cerebral lymphoma (PLC) is a common cause of cerebral mass lesion in patients with the acquired immune deficiency syndrome. Its clinical features and radiological appearance are non-specific in this group of patients who are often quite debilitated at the time of presentation. We present a retrospective series of 9 cases of AIDS related PCL proven by stereotactic biopsy. There were no deaths from the biopsy and only one case in which there was worsening of the preoperative neurological condition. Although the overall outlook for these patients was poor (mean time to death 18 weeks), all but one showed some clinical response to palliative treatment with radiotherapy and steroids. In this context, we suggest that stereotactic biopsy as a means to positively establish the diagnosis prior to treatment is a safe technique to use in this group of often debilitated patients. Copyright 1999 Harcourt Publishers Ltd.

Teaching evidence-based medicine to surgical subspecialty residents.

Curricula for the teaching of evidence-based medicine to residents have been the subject of reports, analyses, and commentary. Specific programs for teaching evidence-based medicine principles to surgical subspecialty residents have not been identified by the authors. The objective of this article is to report our experience in establishing a teaching program in the principles of evidence-based medicine to surgical subspecialty residents. We established a teaching program in the principles of evidence-based medicine for neurosurgical residents in a busy neurosurgical training program. Two hours were set aside every other week, replacing traditional professors' rounds with sessions led jointly by a neurosurgeon and an epidemiologist, but based on case presentations from patients currently being treated. From these presentations, searchable clinical questions were developed, and the literature was searched, critically analyzed, and summarized. Results of several cycles on this process are reported. The group developed a repository of Internet-based resources for evidence-based education and practice. Using these resources, the group analyzed six topics in the first 2 years of the program. These included the "best" way to clinically grade patients after subarachnoid hemmorhage, considerations in the biopsy and treatment of enhancing intracerebral mass lesions in patients with acquired immunodeficiency syndrome, the use of prophylactic anticonvulsants in patients with primary brain tumors, the identification of cervical spine injuries in the emergency department, the grading of the fractures of the odontoid process, and the value of removing retained bullets from the spinal canal. The outcomes ranged from finding insufficient evidence to reach a conclusion, through the identification of well-conducted and well-reported critical syntheses of the topic already available in literature, to the development of the detailed algorithm for cervical spine clearance that was accepted by the institution's emergency department. By dedicating some specific time and using resources readily available in most academic health centers, it is possible to incorporate the teaching of the principles of evidence-based practice into the ongoing education of residents on a busy surgical subspecialty service.

耳下腺および副咽頭間隙に再発した急性白血病の１例

We report a case of an extramedullary relapse of acute myelogenous leukemia [M2 t (8; 21)] in the parotid gland and parapharyngeal space of a 50-year-old male. A Papanicolaou stain, revealed scattered small blasts with enlarged. nuclei. The blast-like cells were difficult to definitively diagnose by Papanicolaou stain. but the clinical findings enabled a diagnosis of the extramedullary spreading of acute leukemia cells to be confirmed using immunohistochemistry for peroxidase as well as May Giemsa staining. The possibility of extramedullary extensions or relapses should be kept in mind during the cytological examination of solid mass lesions in patients undergoing chemotherapy for acute myelogenous leukemia.

SPECT Thallium-201 Combined with Toxoplasma Serology for the Presumptive Diagnosis of Focal Central Nervous System Mass Lesions in Patients with AIDS

