Ali Mahta

Levetiracetam-induced interstitial nephritis in a patient with glioma

A 45-year-old man with a new diagnosis of low grade glioma was started on an escalating dose of levetiracetam (Lev) for seizure management. He gradually developed intractable nausea/vomiting and a high creatinine concentration due to acute renal failure which was attributed to Lev-induced interstitial nephritis. The medication was changed and his renal function rapidly improved to his baseline.

Cerebral syphilitic gumma: a case report and review of the literature

A 45-year-old male presented with subacute onset of a right-sided hemiparesis, right homonymous hemianopsia, and slurred speech. The brain imaging revealed two separate intraparenchymal enhancing lesions. The cerebrospinal fluid rapid plasma reagin and venereal disease research laboratory test were positive and consistent with syphilitic gumma, and the patient responded dramatically to penicillin G. Despite, currently low incidence of syphilis; CNS gummas should be in the differential of mass lesions as they are eminently treatable.

Paraganglioma with intracranial metastasis: a case report and review of the literature.

Paragangliomas are rare neuroendocrine tumors of neural crest origin. They are mostly benign, however; malignant tumors with aggressive behavior and distant metastasis can also occur. Intracranial involvement is extremely rare and has been sporadically reported in the literature. Here we report a case who presented with progressive neurologic deficits due to multiple intracranial lesions found to be metastasis from an occult retroperitoneal malignant paraganglioma.

Durable remission of leptomeningeal metastases from hormone-responsive prostate cancer

Prostate cancer is rarely associated with leptomeningeal metastasis. An 87-year-old man with a history of prostate cancer presented with leptomeningeal metastasis. He received hormonal therapy with leuprolide. Subsequently, he achieved an impressive response, indicated by a constant fall in his PSA levels and by the stabilization of leptomeningeal disease and clinical improvement. Hormonal therapy may be effective in inducing remission in hormone-sensitive prostate cancer with leptomeningeal metastasis.

Cerebellar glioneuronal tumor: a case report and review of the literature.

Glioneuronal tumors are pathologically heterogeneous group of tumors containing both glial and neural components. These tumors have been mostly reported in younger patients with a long standing and medically intractable seizures. From a histopathologic perspective, glioneuronal tumors are categorized into the following groups: gangliogliomas, dysembryoplastic neuroepithelial tumors (DNETs), desmoplastic infantile gangliogliomas, and 2 recently World Health Organization (WHO) recognized tumors—papillary glioneuronal tumors (PGNTs) and rosette-forming glioneuronal tumors (RGNTs) [1–4]. RGNTs usually tend to arise from fourth ventricle with less than 50 cases reported in the literature thus far, while other glioneuronal tumors mostly affect cerebral hemispheres [2]. Here we report a case of an adult with cerebellar glioneuronal tumor.

Radiation induced myelopathy in a patient with tongue cancer: a case report.

A 47-year-old male with no significant past medical history presented with a gradually progressive right neck mass over a period of 18 months. initial evaluation by an otolaryngolosit revealed a proliferative lesion of size 2 cm at the right base of tongue and a 3 cm to 4 cm right cervical lymph node which was non-tender and mobile involving level ii. He underwent flexible laryngoscopy that also showed a 2 cm proliferative lesion at the base of tongue, not crossing the midline, but no other additional findings. Biopsy from the base of tongue lesion reported poorly differentiated squamous cell carcinoma. A neck computed tomography scan with contrast confirmed a 2 cm enhancing lesion at the base of tongue and a 4 cm right cervical lymph node involving level iiA. The tumor was staged as a T1n2aM0 squamous cell carcinoma. He was treated with intensity modulated radiation therapy to a total dose of 70 Gy delivered in 5 fractions per week over seven weeks concurrently with weekly cisplatin of 40 mg/m2. Maximum spinal cord dose was limited to 44.8 Gy. He was immobilized using an S-frame, head, neck and shoulder mask. Daily set-up verification for radiation therapy was performed using on board KvCT volumetric imaging. Seven months after completion of chemoradiation therapy he presented with a recurrent right cervical lymphadenopathy and underwent right modified radical neck dissection. After surgery, he shortly developed sensory loss from the nipples down bilaterally, and over a twomonth period his symptoms worsened. in addition, he also developed bowel and bladder incontinence, gait instability, and mild weakness of all four extremities. His physical exam was remarkable with mild weakness in the upper extremities and decreased sensation to light touch, pin-prick, and temperature from the C4 down. Additionally, he had markedly reduced vibratory and position sense in all four extremities. He could walk, but his gait was widebased and required assistance. His laboratory studies including vitamin B12 level were unremarkable. His CSF revealed a negative cytology and no oligoclonal bands were detected. in addition, gram stain, fungal, and bacterial cultures, vZv, CMv, and EBv testing were negative from the CSF. Magnetic resonance imaging of his spinal cord revealed a T2 bright (Figure 1A) and T1 post-gadolinium enhancing lesion (Figure 1B) in the cervical spinal cord. He underwent a C2-C4 laminectomy for biopsy. He was eventually discharged to home with a percutaneous gastrotomy tube and continued physical therapy. The next month, he was hospitalized for right lower lobe pneumonia and methicillin resistant staphylococcus aureus (MRSA) bacteremia then unfortunately rapidly deteriorated and became unresponsive. He was not intubated in accordance with his prior decision, and he eventually expired. An autopsy was performed and the histopathology of the cervical spinal revealed significant damage particularly prominent in some areas of the lateral funiculi (Figure 2), which normally carry corticospinal, rubrospinal, spinocerebellar and reticulospinal fibers. The presence of spheroids (Figure 3A, circles) was indicative of an axonal type injury compatible with myelopathy. in addition, specific staining of myelin revealed demyelination in that area (Figure 3B). other important findings included vascular damage which was suggestive of radiation myelopathy. The small vessels had lost their endothelial lining, which was replaced by hyaline material (Figure 3C, arrows). The surrounding skeletal muscle also showed signs of damage from the radiation (Figure 3D). Radiation myelopathy (RM) mostly occurs between six months to three years after ionizing radiation therapy for tumors in the area in which some parts of the spinal cord are inevitably exposed. The clinical manifestation is usually variable and A ct a O nc ol D ow nl oa de d fr om in fo rm ah ea lth ca re .c om b y 99 .7 4. 21 7. 94 o n 12 /2 3/ 12

