Repeat MRI Scan Research Articles

Ocular and cerebral aspergillosis in a non-neutropenic patient following alemtuzumab and methyl prednisolone treatment for chronic lymphocytic leukaemia

To the Editor, Unlike with acute forms of leukaemia, fungal infections are rare in chronic lymphocytic leukaemia (CLL). Most previous reports have been on patients with prolonged neutropenia or after allogeneic stem cell transplantation (SCT). We would like to document a patient with CLL who had a fungal infection at unusual sites as a result of combination therapy with alemtuzumab (Campath-1H) and methyl prednisolone. This patient was neither neutropenic nor had he received SCT. A 65-year-old man was on treatment with alemtuzumab, methyl prednisolone and ciclosporin for relapsed CLL and autoimmune haemolytic anaemia. He had a neutrophil count of 2.7 9 10/L with normal serum levels of immunoglobulins and was hence not on prophylactic antimicrobials. He presented with acute onset of pain in his right eye and developed a partial loss of vision in his right temporal field over the next 24 h in the absence of fever or raised inflammatory markers. He was referred to a tertiary care centre for ophthalmological evaluation and management. Examination of the right eye revealed pan-uveitis with a vitreous abscess (Fig. 1). A vitreous biopsy showed infection by Aspergillus fumigatus. MRI scan of the brain revealed a 4 mm ring-enhancing lesion in the cortex of the left frontal lobe, consistent with cerebral aspergillosis (Fig. 2). Toxoplasma serology was negative. A highresolution CT scan of his chest was normal. He was treated with oral voriconazole and intravitreal amphotericin instillations complicated by vitreal haemorrhage due to thrombocytopenia. Both the fungal infection and the haemorrhage improved over the next 6 weeks and his vision cleared gradually. A repeat MRI scan of his brain showed complete resolution of the lesion. The combination of alemtuzumab and high-dose methyl prednisolone (CamPred) is now increasingly being used to treat patients with CLL refractory to purine analogues and those with deletions of the TP53 gene [1–3]. Alemtuzumab, a humanised anti-CD52 monoclonal antibody, targets both B and T lymphocytes in addition to monocytes, macrophages and a subset of antigen-presenting dendritic cells. It thus significantly impairs the immunological surveillance mechanisms against infections. Whilst on this heavily immunosuppressive regimen, a high index of suspicion against viral reactivations and fungal

A radiological pitfall – large intra-articular ganglion cyst diagnosed in a runner who presented with chronic hip pain and previously reported normal radiological findings

AbstractThe case of a female runner presenting with previously undiagnosed chronic hip pain is reported. Initial X-ray and MRI of her affected hip were reported as normal; a subsequent review of these films by a specialist musculoskeletal radiologist revealed this was incorrect. A repeat MRI scan was performed using dedicated hip views which revealed a large, intra-articular, ganglion cyst within the acetabulum and an acetabular labral tear. This case raises awareness of acetabular ganglions as a possible cause of hip pain. It also reinforces the need to be alert to potential operator variability when interpreting radiology reports.

Increased Intracranial Pressure Caused by Non-Space-Occupying Arachnoid Cysts: Report of Two Patients

In this article we report on two patients with arachnoid cysts previously treated by shunt implantation presenting with clinical signs of an increased intracranial pressure i. e., papilledema, headache and nausea. Repeated MRI scans showed no alteration of the cerebrospinal fluid circulation and no space-occupying effect of the cysts. Although neuroimaging showed no signs of increased intracranial pressure, neurosurgical exploration was performed and revealed a distinctly increased pressure in both arachnoid cysts. After replacement of the shunt a prompt reduction of papilledema and relief of symptoms was observed.

