Multiple Ring-enhancing Lesions Research Articles

Intracranial dissemination of Klebsiella pneumoniae originating from pulmonary infection: a case report

BackgroundMetastatic brain abscesses caused by Klebsiella pneumoniae are extremely rare but life-threatening conditions. To depict a unique case of the middle-aged hypertensive man with an unusual presentation of metastatic brain abscesses originating from a pleural abscess caused by Klebsiella pneumoniae and subsequently leading to loss of consciousness (LOC).Case reportA 52-year-old Iranian man with a history of hypertension presented to the emergency department with a five-day history of worsening cough, high-grade fever, shortness of breath, chest pain, fatigue, and a productive cough. Laboratory tests revealed leukocytosis, elevated C-reactive protein, and respiratory alkalosis. A chest computed tomography scan confirmed pneumonia, and a brain scan revealed multiple hypodense lesions. Despite antibiotic therapy, the patient's condition worsened, leading to confusion, disorientation, and loss of consciousness. Magnetic resonance imaging revealed multiple ring-enhancing lesions, suggesting an abscess formation. Bronchial washings and BAL samples confirmed a lower respiratory tract infection. Cultures from the bronchial washings grew Klebsiella pneumoniae.ConclusionsMetastatic brain abscesses caused by Klebsiella pneumoniae are exceedingly rare but life-threatening conditions. Timely diagnosis and effective antimicrobial treatment are critical for patient outcomes. This case underscores the significance of recognizing atypical presentations of bacterial infections, as early detection and appropriate management can significantly impact patient outcomes.

Paediatric parenchymal neurocysticercosis with pleomorphic clinico-radiological presentations: a case series

BackgroundNeurocysticercosis (NCC) is thought to be the most common helminthic infection of central nervous system in India. In children, it has pleomorphic clinical and radiological presentations depending on location and stage of lesion. Solitary cystic granuloma appearing as a single ring enhancing lesion is the most frequently encountered neuroimaging finding in patients with neurocysticercosis or tuberculoma in India. This series reports unusual clinico-radiological aspects of pediatric neurocysticercosis patients of Asian ethnicity.Case presentationIn the present case series, we have described socio-demographic and clinico-radiological profile of eight cases of neurocysticercosis with parenchymal lesions in varying stages of development. Among these two had single discrete ring enhancing lesion (SDREL), two had single conglomerated ring enhancing lesion (SCREL), and five cases reported to have multiple ring enhancing lesions (MREL). Two cases with recurrent neurocysticercosis have been reported which is quite rare. Magnetic resonance spectroscopy helps to differentiate between neurocysticercosis and tuberculoma and may avoid brain biopsies or unnecessary anti-tubercular treatment. Magnetic resonance spectroscopy (MRS) was done in three cases with findings of absence of lipid peak and choline/creatinine ratio less than 1.2.ConclusionDespite the advances in neuroimaging, accurate diagnosis of NCC is still sometimes difficult, which is related to the pleomorphic nature of disease and significant overlapping features with tuberculoma. A combination of proper diagnostic criteria and neuroimaging findings are helpful in making the diagnosis without invasive and potentially harmful investigations in paediatric patients.

Utility of Clinical and Radiological Markers in Diagnosing Cerebral Tuberculoma and Neurocysticercosis

