On the other hand in an immunocompromised patient the order of these diagnoses shifts to include:
- lymphoma
- infection
- metastatic disease
- high grade glioma
As you can see, lymphoma and infection jump to the top in an immunocompromised patient.
The diagnosis is: CNS lymphoma
CNS lymphoma can occur when associated with systemic lymphoma or primarily in the CNS, as in this case. This is most commonly a diffuse large B-cell lymphoma. It is more common in immune compromised patients. It often occurs in the basal ganglia and periventricular white matter and can often be multifocal. Lymphoma is one of the rare diseases which is T2 hypointense, so you should think about it if you see a T2 hypointense mass.
In immunocompetent patients, lymphoma most commonly has solid enhancement. However, in immunocompromised patients it is much more likely to show central necrosis, as in this case. Also, in an immunocompromised patient, it can be hard to differentiate lymphoma from infection, particularly toxoplasmosis. The two most common ways to try to differentiate this are to start a trial of toxoplasmosis therapy for a few weeks and see if the lesions improve and to perform a thallium-201 chloride nuclear medicine scan. Lymphoma has thallium uptake, while toxoplasmosis does not.
Summary
In this board review lecture, you’ve seen a lot of different tumors and how they manifest in different situations. In many cases, you can’t make a definitive diagnosis but you should always be able to come up with a reasonable differential diagnosis. It’s also helpful to know some of the basics about treatment and prognostic factors.
There are two key strategies that I hope can help you get a few additional points, the approach to CP angle masses and the approach to cortical tumors.
Cerebellopontine angle masses
As we’ve seen in some of the other cases, cerebellopontine angle masses can be solid or cystic. Solid masses that involve the IAC and expand it are likely schwannomas, while others outside the IAC are likely meningiomas. Arachnoid cysts and epidermoids are the most common cystic masses which are differentiated by DWI (which is bright in ependymomas.
Cortical tumors
Several of the cases in this series dealt with cortical temporal tumors. Ill-defined masses that are larger are more likely to be low grade gliomas (oligodendrogliomas and astrocytomas). Completely non-enhancing bubbly masses favor DNET. A little nodular enhancement favors ganglioglioma, while pleomorphic xanthoastrocytoma (PXA) can be more avidly enhancing and irregular.