Adénomes hypophysaires non fonctionnels et gonadotropes

Clinically non-functioning pituitary adenomas and gonadotroph-cell adenomas are relatively common: microadenomas (< 1cm) are usually pituitary incidentalomas while most macroadenomas are revealed by mass effect and/or hypopituitarism. They are rarely associated with high gonadotropin (Luteinizing hormone, LH; Follicle-stimulating hormone FSH) levels while increased alpha-subunit levels are more frequent. Immunocytochemistry of pituitary tumor confirms the diagnosis of clinically non-functioning or gonadotroph-cell adenoma. Pituitary MRI follow-up seems to be indicated for microadenoma. Treatment of macroadenoma with visual field defect or hypopituitarism is transphenoidal surgery, but cure is rarely obtained and tumor recurrence is significant during follow-up. Therefore postoperative treatment (pituitary radiotherapy or medical treatment with dopamine agonists or somatostatin analogs) should be discussed against close follow-up with repeated MRI scans.

Intracranial meningioma in a patient with osteogenesis imperfecta

Abstract Osteogenesis imperfecta (OI) is a heritable disorder characterized mainly by connective tissue manifestations. In dinstinct cases, several neurological features have also been described. A 46-year-old male with a known family history of OI type I presented with progressive gait disturbances and diminished muscle strength. Brain MRI scans revealed an infiltrative intracranial mass occupying both frontoparietal lobes. The patient underwent surgical intervention. The histological diagnosis was an atypical (Grade II) meningioma. The bony parts demonstrated a mixture of osseous defects due to OI and infiltration by the tumor. At one-year follow up the patient′s muscle power partially returned while repeat MRI scans were negative for tumor recurrence.

More than a prolactinoma

A 39-year-old man presented with frontal headaches and erectile dysfunction with loss of libido. He had normal secondary sex characteristics and a testicular volume of 15 ml. Visual fields were normal. Diagnostic work-up revealed very high serum prolactin levels (77,800 mU/l), indicative of a prolactinoma (normal\450 mU/l). Morning serum testosterone levels were reduced to 6.1 nmol/ml indicating partial gonadotropin deficiency (LH, 2 IU/l and FSH, 4 IU/l). He was also growth hormone deficient (GH \1.0 mU/l in an insulin tolerance test), but adrenal and thyroid function were normal. MRI scan of brain demonstrated a large pituitary macroadenoma, with a large suprasellar component with chiasmal compression (Fig. 1a). He was medically treated with the dopamine agonist Cabergoline (0.5 mg on alternate days) and his serum prolactin levels normalised (\50 mU/l) within the first 4 months of treatment. Serum testosterone also increased to normal levels (10.3 nmol/l) and he became asymptomatic. All other pituitary functions were normal. Repeat MRI scanning after 3 years of treatment revealed that the pituitary tumour had almost disappeared (Fig. 1b). However, a residual lesion could be seen on the left cavernous sinus wall (Fig. 1b; arrow). This component appeared larger in a further scan taken at 5 years post-treatment, despite normal prolactin levels (Fig. 1c; arrow). To establish the diagnosis, the left cavernous lesion was surgically debulked via a left frontotemporal craniotomy. Histology confirmed this to be a meningothelial meningioma (WHO grade I). The present case of a mixed prolactinoma-meningioma illustrates the effectiveness of dopamine agonist therapy for a macroprolactinoma, but also the necessity for longterm radiological follow-up in patients with pituitary tumours, which may reveal other co-existing pathology.

Voxel-based cortical thickness measurements in MRI

The thickness of the cerebral cortex can provide valuable information about normal and abnormal neuroanatomy. High resolution MRI together with powerful image processing techniques has made it possible to perform these measurements automatically over the whole brain. Here we present a method for automatically generating voxel-based cortical thickness (VBCT) maps. This technique results in maps where each voxel in the grey matter is assigned a thickness value. Sub-voxel measurements of thickness are possible using sub-sampling and interpolation of the image information. The method is applied to repeated MRI scans of a single subject from two MRI scanners to demonstrate its robustness and reproducibility. A simulated data set is used to show that small focal differences in thickness between two groups of subjects can be detected. We propose that the analysis of VBCT maps can provide results that are complementary to other anatomical analyses such as voxel-based morphometry.