Abstract Background Ring-enhancing lesion is one of the most common radiological findings in a spectrum of diseases affecting the central nervous system (CNS) including infectious, inflammatory, demyelinating, and neoplastic pathologies. Objective The aim of this study was to analyze the clinical and radiological parameters of pathologies presenting as ring-enhancing lesions in the brain, especially tuberculoma and neurocysticercosis. Materials and Methods In this study, 58 patients with ring-enhancing lesions on brain magnetic resonance imaging (MRI) were recruited. Cases were studied for different clinical and radiological variables. Data were analyzed using SPSS 20 version. Results Tuberculoma is the most common pathology accounting for ring-enhancing lesions in the brain, followed by neurocysticercosis. Seizures were present in the majority of cases, with focal onset seizures being more common than generalized seizures. Multiple ring-enhancing lesions were present in the majority of cases, with the cerebral cortex being the most frequently involved site. On T2 fluid-attenuated inversion recovery (FLAIR) sequence, 2/3rds of the neurocysticercosis cases showed full suppression, whereas only 1/10th of tuberculoma cases showed full suppression. On diffusion-weighted imaging (DWI), a minority of neurocysticercosis cases showed diffusion restriction, while more than one-fifth of tuberculoma cases showed diffusion restriction. MR spectroscopy (MRS) results showed that a normal lipid lactate peak was observed in the majority of neurocysticercosis cases, whereas more than half of tuberculoma cases had a high lipid lactate peak. The choline-to-creatine ratio (Chol/Cre ratio) was less than 1.2 in one-third of neurocysticercosis cases and between 1.2 and 2.0 in two-thirds of the cases. In contrast, more than half of tuberculoma cases showed a Chol/Cre ratio between 1.2 and 2.0. Conclusion Tuberculoma and NCC are the two most common causes of ring-enhancing lesions in developing world. Radiological characteristics like FLAIR suppression and diffusion restriction on MRI and Chol/Cre ratio and lipid peak on MRS can substantiate the clinical parameters in distinguishing the two pathologies to a good extent.

Cerebral Tuberculoma Diagnosed by Nested Polymerase Chain Reaction of a Formalin-fixed Paraffin-embedded Brain Biopsy Sample.

A 38-year-old man was taken to hospital with generalized clonic seizure. Brain magnetic resonance imaging (MRI) showed multiple ring-enhancing lesions centered in the left frontoparietal lobe. A histopathological examination of a brain biopsy sample revealed granulomatous lesions with caseous necrosis. We extracted DNA from a formalin-fixed paraffin-embedded (FFPE) brain specimen, and nested polymerase chain reaction (PCR) of the DNA sample detected the Mycobacterium tuberculosis-specific insertion sequence IS6110. The lesions worsened after anti-tuberculosis drugs were administered, which we considered to be a paradoxical response and continued treatment. A genetic diagnosis of M. tuberculosis using FFPE specimens is useful for diagnosing tuberculoma.

Clinical diagnosis and management of multiple cerebral ring-enhancing lesions-study of 50 patients at a tertiary healthcare center.

Multiple ring-enhancing lesions are commonly experienced group of brain pathologies which we come across in day-to-day practice. Clinical symptoms in these lesions are quite non-specific, and hence, it is difficult to reach a final diagnosis. However, these lesions have a varied group of differential diagnosis and it is sometimes difficult to have an accurate diagnosis on conventional MRI. This article was written with the objective of discussing the demographical study and etiology, clinical diagnosis and management for these patients. It is a prospective study carried out at the Department of Neurosurgery, Dr. D Y Patil Medical College and Hospital, Pune, from September 2019 to August 2022 and included 50 patients who presented to us multiple ring-enhancing brain lesions. In our study, 50 patients between age (1-70 years) with multiple ring-enhancing lesions were analyzed. Majority of the patients were between age group 30-39 years. Males (76%) were majority in our study than females (24%). Most common pathology was primary neoplasm (glioma) and metastasis, followed by nine patients of pyogenic abscess and tuberculosis each. Neurocysticercosis was seen in eight patients and three patients were diagnosed with CNS lymphoma. Most of our patients presented with headache (38 patients) and a subset of patients had associated seizures (28 patients). Two patients with primary neoplasm were diagnosed to have WHO grade 3 glioma and seven patients were diagnosed to have WHO grade 4 glioma. Glioblastoma multiforme presented as multifocal and multicentric lesions. Among the patients with primary neoplasm, three patients underwent stereotactic biopsy for diagnosis and the rest of seven patients underwent maximum safe resection followed by chemotherapy and radiotherapy. Ten patients were diagnosed with metastatic lesions, among them six patients underwent stereotactic biopsy for histopathological diagnosis and immunohistochemistry, and rest of the patients were managed on the basis of the primary lesion. Five patients were immune-compromised, among them two patients presented with abscess and three patients presented with primary neoplastic lesion. Thirty-six patients underwent biopsy, among them seven patients underwent frameless, seven patients underwent frame stereotactic biopsy, and the rest 22 patients underwent excision biopsy. Multiple ring-enhancing lesions of brain pose a challenge in terms of achieving an accurate diagnosis and planning further treatment. It is of utmost importance to have a diagnosis in mind based on radiological investigations, so that surgical intervention can be planned accordingly be it by invasive or minimal invasive techniques. An idea toward the diagnosis also helps in prognosticating these patients which could avoid costly whole-body scans and unnecessary surgical intervention.