Objective: To determine the utility of brain thallium-201 single photon emission computerized tomography (Tl-201 SPECT) combined with Toxoplasma serology for the diagnosis of focal CNS lesions in patients with AIDS.Methods: Sixty-one consecutive HIV-infected patients with focal CNS lesion(s) on head computed tomography (CT) or MRI scan who underwent brain Tl-201 SPECT and serum Toxoplasma serology were evaluated, retrospectively. Thallium-201 uptake ratios were calculated by comparing lesion activity to contralateral scalp activity. Diagnoses were made by a combination of histology, serology, PCR, and empirical response to therapy. Toxoplasma serologies (IgG IFA) were compared in the patients with central nervous system (CNS) toxoplasmosis and those without CNS toxoplasmosis.Results: Fifty-six patients were evaluable and a definitive diagnosis was made in 38 patients: toxoplasmosis (17), lymphoma (14), PML (three),Aspergillus (one), tuberculoma (one), Cryptococcus (one), varicella-zoster virus (one). Patients with lymphoma had significantly higher lesion/contralateral scalp ratios compared to patients without lymphoma: 1.03 vs. 0.67,P <0.05. Using a cut-off of 0.90 for the lesion/scalp uptake ratios (based on analysis of ROC curves) the sensitivity and specificity for the diagnosis of lymphoma were 86% and 83%, respectively. Serum Toxoplasma IgG titres were significantly higher in patients diagnosed with toxoplasmosis compared to those with a diagnosis other than toxoplasmosis, 1:5444 vs. 1:15, P<0.05. Only one patient with confirmed toxoplasmosis had a Toxoplasma serology <1:256, while no patients without toxoplasmosis (including all lymphoma patients) had serologies >1:256.Conclusions: In a series of HIV-infected patients, Tl-201 SPECT was able to accurately differentiate primary brain lymphoma from other causes of focal CNS lesions in most patients; however, both false positive and false negative results occurred. By combining Tl-201 SPECT with serumToxoplasma IgG, diagnostic accuracy was improved.

4570 Yield of eus-guided fine needle aspiration cytology of pancreatic juice for diagnosis of pancreatic malignancy.

Objectives: Endosonographic imaging of the pancreas is a widely accepted method of evaluating patients with suspected pancreatic malignancy. Patients with pancreatic neoplasia often have dilated pancreatic ducts which are easily sampled with FNA facilitated by EUS guidance.We reviewed retrospectively a consecutive series of patients over a 28 months who had EUS guided pancreatic duct aspiration for diagnostic yield, ease of performance, and complications. Methods: All patients who underwent EUS guided FNA of the pancreatic duct from July 1997 to November 1999 were reviewed. Cytologic diagnosis was compared to initial EUS interpretation and final diagnosis (surgical pathology on pancreatic resection or diagnostic FNA of a pancreatic mass). Results: Thirty-three consecutive pancreatic duct FNA's were identified during a 28 month interval. Of these, three aspirates (9%) were deemed unsatisfactory for cytologic analysis. Eight aspirates (24%) were interpreted as negative, five patients were later proven to have adenocarcinoma, and three had chronic pancreatitis. Nine (27%) aspirates were cytologically diagnostic and confirmed the initial EUS findings: six with pancreatic adenocarcinoma and three with IPMT. Thirteen aspirates (39%) were interpreted as indeterminate; 11 of these proved to be associated with pancreatic adenocarcinoma and 2 IPMT's. Nineteen aspirates were obtained from pancreatic mass lesions. Sixteen were diagnostic for adenocarcinoma, 1 unsatisfactory for evaluation and 3 were indeterminate. Six aspirates were obtained from pancreatic mass lesions in patients later proven to have IPMT: 4 were diagnostic, 1 unsatisfactory and 1 indeterminate. All were performed successfully with one pass of a 22 gauge needle through the working channel of the echoendoscope. None of the patients had complications related to the procedure (bleeding, pancreatitis, or infection). Conclusions: Although technically straightforward, safe and specific, EUS-guided FNA of the pancreatic duct is an insensitive test for the presence of malignancy. Objectives: Endosonographic imaging of the pancreas is a widely accepted method of evaluating patients with suspected pancreatic malignancy. Patients with pancreatic neoplasia often have dilated pancreatic ducts which are easily sampled with FNA facilitated by EUS guidance.We reviewed retrospectively a consecutive series of patients over a 28 months who had EUS guided pancreatic duct aspiration for diagnostic yield, ease of performance, and complications. Methods: All patients who underwent EUS guided FNA of the pancreatic duct from July 1997 to November 1999 were reviewed. Cytologic diagnosis was compared to initial EUS interpretation and final diagnosis (surgical pathology on pancreatic resection or diagnostic FNA of a pancreatic mass). Results: Thirty-three consecutive pancreatic duct FNA's were identified during a 28 month interval. Of these, three aspirates (9%) were deemed unsatisfactory for cytologic analysis. Eight aspirates (24%) were interpreted as negative, five patients were later proven to have adenocarcinoma, and three had chronic pancreatitis. Nine (27%) aspirates were cytologically diagnostic and confirmed the initial EUS findings: six with pancreatic adenocarcinoma and three with IPMT. Thirteen aspirates (39%) were interpreted as indeterminate; 11 of these proved to be associated with pancreatic adenocarcinoma and 2 IPMT's. Nineteen aspirates were obtained from pancreatic mass lesions. Sixteen were diagnostic for adenocarcinoma, 1 unsatisfactory for evaluation and 3 were indeterminate. Six aspirates were obtained from pancreatic mass lesions in patients later proven to have IPMT: 4 were diagnostic, 1 unsatisfactory and 1 indeterminate. All were performed successfully with one pass of a 22 gauge needle through the working channel of the echoendoscope. None of the patients had complications related to the procedure (bleeding, pancreatitis, or infection). Conclusions: Although technically straightforward, safe and specific, EUS-guided FNA of the pancreatic duct is an insensitive test for the presence of malignancy.