Vagus nerve stimulation improves severely impaired heart rate variability in a patient with Lennox-Gastaut-Syndrome

Vagus nerve stimulation (VNS) is a new therapeutic option for refractory epilepsy. We report a patient with Lennox-Gastaut-Syndrome (LGS) and a severe impairment of heart rate variability (HRV), we could demonstrate in our patient that HRV was improved by VNS.

Could increasing the dose of radiation following preoperative chemoradiation for advanced rectal cancer improve surgical outcomes? Clatterbridge experience with HDR brachytherapy boost: Preliminary results

14563 Introduction: Preoperative radiotherapy has been shown to improve local control in advanced rectal carcinoma compared to surgery alone. Recent large randomised trials have confirmed that chemoradiotherapy (CRT) was better than radiotherapy alone. This pilot study was designed to increase the radiation dose by using High dose rate (HDR) brachytherapy boost following preoperative CRT to evaluate whether this strategy improve surgical outcomes, without increase in toxicity. Methods: Since, October 2004 we have used the new Nucletron rectal HDR applicator for brachytherapy boost in 12 patients following pre-op CRT. The patients were staged by CT and MRI Scans. All had locally advanced disease either bulky low T2 or T3 with threatened CRM and multiple suspicious lymph nodes. They were offered preoperative chemoradiotherapy using either 5FU infusion 1G/m2 day 1–4 (wk 1+5) or oral Capecitabine 825mg/m2 Mon-Fri for 5 weeks together with CT planned external beam RT 45Gy in 25 fraction over 5 weeks. Those downstaged on repeat MRI scan were offered additional HDR Boost 10Gy directly to the tumour followed by surgery 6–8 weeks later. Results: Evaluation was done on the first 12 patients. Eleven males and 1 female. Median age 68 (range50–80 years). PS 0–1. Clinical stages at presentation were cT2 in two patients and cT3 in 10 patients. No suspicious lymph nodes in 2 and cN1 in 10 patients. Eleven patients had chemoradiotherapy and one had radiotherapy alone. All patients completed treatment without interruptions. Anterior resection was carried out in 6 patients and 6 had APR. All patients had RO resection (100%) compared to 60–80% with conventional preoperative chemoradiotherapy using 5FU ± Irinotecan or Oxaliplatin regimes. Pathological complete remission pCR was achieved in 6 patients (50%) compared to 12–30% with conventional CRT. There was no increase in G3–4 toxicity from HDR boost and no delay in wound healing or anastamotic leakages. Discussion: Pre operative chemoradiotherapy using 5FU regimes had shown improvement in local control compared to radiotherapy alone but so far, none of the trials showed survival benefit. Newer novel agent such as Irinotecan or Oxaliplatin has been used in addition to 5FU or capecitabine for the pre operative chemoradiotherapy regimes in an attempt to improve surgical out comes. However, there were increased in radiation related G3–4 complications up to 30%. This study has shown that Increasing the dose of radiation by HDR Brachytherapy boost appears to improve the RO resection rates compared to conventional CRT and also increased in pCR rates. The follow up is still too short to evaluate whether there is improvement in DFS but based on previous CRT studies, the local control rate is predicted to improve further without added toxicity. We plan to extend this study to compare this strategy in a randomised phase 3 trial with conventional chemoradiotherapy in patients who are not fit for more intensive chemoradiotherapy using triplet regimes. This approach is suitable for elderly or medically compromised patients who are not fit for intensive chemoradiotherapy with newer agents. No significant financial relationships to disclose.

Technique of obtaining internal rotation radiographs in fractured neck of femur

Occult femoral neck fractures necessitate repeat radiographs or MRI scans to confirm the diagnosis. The treatment of intracapsular fractures differs from extra capsular fractures. Therefore, differentiation between these two is mandatory preoperatively. Failure to diagnose the fracture in some cases may be due to the position of the limb at the time of obtaining radiographs. In general, the position of a fractured or painful hip is external rotation. A prominent lesser trochanter seen on plain radiograph confirms that the hip was externally rotated when Xrayed. Lesser trochanter becomes less prominent in an internal rotation view.