Diagnostic Dilemma of Central Nervous System Tuberculosis with Neurocysticercosis and Neurosarcoidosis: A Case Report.

brain; case reports; neurocysticercosis; sarcoidosis; tuberculoma.

P144 The uncommon meets the common: Invasive Aspergillosis and tuberculosis co-infection in non-neutropenic patients— arare association

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PMBackground and ObjectiveInvasive aspergillosis (IA) is known to occur in immunocompromised patients including neutropenic patients. But, recently increasing cases have been reported in patients with non-classical risk factors and non-neutropenic patients like diabetes mellitus, chronic lung disease, HIV infection, critically ill patients, etc. According to ISHAM these non-classical risk factors should be included in EORTC/MSG host criteria for diagnosis of invasive aspergillosis.India has a high tuberculosis (TB) burden, and this is always considered as the first differential for any patient with fever, cough, hemoptysis, and weight loss. Post-tubercular chronic pulmonary aspergillosis common reported condition. However, co-infection of active TB and invasive aspergillosis is less reported. This co-infection could be one of the contributors of high morbidity and mortality in cases with tuberculosis.We hereby present a series of five cases of TB concomitant with invasive aspergillosis in non-neutropenic patients.MethodsThis is a prospective observational study, all patients admitted with molecular diagnosis (GeneXpert) of tuberculosis and with at least one non-classical risk factor for invasive aspergillosis were subjected to further evaluation. Diagnosis of invasive aspergillosis was considered in patients who had at least one clinical and one mycological EORTC criteria. Galactomannan level in different samples was measured via PlateliaTM ELISA. The efficacy of different antifungals and outcomes were analyzed.ResultsTotal 57 patients with TB underwent for evaluation of invasive aspergillosis. Among them, five patients were diagnosed to have concomitant TB and invasive aspergillosis, of which three cases of CNS TB and CNS aspergillosis and two had concomitant pulmonary infections. The average age was 31 ± 12 years with a female preponderance (4/5). Two patients were HIV positive, while among non-HIV patients, one had CD4 cytopenia (CD4-171). One patient had no known predisposing factor. Radiologically, most common pulmonary lesions were patchy consolidation with centrilobular nodules with tree in bud appearance, while CNS lesions showed multiple ring-enhancing lesions. All the patients had CBNAAT positive, two from BAL sample, 1 from CSF, and 1 from the lymph node. Rifampicin was sensitive in all, except one who had rifampicin resistance indeterminate. Of these patients, four were probable invasive aspergillosis satisfying the host, mycological and clinical factors as per the EORTC/MSGERC 2021 guidelines. The treatment of coinfection is challenging due to the interaction of rifampicin with voriconazole, which is the drug of choice for invasive aspergillosis. Here, 3 patients were treated with Inj amphotericin B, while the other 2 patients were started on voriconazole with rifampicin sparing regimen for TB. Of the 5 patients, 4 patients survived with excellent response to the treatment, with one fatality.ConclusionThe possibility of concurrent TB and invasive aspergillosis in non-neutropenic hosts should be considered to avoid devastating outcomes. The lack of clinical suspicion may result in misdiagnosis, and most importantly, the chronicity of the infection makes it indistinguishable from TB. Moreover, the co-administration of antifungal and anti-TB medications presents significant therapeutic challenges necessitating thorough evaluation and monitoring.