The utility of fine-needle biopsy of liver mass lesions in patients with cirrhosis and serum alphafetoprotein less than 500

The utility of fine-needle biopsy of liver mass lesions in patients with cirrhosis and serum alphafetoprotein less than 500

HIV-related primary cerebral lymphoma: the role of stereotactic biopsy

Primary cerebral lymphoma (PLC) is a common cause of cerebral mass lesion in patients with the acquired immune deficiency syndrome. Its clinical features and radiological appearance are non-specific in this group of patients who are often quite debilitated at the time of presentation. We present a retrospective series of 9 cases of AIDS related PCL proven by stereotactic biopsy. There were no deaths from the biopsy and only one case in which there was worsening of the preoperative neurological condition. Although the overall outlook for these patients was poor (mean time to death 18 weeks), all but one showed some clinical response to palliative treatment with radiotherapy and steroids. In this context, we suggest that stereotactic biopsy as a means to positively establish the diagnosis prior to treatment is a safe technique to use in this group of often debilitated patients.

Glucocorticoid treatment of primary CNS lymphoma.

Glucocorticoid therapy may result in the rapid resolution of cerebral mass lesions in patients with primary CNS lymphoma. Since glucocorticoids will obscure the histological diagnosis of primary CNS lymphoma upon biopsy, steroids should be withheld if primary CNS lymphoma is a likely diagnosis by neuroradiological criteria. The lympholytic effect of glucocorticoids is mediated by cytoplasmic steroid receptors which are translocated to the nucleus and signal apoptosis. Glucocorticoid-induced apoptosis of lymphoid cells does not require wild-type p53 activity, seems not to depend on caspase activation, but is attenuated by the bcl-2 protooncogene product. Longterm glucocorticoid therapy of primary CNS lymphoma is not recommended because relapse is probably inevitable and because of the prominent side effects of long-term glucocorticoid treatment. Further, long-term glucocorticoid treatment is contraindicated in immunocompromised patients with primary CNS lymphoma.

Pearls and pitfalls in the diagnosis and management of central nervous system infectious diseases.

Laboratory techniques for the diagnosis of central nervous system (CNS) infections are rapidly improving but at present have limitations that necessitate our guarded enthusiasm. Enteroviruses are the most common infectious agents of viral meningitis for which an etiology can be determined, and it is anticipated that the use of the reverse transcriptase polymerase chain reaction (RT-PCR) technique should significantly improve the identification of the etiologic agent of aseptic meningitis. The combination of the polymerase chain reaction technique with laboratory methods for the determination of intrathecal antibody production to herpes simplex virus and varicella-zoster virus have improved the rapidity with which these viral infections can be diagnosed. The pearls and pitfalls of the use of these laboratory techniques in the diagnosis of viral meningitis, recurrent meningitis, and focal encephalitis are included. Recommendations for the empiric therapy of bacterial meningitis in children and adults have changed because of the emergence of penicillin and cephalosporin-resistant pneumococcal organisms. The currently recommended antibiotics and their dosages are included. The evidence for the efficacy of dexamethasone therapy in bacterial meningitis is provided. Meningitis due to Mycobacterium tuberculosis is increasingly recognized, and the initiation of empiric antituberculous chemotherapy should not await the results of CSF cultures. Toxoplasma encephalitis and primary CNS lymphoma are the most common cause of mass lesions in patients with HIV, and the diagnostic techniques to distinguish between these two infections is reviewed. A short discussion of the best test for the diagnosis of neurosyphilis is provided.