Shoulder Pain Professional Baseball Pitcher

HISTORY A 28 year old professional baseball pitcher was promoted to the major league club after Spring training and pitched successfully with no pain until the end of April when he began to have insidious onset of pain in his throwing shoulder. The pain was posteriorly and gradually worsened. Evaluation by the trainer suggested an infraspinatus or teres minor strain and he was treated with stretching, modalities and ibuprofen. Despite treatment his pain worsened so that he was sore for hours after pitching. He was evaluated by the team physician and radiographs were normal. After 3 weeks of continued treatment he could no longer throw due to the pain. EXAMINATION Upon initial evaluation he had no atrophy or deformity with no winging, but when viewed from behind he was noted to have scapular dyskinesia. He had full ROM of his shoulders with no suggestion of GIRD. He was entirely neurologically intact for sensation, motor and reflexes. He had pain with resisted external rotation with his arm at the side, but he had no weakness. He had a negative apprehension sign, relocation sign, lift off test, Whipple test, Speed's test and Spurling maneuver. He had tenderness on the lateral border of his scapula but not over his posterior joint line. DIFFERENTIAL DIAGNOSIS Labrum tear “Occult” instability Strain teres minor or infraspinatus Stress fracture TESTS AND RESULTS Plain radiographs normal MRI of scapula: edema lateral border CT scan of scapula: stress fracture lateral scapula Evaluation by orthopaedic oncologist who ruled out tumor WORKING DIAGNOSIS Stress fracture of scapula TREATMENT Rest from throwing for 4 to 6 weeks Gradual return to throwing after 2 months Developed elbow pain and shut down for remainder of season Repeat MRI and CT scan show resolution of the fracture

Reversible Weight Gain and Prolactin Levels - Long-term Follow-up in Childhood

In adult patients weight gain is a frequent complaint of hyperprolactinaemia and it has been associated with a high prevalence of obesity. Normalization of prolactin (PRL) levels result in weight loss. The nature of this link is poorly defined. In this report we describe a 14 year-old female with primary amenorrhea and persistent progressive weight gain. The patient's height, weight and BMI were 152 cm, 70 kg, and 30.3 kg/m2, respectively. Basal hormonal investigation showed normal free thyroxin, TSH, IGF-I, cortisol and ACTH values. Serum PRL level was very high (16,278 mIU/l; normal range 63-426 mIU/l). Magnetic resonance imaging scan showed the presence of a pituitary microadenoma. Treatment with the non-selective dopamine agonist pergolide caused a significant reduction of serum PRL concentration with a remarkable decrease of body weight. During follow-up, repeat MRI scan revealed disappearance of the microadenoma. The reduction of the daily dose of pergolide was associated with an increase of serum PRL with significant weight gain. A further reduction of body weight was subsequently observed with an increase of pergolide dosage. Serum PRL measurement may be useful as part of the endocrine work-up of obese children with a history of unexplained recent weight gain, especially if associated with pituitary-gonadal axis dysfunction. The relationship between PRL secretion and weight change needs to be examined in prospective larger studies.

Unilateral Septic Arthritis of a Lumbar Facet Joint Secondary to Acupuncture Treatment - a Case Report

This report describes a case of septic arthritis of the lumbar facet joint probably as a result of acupuncture treatment. A 48 year old man with a long history of back pain presented with a two week history of increasing pain following a third session of acupuncture. Examination revealed tenderness in the right lumbosacral area and laboratory investigations revealed raised inflammatory markers with negative blood cultures. A bone scan and MRI scan showed evidence of septic arthritis of the right L5/S1 facet joint. An x ray computed tomography guided biopsy was carried out which isolated staphylococcus aureus. The patient was initially treated with intravenous antibiotics. A repeat MRI scan demonstrated persistent septic arthritis with adjacent early abscess formation. Surgical debridement of the facet joint was therefore performed. The patient had resolution of his symptoms and the inflammatory markers returned to normal. He regained a full range of movement of the lumbar spine. Very few cases have been reported of lumbar facet joint septic arthritis and this condition is rare in association with acupuncture treatment. A high index of suspicion needs to be maintained and if conservative management fails then debridement can result in an acceptable outcome.