Reactivation of Disseminated Histoplasmosis With Central Nervous System Involvement Following a Primary Gastrointestinal Histoplasmosis Infection: A Case Report

A 78-year-old white male with chronic pancytopenia presented with acute transient aphasia and dysarthria. He had a National Institutes of Health Stroke Scale (NIHSS) of zero. Physical examination revealed slight aphasia with mild dysarthria. Brain magnetic resonance imaging (MRI) revealed nine ring-enhancing lesions in the left precentral gyrus with significant vasogenic edema. Lung computed tomography (CT) showed no evidence of pulmonary nodules. The serology of blood and urine for infectious organisms was negative. Four weeks later, the patient was re-admitted with worsening dysarthria and right upper extremity weakness. Repeat head MRI showed a slight increase in the size of the multiple supratentorial ring-enhancing lesions. The magnetic resonance spectroscopy (MRS) findings of the evaluated lesion suggested a fungal etiology. Empiric amphotericin B treatment was initiated, which mitigated central nervous system (CNS) ring-enhancing lesions and resolved the patient’s neurological deficits. Early empiric medical treatment of CNS histoplasmosis should be considered in the setting of multiple CNS ring-enhancing lesions and a positive history of histoplasmosis infection, despite negative serological studies.

64-Year-Old Woman With Aphasia and Troponin Elevation

64-Year-Old Woman With Aphasia and Troponin Elevation

A rare cause of acute onset central hypersomnia

Tuberculosis of the nervous system constitutes about 10% of total cases and is more common in developing countries like India. Varied clinical presentations, ranging from meningoencephalitis, tuberculoma, multiple cranial palsies to myelo-radiculitis, are noted. Here we highlight central sleep apnoea as an acute presentation, which is unusual in a neurological setting. Here, we present a 49-year old male, presented with acute onset of excessive daytime sleepiness for two weeks. Clinically he had no focal deficits. MRI brain plain and contrast showed multiple conglomerate ring-enhancing lesions with vasculitic infarcts consistent with tuberculosis. CSF analysis was normal apart from slightly elevated protein. He was initiated on steroids and anti-tuberculous therapy. Hypersomnia as an acute and solitary neurological presentation secondary to subacute infections is a rarity. Apart from vascular insults, infections like tuberculosis needed to be considered as one of the differentials. Early evaluation helps in prevention of associated complications and improve the quality of life.

A Rare Case of Multiple Ring-Enhancing Lesions on Magnetic Resonance Imaging of the Brain in Varicella-Zoster Virus Encephalitis with Human Immunodeficiency Virus.

A Rare Case of Multiple Ring-Enhancing Lesions on Magnetic Resonance Imaging of the Brain in Varicella-Zoster Virus Encephalitis with Human Immunodeficiency Virus.

Toxoplasma encephalitis – A presenting feature of HIV disease

Central nervous system (CNS) toxoplasmosis is one of the leading causes of secondary CNS infection and seizures in human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) patients along with cryptococcosis and tuberculosis. Encephalitis can be a primary presentation in undiagnosed HIV patients. We are reporting a rare case of HIV/AIDS that presented to us with encephalitis and was later diagnosed as toxoplasma encephalitis. A 32-year-old male truck driver presented with altered behaviour for about 1 month and vomiting for 4 days. On clinical examination, papilloedema was present. Further investigations revealed serologically proven HIV with CD4 T lymphocyte count of 56 cells/microL. Brain imaging showed multiple ring-enhancing lesions in the bilateral cerebral hemispheres and right cerebellar hemisphere. Serum toxoplasma antibodies were found to be positive and a diagnosis of CNS toxoplasmosis encephalitis was made. Treatment with trimethoprim–sulphamethoxazole and highly active antiretroviral therapy was initiated following which there was a significant improvement in the patient's clinical condition. The patient is on regular follow-up now.