Intracerebral mass lesions in patients with human immunodeficiency virus infection and cryptococcal meningitis

The frequency of intracerebral mass lesions (ICML) in patients with human immunodeficiency virus (HIV) infection and cryptococcal meningitis (CM) is not well established. Cryptococcoma seems to be a rare affiction. The objective of this study was to analyze the etiology of ICML in patients with HIV infection and CM. The methodology was a retrospective review of cases diagnosed in two Spanish hospitals between September 1988 and April 1995. Eighteen cases of CM were identified. Computed tomography was performed on presentation in 17 cases. Only one patient had ICML, which progressed while on antifungal treatment and regressed when anti-Toxoplasma treatment was established. During follow-up, two additional patients developed ICML and were successfully treated as toxoplasmosis. Overall, 3 out of 17 patients (18%) developed ICML and all three were cured when anti-Toxoplasma treatment was implemented. In our study, cerebral toxoplasmosis was the only presumed cause of ICML. In areas of high prevalence of toxoplasmosis, ICML in patients with CM may not by cryptococcomas. Consequently, in these areas of high prevalence, a trial of toxo-therapy should be strongly considered for patients with CM and ICML.

Differentiation of central nervous system lesions in AIDS patients using positron emission tomography (PET).

To determine if positron emission tomography (PET) imaging using F-18 fluorodeoxyglucose (FDG) can accurately distinguish between malignant and infectious central nervous system (CNS) mass lesions in patients with human immunodeficiency virus (HIV) infection, a prospective case series of 18 patients with HIV infection and focal CNS lesions on computed tomography (CT) or magnetic resonance (MR) scans was analysed. The patients were divided into 3 groups based on biopsy results, serology and response to therapy. Group 1 consisted of 8 patients with infectious lesions (4 with toxoplasmosis, 2 with neurosyphilis, 2 with progressive multifocal leukoencephalopathy (PML)). Group 2 consisted of 5 patients with biopsy proven CNS lymphoma. Group 3 consisted of 5 patients with presumed CNS lymphoma. Patients underwent FDG-PET studies as an adjunctive diagnostic procedure. The metabolic activity of each patient's lesion was graded using both a qualitative visual score and a semi-quantitative count ratio comparing the lesion with contralateral brain. CNS lesions diagnosed as lymphomas had statistically higher visual scores (P = 0.001) and count ratios (P = 0.002) than CNS lesions diagnosed as infections. FDG-PET could accurately differentiate lymphoma from infections in 16 of 18 cases. Two cases of PML had high metabolic activity and could not be differentiated from lymphoma. FDG-PET shows great promise in differentiating lymphoma from infectious lesions in the CNS of patients with HIV infection. If larger prospective studies confirm this impression, more specific and rapid treatment of CNS lesions could be performed and perhaps obviate the need for brain biopsy in many cases.

AIDS-Associated Cytomegalovirus Infection Mimicking Central Nervous System Tumors: A Diagnostic Challenge

We reviewed cases of cytomegalovirus (CMV) infection of the central nervous system (CNS) that initially masqueraded as tumors in 37 of 543 consecutive patients infected with human immunodeficiency virus (HIV) and CMV who were seen at the Pasteur Institute Hospital and Saint-Louis Hospital (Paris) between 1992 and 1994. We detail the clinical features of three patients who presented with ring-enhanced space-occupying lesions mimicking CNS tumors. They were all profoundly immunodepressed (mean CD4 cell count, 13/mm3). Magnetic resonance imaging (MRI) showed enlargement of the spinal cord in one case, consistent with a space-occupying lesion and showing gadolinium enhancement; in the other two cases, ring-enhanced mass lesions were seen in the cerebral hemispheres. In all three cases marked edema and a mass effect were present. Image-guided stereotactic biopsies confirmed the diagnosis of CMV infection. The three patients' conditions improved with specific therapy. MRI showed enhanced focal intraparenchymal lesions consistent with marked focal necrosis, probably related to the severity of immunodepression, as HIV infection had been diagnosed several years previously. CMV infection should be considered as a cause of ring-enhanced space-occupying mass lesions in patients with HIV-1 infection. Earlier identification of these unusual tumorlike forms of CMV infection by means of MRI should result in improved outcome.