Cyclophosphamide responsive primary angiitis of the CNS in a 61-year-old female.

Dear Sir – A 61-year-old female with no significant past medical history presented with flu like symptoms including fever, chills and headaches after returning from a trip to Hawaii. First saw her primary care physician who advised conservative management. A couple of days later, she presented with worsening of her headaches and was admitted for meningitis work up. The neurologic exam was unremarkable. A lumbar puncture revealed a pleocytosis with 206 WBC and an elevated total protein of 75 mg/dl. PCR was negative for West Nile, HSV and enterovirus. Malaria smear, leptospira, and cryptococcal antigen were also negative. A brain MRI was unremarkable except some slight periventricular T2 changes near the anterior horn of the lateral ventricle. She was eventually discharged with presumptive diagnosis of aseptic meningitis. However, she failed to improve with persistent nausea and unsteadiness of gait and vision gradually became blurry. A repeat brain MRI showed multifocal abnormal T2 prolongation in periventricular regions (Figure 1A, B) with contrast enhancement on T1-weighted images (Figure 1C). In addition, MRI of cervical, thoracic and lumbar spine showed significant T2 signal changes in the cervical and thoracic cord with enhancement, both patchy and confluent. She underwent a brain biopsy and the preliminary pathology was concerning for lymphoma or vasculitis. Intravenous methylprednisolone was initiated afterwards and the patient improved immediately. The pathology revealed white matter with perivascular cellular infiltrates. Lumens were nearly obliterated by reactive endothelial cells and, percolating through the blood vessel walls, were populations of predominantly small mature appearing lymphocytes (Figure 2A) accompanied by reactive microglia or macrophages. The inflammatory infiltrates showed no significant cytologic atypia. The blood vessel walls, while perturbed by the passing lymphocytes and microglia, did not show fibrinoid necrosis. No granulomas were identified. Surrounding parenchyma was hypercellular as a result of infiltration

Relapsing tumefactive lesion in an adult with medulloblastoma previously treated with chemoradiotherapy and stem cell transplant.

Herein, we present an adult case of medulloblastoma who received chemotherapy, radiation therapy and stem cell transplantation, and underwent multiple surgical resections for what were thought to be recurrences; however pathology confirmed a diagnosis of relapsing tumefactive lesions. This phenomenon seems to be a consequence of stem cell transplantation rather than a simple radiation treatment effect.

Refractory seizures due to a dural-based cavernoma masquerading as a meningioma.

A 37-year-old female presented with medically intractable complex partial seizures with secondary generalization. She was found to have a dural-based lesion with radiologic features of meningioma. A gross total resection was performed and pathology confirmed a diagnosis of cavernous angioma and she became seizure free after the surgical resection. Cavernous angioma should be considered in differential diagnosis of a dural-based lesion manifesting with refractory seizures.

Fourth ventricular choroid plexus papilloma

Dear Editors, A 19-year-old girl presented with headache and dizziness over a 6–month-period. The headaches were frontal and postoccipital with dull throbbing quality and she was taking over the counter pain medications. Her headaches did not occur with coughing or straining. She initially thought that this was related to her recent 90 lb weight loss since being on a diet and exercise. She also noted intermittent dizziness accompanied by gait difficulty and a generalized weakness. The week prior to the admission, she had a severe headache, nausea, dizziness, shortness of breath and diffuse weakness. Her physical examination was remarkable for slight bilateral dysmetria, occasional bilateral hypometric saccades, and nystagmus on end gaze. The T1-weighted MRI with gadolinium revealed a heterogeneously enhancing mass fungating into the fourth ventricle and an obstructive hydrocephalus (Fig. 1). The patient underwent surgical resection, and the pathology confirmed a diagnosis of choroid plexus papilloma. Choroid plexus papillomas, which account for about 0.3–0.7 of all intracranial tumors, are more commonly seen in the pediatric population. The most common reported locations are the lateral ventricles (50%), followed by the fourth (40%) and third ventricles (10%) [1–3]. Given their hypervascularity, they usually demonstrate an intense enhancement on postcontrast images [1, 2]. From histopathologic perspective, choroid plexus papillomas are the most common tumor type arising from choroid plexus. Other pathologies include choroid plexus carcinomas and diffuse choroid plexus hyperplasia. Surgical resection is the treatment of choice for choroid plexus papillomas and progression-free survival approaches 100% even despite an incomplete resection [4]. However, choroid plexus carcinomas, which account for about 8–25% of all choroid plexus tumors, have a strong tendency to spread along the cerebrospinal fluid pathway with a variable response to surgery and adjuvant therapy. Hence, it is important to differentiate benign choroid plexus papillomas from this type of tumors [5].