Intracranial tuberculomas or neurocysticercosis: differentiated by cervical lymph node pathology

BackgroundDiagnosis of tuberculomas can be difficult in the absence of pulmonary involvement due to numerable mimics.Case reportWe report an immunocompetent 20-year-old female patient, who was admitted with new-onset generalized seizure. Cranial magnetic resonance imaging (MRI) revealed multiple ring-enhancing lesions. There was no reported systemic symptom such as weight loss, fever or night sweating. Polymerase chain reaction for SARS-COV-2 was negative. Computed tomography of thorax was normal. With an initial diagnosis of neurocysticercosis, she was treated with albendazole for one month. Follow-up cranial MRI showed no improvement. On follow-up visit, an enlarged cervical lymph node was recognized. Biopsy of the lymph node led to the diagnosis of tuberculosis. Two months after the onset of anti-tuberculosis therapy, follow-up cranial MRI showed near-complete resolution.ConclusionInvestigation of any involvement of disease other than the central nervous system can enable accurate and timely diagnosis of tuberculomas in the absence of pulmonary involvement.

260. The Unfortunate Consequence of Immunosuppression in a Renal Transplant Patient

BackgroundNocardia is a slow-growing aerobic-actinomycete that belongs to the family Nocardiaceae. Major predisposing factors include corticosteroid use, organ transplantation, low CD4 count, and hematologic malignancies. The most commonly affected organs are lungs, mainly via inhalation; however, the most common extrapulmonary site is central nervous system.MethodsMatrix Assisted Laser Desorption Ionization - Time of Flight (MALDI-ToF) or 16srRNA sequencing are more reliable methodologies for accurate identification of Nocardia to the species level. To our knowledge, our patient represented the first U.S. case of N. bejingensis opportunistic disseminated infection in a renal transplant patient although similar cases have been previously reported outside the U.S.GMS stain Gram Stain of Nocardia ResultsWe present a 31-year-old Caucasian male status post renal transplant four years ago on immunosuppressants with left arm myoclonic jerks. In addition, there was an associated unilateral left frontal headache of four to five day duration. His chest CT revealed consolidative process in the right lower lobe and pleural effusion. MRI of the brain revealed multiple ring-enhancing lesions. Patient underwent left frontal craniotomy with resection and a complete evacuation of brain abscess. His brain abscess and pleural fluid cultures revealed Gram positive rods, which were subsequently identified as Nocardia beijingensis by MALDI-TOF and confirmed by 16srRNA sequencing. He was treated with intravenous imipenem & trimethoprim – sulfamethoxazole with subsequent clinical improvement.MRI Brain w/ contrast Head CT s/p left frontal craniotomy with resection & evacuation of abscess Chest CT ConclusionDifferent Nocardia species have a wide geographic distribution with varying pathogenic traits, and antimicrobial susceptibility. Hence, the identification of the specific species of Nocardia is crucial to provide a proficient level of patient care. Nocardia bejingensis is a newly discovered species of Nocardia that was first isolated in 2001 in China. Only six cases of N. beijingensis affecting CNS have been reported up to date in the United States. It is unclear of the geographic distribution and variable antimicrobial susceptibility of Nocardia bejingensis but we can confirm the first reported case of an opportunistic disseminated infection in a renal transplant patient in the United States.Agar Disclosures All Authors: No reported disclosures

