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Washington University Experience | VASCULAR | Vasculitis - PACNS | 4A0 Case 4 History
Case 4 History ---- The patient is a 50 year old man with weakness of his right leg, as well as numbness on the left side of his body. Since January 2011 he started to have nagging back pain. An MRI in May 2011 showed a signal abnormality in the right MCP adjacent to the seventh and eight cranial nerve, as well as a C-spine T2 hyperintensity and an expansile lesion extending from C5 to T2. He was originally treated for multiple sclerosis from June to August. He reported minimal improvement of symptoms and but developed weakness of his right leg eventually requiring a cane to ambulate. Current MRI of the brain and spinal cord showed scattered foci with signal abnormalities with discontinuous enhancement in the right cerebellar hemisphere, the right brachium pontis and a long expanded segment of the cord (C4 to T4). In addition, there were some foci of leptomeningeal enhancement. The clinical and radiological differential diagnosis included lymphoma, metastasis, granulomatous inflammation/infection. Operative procedure: Suboccipital craniotomy for biopsy of the cerebellar lesion. ---- Immunohistochemistry for CD68 showed a large collection of histiocytes focally, and also highlighted numerous granulomas spread through the cerebellum. In addition, numerous CD3 positive T cells were seen scattered throughout the dense histiocytic infiltrate. The lymphocytic infiltrate in the leptomeninges is focally rich in bland CD20 positive B cells, none of which show large, atypical nuclei. Smooth muscle actin (SMA) highlights the structure of the blood vessel walls and demonstrates examples of damage predominantly involving small vessels. A pentachrome special stain highlights elastin, collagen, and smooth muscle components of the vessels and reactive changes, as well as damage to small vessel walls. The blood vessels involved show multiple stages of reactivity ranging from patent lumens with only minimal reactive endothelial changes to complete luminal obliteration. Special stains for acid fast bacilli (AFB) as well as fungal microorganisms (GMS) were negative