Retrograde drilling of osteochondral lesions of the talus (SS-107)

Osteochondral lesions of the talus that maintain an intact articular surface may be successfully treated with retrograde decompression of the cystic lesions utilizing a novel cannulated system. The surgical management of symptomatic osteochondral defects of the medial talar dome is difficult. When the articular surface is intact retrograde drilling through the body of the talus is accepted as one alternative to stimulate bone healing for stabilization of the OCD fragment. Between 1999 and 2001, eight consecutive patients underwent surgical treatment for symptomatic posterior medial OCD lesion of their talar dome. All patients underwent arthroscopy of the ankle followed by retrograde drilling of the talar lesion. A novel cannulated system was used to target the lesion, remove the necrotic segment and then backfill using Grafton. The average age of the patients was 36 years old (range 12–49 years). Follow-up ranged from 8 months to 44 months (mean 24 months). One patient was lost to follow-up. Of the remaining seven, outcomes were assessed with a modified American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and the SF-12 general health survey. Four patients have repeat MRI scans at one year follow-up. The preoperative AOFAS scores from the modified hindfoot scale ranged from 0 to 41 (mean 22). Postoperative scores ranged from 52 to 68 (mean 56). Mean improvement of 34 points. The SF-12 has two components: the Physical Component Score (PCS) and the Mental Component Score (MCS). Mean preoperative and latest follow-up SF-12 PCS were 35.8 and 44.0, respectively. Mean preoperative and latest follow-up SF-12 MCS were 40.7 and 52.8, respectively. In this limited series, this technique appears to give comparable short-term results to previously described techniques. The new cannulated system simplifies the surgical procedure allowing the expansion of the technique to the general orthopedic surgeon and potentially greater safety. Overall, this procedure offers decreased operative time and maximizes safety and accuracy with retrograde talar drilling. Osteochondral lesions of the talus that maintain an intact articular surface may be successfully treated with retrograde decompression of the cystic lesions utilizing a novel cannulated system. The surgical management of symptomatic osteochondral defects of the medial talar dome is difficult. When the articular surface is intact retrograde drilling through the body of the talus is accepted as one alternative to stimulate bone healing for stabilization of the OCD fragment. Between 1999 and 2001, eight consecutive patients underwent surgical treatment for symptomatic posterior medial OCD lesion of their talar dome. All patients underwent arthroscopy of the ankle followed by retrograde drilling of the talar lesion. A novel cannulated system was used to target the lesion, remove the necrotic segment and then backfill using Grafton. The average age of the patients was 36 years old (range 12–49 years). Follow-up ranged from 8 months to 44 months (mean 24 months). One patient was lost to follow-up. Of the remaining seven, outcomes were assessed with a modified American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and the SF-12 general health survey. Four patients have repeat MRI scans at one year follow-up. The preoperative AOFAS scores from the modified hindfoot scale ranged from 0 to 41 (mean 22). Postoperative scores ranged from 52 to 68 (mean 56). Mean improvement of 34 points. The SF-12 has two components: the Physical Component Score (PCS) and the Mental Component Score (MCS). Mean preoperative and latest follow-up SF-12 PCS were 35.8 and 44.0, respectively. Mean preoperative and latest follow-up SF-12 MCS were 40.7 and 52.8, respectively. In this limited series, this technique appears to give comparable short-term results to previously described techniques. The new cannulated system simplifies the surgical procedure allowing the expansion of the technique to the general orthopedic surgeon and potentially greater safety. Overall, this procedure offers decreased operative time and maximizes safety and accuracy with retrograde talar drilling.