RARE PRESENTATION OF DISSEMINATED TB: MULTIPLE RING ENHANCING LESIONS IN BRAIN

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cerebral tuberculomas is a rare form of extrapulmonary tuberculosis (TB). Due to lack of tests available for confirmatory diagnosis, the diagnosis is difficult. However, missing the diagnosis could lead to catastrophic consequences. Here, we report a case of disseminated tuberculosis presented with multiple ring enhancing lesions in the brain. CASE PRESENTATION: A 75-year-old male presented with progressive generalized weakness associated with fever and chills for 3 weeks. He has a history of bronchial carcinoid tumor status post radiation therapy, Waldenstrom's macroglobulinemia, heart failure with reduced ejection fraction, implantable cardiac defibrillator placement, coronary artery disease, stroke, and type 1 diabetes. He appeared tired with mild symmetrical lower limb weakness, but there were no meningeal signs. CT of head revealed innumerable ring-enhancing lesions in both cerebrum, cerebellum and brainstem. Analysis of cerebrospinal fluid (CSF) showed lymphocyte predominant pleocytosis (WBC of 253/cumm), elevated protein (155 mg/dl) with low glucose ratio (CSF/serum glucose ratio of 0.4). Empirical treatment for meningitis were started, but intermittent spiking fever persisted. Unfortunately, the patient had a cardiac arrest while he was undergoing brain MRI. Postmortem autopsy revealed multiple necrotizing granulomatous nodules with AFB positive bacteria in multiple organs, including brain, lung, liver, spleen, thyroid, pulmonary and extrapulmonary lymph nodes. Mycobacterium tuberculosis complex was isolated from CSF subsequently. A diagnosis of disseminated TB was made. Upon further investigation, the patient did not have exposure history, except for travelling around the globe when he was young. DISCUSSION: The differential of multiple ring-enhancing lesions in the brain is broad, which include neurocysticercosis, toxoplasmosis, cryptococcosis, bacterial abscess, CNS lymphoma and cerebral metastases. Given the complicated medical history of our patient and lack of risk factor for TB, empirical treatment for TB was not given. In such a clinical scenario, a more sensitive test, e.g. nucleic acid amplification (NAA), would be the deciding factor for initiation of therapy. Unfortunately, there is a lack of data to support the use of NAA in patients at risk for cerebral tuberculoma. Future studies would be warranted to explore the use of NAA in the setting of extra-pulmonary tuberculosis. CONCLUSIONS: Disseminated tuberculosis is a lethal disease if missed. However, diagnosis of disseminated tuberculosis remains a huge challenge, especially when pulmonary symptoms are absent. A high index of suspicion is required to diagnose and treat disseminated tuberculosis. More researches are warranted to expedite the diagnosis of TB. REFERENCE #1: Suárez I, Fünger SM, Jung N, et al. Severe disseminated tuberculosis in HIV-negative refugees. Lancet Infect Dis 2019; 19: e352–e359. REFERENCE #2: Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention clinical practice guidelines: diagnosis of tuberculosis in adults and children. Clin Infect Dis 2017; 64:e1–33. DISCLOSURES: No relevant relationships by Gin Yi Lee, source=Web Response No relevant relationships by Kaiqing Lin, source=Web Response No relevant relationships by Guangchen Zou, source=Web Response

DISSEMINATED ACTINOMYCETOSIS WITH PNEUMONIA, LEFT GLUTEAL, LEFT EYE, AND BRAIN ABSCESSES IN A PATIENT WITH SJÖGREN AND INTERSTITIAL LUNG DISEASE