Isolated toxoplasmosis of the thoracic spinal cord in a patient with acquired immunodeficiency syndrome

Toxoplasmosis and lymphoma are the two most common causes of intraparenchymal cerebral mass lesions in patients with acquired immunodeficiency syndrome (AIDS). The clinical and radiographic features of the intracranial lesions have been well described. Because of the high frequency of toxoplasmosis in the AIDS population, common therapy for patients presenting with intracranial mass lesions consists of an empirical trial of anti-Toxoplasma chemotherapy, with biopsy reserved for cases demonstrating features considered to be more consistent with lymphoma, or for lesions that do not improve despite adequate anti-Toxoplasma treatment. A similar treatment algorithm does not exist for intramedullary lesions of the spinal cord. The authors describe a patient who presented with paraparesis resulting from an isolated thoracic intramedullary lesion. An open biopsy of the lesion revealed characteristic structures containing Toxoplasma tachyzoites. The clinical and radiographic presentation of the lesion is discussed, the available literature is reviewed, and a treatment strategy for spinal cord lesions in AIDS patients is proposed.

Cerebral mass lesions due to cytomegalovirus in patients with AIDS: Report of two cases

Cytomegalovirus (CMV) is an increasingly important opportunistic pathogen in patients with HIV infection and advanced immune deficiency. Neurological complications due to CMV cause significant morbidity but may be treatable with specific anti-viral therapy: cerebral mass lesions are not a generally recognised manifestation. We report two patients with CMV encephalitis presenting as a cerebral mass lesion, with simultaneous occurrence of a pleuro-pulmonary mass also caused by CMV in one case, and with concurrent polyradiculomyelopathy in the other. The spectrum of previously reported clinical and radiological features of CNS involvement in AIDS is discussed. CMV should be considered in the differential diagnosis of cerebral mass lesions in patients with HIV infection and severe immune deficiency so that anti-viral therapy can be rapidly deployed.

Anatomic Temporal Lobe Resections for Temporal Lobe Epilepsy

Temporal lobe epilepsy is not a single clinicopathologic entity but a group of syndromes requiring different surgical solutions. Anatomic resections planned for the treatment of these syndromes are aimed at pathologic substrates minimizing ablation of normal tissue. Most of these procedures involve mesial and lateral temporal resections. The syndrome of mesial temporal sclerosis should be treated with resection aimed at hippocampus and the PHG, including entorhinal cortex, and at part of the amygdala. Improvement in diagnostic methods and refinement of anatomic surgical procedures that maximize resection of hippocampus resulted in excellent outcome in the treatment of patients with this syndrome. Mass lesions in patients with intractable seizures should be resected with some surrounding margins, but additional clinical studies will be required to determine the role of anatomic resections, including hippocampectomy, in the treatment of these patients. Extrahippocampal temporal lobe epilepsy is the most difficult to evaluate and treat. Tailored individualized resections based on acute or chronic EEG recordings may be required until and if discrete anatomically based syndromes can be identified in this patient population.

Empiric Treatment of Acute Toxoplasma Encephalitis in Patients With Acquired Immunodeficiency Syndrome

To the Editor.— We have read with interest the article by Cimino et al1about patients infected with human immunodeficiency virus (HIV) presenting with brain mass lesions. The fact that one third of their patients withToxoplasmaencephalitis, diagnosed bymeans of brain biopsy, did not respond to treatment with pyrimethamine and sulfadiazine (doses of which were not mentioned by the authors) deserves special attention. Empiric treatment of brain mass lesions in patients with HIV infection with the use of anti-Toxoplasmatherapy is currently accepted. Nevertheless, consensus about the optimal daily doses of pyrimethamine and sulfadiazine has not been established. Proposed doses ranged from 25 to 200 mg/d for pyrimethamine and from 4 to 8 g/d for sulfadiazine.2-9 Pyrimethamine is a powerful antiToxoplasmadrug and, to our knowledge, no in vitro resistances against it have been reported. The Pharmacokinetic profile of pyrimethamine shows a variable half-life bioavailability (35

Cushingʼs Syndrome With Cranial and Pulmonary Lesions

This report describes two cases of Cushing's syndrome associated with radiologic abnormalities in the lung and brain. In both cases, the pathologic diagnosis of the intracranial lesion was unsuspected and prompted changes in management. These cases illustrate that the etiology of pulmonary and central nervous system mass lesions in patients with Cushing's syndrome may not be predicted on clinical grounds or by conventional radiologic methods. A tissue diagnosis is essential as a guide to appropriate management, and biopsies of such lesions are indicated.