Retrograde drilling of osteochondral lesions of the Talus (SS-36)

Summary: Osteochondral lesions of the talus that maintain an intact articular surface may be successfully treated with retrograde decompression of the cystic lesions utilizing a novel cannulated system. The surgical management of symptomatic osteochondral defects of the medial talar dome is difficult. When the articular surface is intact retrograde drilling through the body of the talus is accepted as one alternative to stimulate bone healing for stabilization of the OCD fragment. Between 1999 and 2001, eight consecutive patients underwent surgical treatment for symptomatic posterior medial OCD lesion of their talar dome. All patients underwent arthroscopy of the ankle followed by retrograde drilling of the talar lesion. A novel cannulated system was used to target the lesion, remove the necrotic segment and then backfill using Grafton. The average age of the patients was 36 years old (range 12 – 49 years). Follow-up ranged from 8 months to 44 months (mean 24 months). One patient was lost to follow-up. Of the remaining seven, outcomes were assessed with a modified American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and the SF-12 general health survey. Four patients have repeat MRI scans at one year follow-up. The preoperative AOFAS scores from the modified hindfoot scale ranged from 0 to 41 (mean 22). Postoperative scores ranged from 52 to 68 (mean 56). Mean improvement of 34 points. The SF-12 has two components: the Physical Component Score (PCS) and the Mental Component Score (MCS). Mean preoperative and latest follow-up SF-12 PCS were 35.8 and 44.0, respectively. Mean preoperative and latest follow-up SF-12 MCS were 40.7 and 52.8 respectively In this limited series, this technique appears to give comparable short-term results to previously described techniques. The new cannulated system simplifies the surgical procedure allowing the expansion of the technique to the general orthopedic surgeon and potentially greater safety. Overall, this procedure offers decreased operative time and maximizes safety and accuracy with retrograde talar drilling.

Lower Leg Pain in a 17-Year-Old BoyOrthopaedic-Radiology-Pathology Conference

Lower Leg Pain in a 17-Year-Old BoyOrthopaedic-Radiology-Pathology Conference

Peripheral primitive neuroectodermal tumour of the left maxillary sinus

Peripheral primitive neuroectodermal tumours (pPNETs) are highly malignant, small-cell neoplasms found mainly in children and young adults. Recent advances in immunohistochemistry and genetic typing have led to reports of a close relationship between pPNET and the previously difficult-to-classify Ewing's sarcoma. We report a case of pPNET involving the left maxillary sinus in a 23-year-old female who presented with a 2-month history of unilateral left-sided nasal obstruction, rhinorrhoea and recurrent bloody nasal discharge. A CT scan of the paranasal sinuses showed a large mass (10 x 7 x 3 cm3) arising from the left maxillary sinus, with signs of bone destruction and invasion of the left orbital floor and pterygomaxillary fossa. MRI revealed a heterogeneous hyperintense signal on a T2-weighted image in the left maxillary sinus. The tumour was surgically removed by means of external lateral rhinotomy. Pathological examination showed a sheet of small cells with irregular nuclei. Immunohistochemical studies demonstrated positive immunoreactivity for neurone-specific enolase, synaptophysin, chromogranin, vimentin, S-100 protein and p30-32 MIC-2 gene product. The patient was treated with chemotherapy consisting of cyclophosphamide, vincristine, adriamycin and actinomycin D, together with radiotherapy to a total tumour dose of 60 Gy. After 59 months of follow-up, the patient remained free of disease and a repeat MRI scan was normalized, with no sign of residual tumour.

Neonatal cerebral ischaemia with elevated maternal and infant anticardiolipin antibodies

A baby girl born by elective lower segment caesarean section was found to have left‐sided focal seizures at 48 hours after birth. Her mother had previously had a neonatal death at 26 weeks' gestation and another child born at 32 weeks' gestation had a congenital right hemiplegia with a left middle cerebral artery infarct on CT scan. The mother had raised anticardiolipin IgG antibodies at the time of delivery of her second child, with no thrombotic symptoms. Therefore, during this pregnancy, she had been treated with low molecular weight heparin and aspirin. The baby's mother had raised IgG and IgM anticardiolipin antibodies and the baby had IgG anticardiolipin antibodies at the upper range of normal 4 days after delivery. The seizures were controlled with phenobarbitone and phenytoin. CT and MRI scans showed evidence of cerebral ischaemia. A repeat MRI scan at 4 months of age was normal, anticonvulsants were discontinued, and her latest neurological examination at 5 months was normal.