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: A localized or disseminated infection by an aerobic gram-positive beaded filamentous branching actinomycete Nocardia is called Nocardiosis. Its presence is ubiquitous, causing infection in immunosuppressed and healthy individuals. An increased incidence is due to the greater use of immunosuppressants and improved diagnostic processes. On average, 500-1,000 new cases occur in USA [1] CASE PRESENTATION: 86-year-old female with hypertension, diabetes, Sjogren's, and interstitial lung disease (ILD) on 10 mg prednisone came to the eye clinic for left blurry eye pain for three days. A recent ILD flare was treated with a steroid burst. Eye exam showed acute left eye endophthalmitis with bilateral chorioretinal infiltrates (Figure A1-2). A white cell count was normal with neutrophilia and an absolute lymphocyte count of 903 cells/mm3. Human immunodeficiency virus, syphilis, endemic fungal, and Quantiferon testing and blood cultures were negative. Echocardiogram was normal, while prednisone was held. Computed tomography (CT) of the chest, abdomen, and pelvis revealed interstitial pneumonia, new left lower lobe consolidation, left gluteal and right paraspinal muscle abscess, and left gluteal biopsy showed acid-fast filamentous microorganisms with culture positive for Nocardia farcinica resistant to ceftriaxone, clarithromycin, and tobramycin (Figure B1-4). Magnetic resonance imaging (MRI) brain revealed multiple ring-enhancing lesions in the right midbrain, left cingulate gyrus, parietofrontal and temporal lobe (Figure C1-3). On the 14th day, the left eye revealed a small subretinal abscess. An initial regimen of meropenem and bactrim was changed to amikacin and imipenem for six weeks at discharge. A week later, she was back in intensive care in a comatose state with worse MRI brain changes and placed on comfort care DISCUSSION: Disseminated disease is common in males and often presents with brain lesions, with N. farcinica being the frequent subspecies causing it due to its predilection for brain and skin tissue with an increased mortality rate [2-4]. N. farcinica is resistant to multiple antibiotics, including third-generation cephalosporins. A frequent site of the abscess is the parietofrontal lobe [5]. Mortality in multiple abscesses is higher than with a solitary abscess (66% vs. 33%) [6]. Inappropriate empirical therapy has higher mortality at 31% than an appropriate therapy (10%) [7]. Concomitant involvement of lungs, brain, eye, and muscles is rare. Due to a lower incidence, it is not considered at initial diagnosis CONCLUSIONS: In chronic respiratory disease patients on low-dose steroids, the onset of new visual or nervous system symptoms is a concern for disseminated nocardiosis with a recent history of steroid burst, lymphopenia, and neutrophilia REFERENCE #1: Beaman BL, Burnside J, Edwards B, Causey W. Nocardial infections in the United States, 1972-1974. J Infect Dis. 1976;134(3):286-9 REFERENCE #2: Kramer MR, Uttamchandani RB. The radiographic appearance of pulmonary nocardiosis associated with AIDS. Chest. 1990;98(2):382-5 REFERENCE #3: Sabuncuoğlu H, Cibali Açikgo Z Z, Caydere M, Ustün H, Semih Keskil I. Nocardia farcinica brain abscess: a case report and review of the literature. Neurocirugia (Astur). 2004;15(6):600-3 DISCLOSURES: No relevant relationships by Andres Bran, source=Web Response No relevant relationships by CARLA CARUSO, source=Web Response No relevant relationships by Paragkumar Patel, source=Web Response No relevant relationships by Tarang Patel, source=Web Response No relevant relationships by SACHIN PATIL, source=Web Response No relevant relationships by ANTONY RAWINDRARAJ, source=Web Response

Diagnosing Disseminated Nocardiosis in a Patient With COVID-19 Pneumonia

Signs and symptoms of atypical pneumonia include fever, shortness of breath, cough, and chest pain. During the coronavirus disease 2019 (COVID-19) pandemic, identifying other causes of febrile respiratory illness in patients who tested positive for COVID-19 has been very challenging. Concerns over infecting healthcare personnel and other patients can impede further evaluations like bronchial lavage, lung biopsies, and other invasive tests. A very high index of suspicion, perhaps unreasonably so, is required to perform invasive tests to investigate alternative possible causes of the illness. We present the case of a 63-year-old man who presented to the hospital with dyspnea. Chest X-ray demonstrated a consolidation in the left lower lobe lung field with a possible underlying mass, and the patient tested positive for COVID-19. He received the standard treatment for COVID pneumonia at the time in our institution (remdesivir and dexamethasone), empiric antibiotics for community-acquired pneumonia, and was eventually discharged home with supplemental oxygen. Several days later, the patient returned to the hospital again with worsening dyspnea and was readmitted. Persistent illness and worsening imaging prompted bronchoscopy. The bronchoscopy showed narrowing of the airway in the left upper lobe, and Nocardia asteroides was isolated from bronchial aspirate. The isolation of Nocardia prompted an investigation for central nervous system involvement with an magnetic resonance imaging (MRI) of the head. The MRI demonstrated multiple bilateral ring-enhancing lesions in the brain. To our knowledge, this is the first reported case of disseminated nocardiosis superimposed on COVID-19 pneumonia.

Glioblastoma Multiforme and Papillary Thyroid Carcinoma: Rare Combination of Primary Malignancies

Introduction: Studies have reported thyroid cancer patients are potentially at 30% increased risk of getting second primary cancer when compared to the general population. We are describing a young Caucasian male patient who was diagnosed with two synchronous cancers, papillary thyroid cancer (PTC) and glioblastoma multiforme (GBM). Case Report: A 52 year old Caucasian male with past medical history of hypertension, partial right thyroidectomy in 1999 for thyroid nodular disease, and postsurgical hypothyroidism on levothyroxine. He underwent FNA of left thyroid nodule found on routine monitoring of thyroid nodules showed to be suspicious for malignancy. He underwent left hemi-thyroidectomy in July 2019, revealing PTC, follicular variant, encapsulated, noninvasive type measuring 0.9 x 0.9 x 0.5 cm, completely excised with negative margins; reminder of the right hemi-thyroidectomy performed in February 2020, revealing cystic adenomatoid nodule and no evidence of malignancy. Postoperative thyroglobulin and thyroglobulin antibodies levels were undetectable. A diagnostic whole body iodine scan didn’t show metastasis hence Iodine-131 treatment was not warranted. A week following the right hemi-thyroidectomy he presents to the ER with apraxia, difficulty with concentration, visual difficulty, headaches. CT scan of the brain revealed left occipital region revealed a 3.7 x 2.3 cm lesion concerning for malignancy. A follow up contrast-enhanced MRI brain showing multiple ring-enhancing lesions identified within the left posterior occipital lobe measuring 1.7 x 1.8 cm, additional occipital lobe lesion measuring 2.7 cm, mid and posterior parietal lobe measuring 3.0 cm extending to collateral sulcus measuring 2 x 3 x 1.9 cm compressing the posterior horn of left lateral ventricle. Patient underwent suboccipital craniotomy, pathology revealing glioblastoma NOS, WHO grade IV; further biomarker analysis was not available. CT of the chest, abdomen, pelvis showed no evidence of metastatic disease. Postoperative MRI of the brain revealed postoperative changes with resection of the left occipital portion of the lesion with additional enhancing regions in the left parietal and temporal lobes and splenium unchanged. Patient underwent concurrent, definitive chemo-radiation with temozolomide, now on maintenance temozolomide and levothyroxine. Conclusion: PTC is the most common thyroid malignancy, affecting young patients less than 45 years old. GBM can occur in people of any age, but they are more frequent in older adults. Physicians should maintain high surveillance for second primary cancers at a variety of sites in patients who have been found or treated for primary cancers, especially at a young age. Further evaluation of genetic and environmental factors between papillary thyroid cancer and glioblastoma multiforme will improve our understanding of the etiology of these malignancies.

Bilateral trigeminal motor nucleus syndrome

A 48-year-old man was brought to our unit with deteriorating consciousness but no available history. His Glasgow Coma Scale score was 11/15 (E3, V4, M4). A limited neurological examination identified...

Overcoming the Elusiveness of Neurosarcoidosis: Learning from Five Complex Cases.

The involvement of the central nervous system in sarcoidosis can manifest with a variety of neurological symptoms, and most of them can be nonspecific. The diagnosis of neurosarcoidosis (NS) can therefore be very challenging without a tissue biopsy. Both computed tomography (CT) and magnetic resonance imaging (MRI) are important imaging modalities in the diagnosis of NS, and MRI is the modality of choice due to its superior soft-tissue contrast resolution. We present a case series of NS with interesting neuroimaging features, complex neurological presentations, and clinical courses. We identify five cases presenting with clinically isolated neurosarcoidosis (CINS) without any other signs or symptoms of systemic disease which were diagnosed as NS on biopsy. In the first case, we describe a patient with an intramedullary cervical spinal cord lesion. In the second case we describe a patient presenting with inflammatory changes and enhancement in the orbit. The third case demonstrates a lesion with calcification around the region of the foramen of Monro. The fourth case shows multiple ring-enhancing lesions. Lastly, the fifth case exhibits unusual findings with both optic neuritis and a cerebellar nodule. We aim to describe the complicated clinical course with neurological workup, neuro-imaging, and eventual diagnosis and treatment of these challenging cases to highlight the variable presentations of NS. This case series will remind clinicians that NS should always be in the differential diagnosis when a patient presents with nonspecific neurological symptoms with unusual neuroimaging findings.