2·5 year remission of AIDS-associated progressive multifocal leukoencephalopathy with combined antiretroviral therapy

Progressive multifocal leukoencephalopathy (PML) results from infection of the central nervous system with JC virus, a papovavirus, which causes demyelination in the white matter of the brain. Long-term survival in AIDS patients with PML is rare. There is no consistently effective treatment although cytarabine, interferon, and zidovudine (AZT) may occasionally result in regression. We report remission of PML-associated hemiparesis for 104 weeks during combination antiretroviral therapy including a protease inhibitor. A 35-year-old man and previous intravenous drug user, was admitted due to worsening neurological symptoms, including dysarthria, aphasia, a right-sided facial droop, right arm weakness, and a walk that listed to the right. A T2weighted MRI scan showed confluent high signal intensity in the left centrum semiovale, left corona radiata with extension into the left internal capsule, left cerebral peduncle, and the pontine cortical spinal tracts (left figure). There was faint enhancement without mass effect. The MRI findings were characteristic of those observed with PML. No brain biopsy was done. Laboratory studies (ELISA and western blot) established the diagnosis of HIV infection. The CD4 count was 30 cells/μL and his HIV viral load was 189 900 copies/mL. He began zidovudine 200 mg three times daily and didanosine 200 mg twice daily as part of a controlled trial. Over the next 2–4 weeks the patient’s ability to convey thoughts quickly and to speak clearly improved. By the 10th week of antiretroviral therapy, he began an exercise regimen which included weight-lifting and aerobic activity and, by week 12, he was able to return to work as a fisherman. At week 24, indinavir, a protease inhibitor, was added (600 mg every 6 hours) to the anti-HIV regimen. By week 44, the CD4 count had increased to 230 cells/μL and the viral load was 240 copies/mL. A repeat MRI scan, 16 months after the first, demonstrated improvement in the extent of the T2 abnormalities (right figure). In none of the reported cases of long-term survival of patients treated with zidovudine or cytarabine was the remission as complete as the one cited here, although, since a biopsy was not done, it is possible that the initial presentation of aphasia and right arm weakness was not due to PML, but to an unusual manifestation of HIV. In previously reported cases, either the original symptoms were less severe or the resolution of neurological deficits was not as complete. Our patient has survived beyond the mean (over 2 years from the onset of symptoms) and has regained over 95% of his original function. This remission has been associated with improvement in immune function, evident by the rise in CD4 count. As more effective antiretroviral regimens become available, there may be more frequent remissions in persons with PML.

Approach to the incidentally discovered pituitary mass.

Incidental pituitary adenomas are being found commonly with our improved neuroradiologic imaging procedures. Screening for hormone oversecretion by these tumors appears to be warranted. For patients with macroadenomas, patients should also be screened for hypopituitarism. In the absence of visual-field abnormalities or hypothalamic/stalk compression, it may be appropriate to observe such patients carefully with repeated MRI scans. A limited amount of data suggest that significant tumor enlargement will occur in < 5% of patients with microadenomas [8,11]. However, all macroadenomas must start out as microadenomas, and so periodic follow-up is indicated to assess for this possibility. Macroadenomas, by their very existence at the time of detection, have already indicated a propensity for growth. Over the limited period of follow-up in the two series reported, significant growth occurred in just over one quarter of the patients with macroadenomas [8,11]. Hemorrhage into such tumors is uncommon, but anticoagulation may predispose to this complication. When there is no evidence of visual-field deficits, an attempt at medical therapy with a dopamine agonist or octreotide is reasonable, realizing that only about 10% of such patients will respond with a decrease in tumor size. Surgery is indicated if there is evidence of tumor enlargement, especially when such growth is accompanied by compression of the optic chiasm, cavernous sinus invasion, or the development of pituitary hormone deficiencies.