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2017 Case 2

Case 2

J.G. Hanly1 and A.S. Easton2

1Division of Rheumatology, Department of Medicine, 2Division of Anatomical Pathology, Department of Pathology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, NS

Clinical Summary:

This 20 year old woman, who is a student at Dalhousie University, presented in November 2016 with a single generalized tonic-clonic seizure. She was admitted to the neurosurgery service, where an MRI scan revealed a 1.3cm diameter ring enhancing lesion in the right motor cortex with surrounding edema. Stereotactic biopsy was performed during this admission. Other than introducing the anti-seizure medication levetiracetam (Keppra), no additional medications were introduced, and she was discharged from hospital shortly after the biopsy. Two MRI scans showed a reduction in the size of the lesion and its accompanying edema (December 2016), progressing to complete resolution (March 2017). She is currently stable, and has had no new seizures.

She was diagnosed with systemic lupus erythematosus (lupus) in February 2012 at age 15 with malar rash, inflammatory arthritis, biopsy confirmed lupus nephritis (ISN/RPS class IV), positive ANA and thrombocytopenia. She has no current symptoms of active lupus, such as skin rashes, oral ulcers, pleuritic chest pain, joint pain or swelling. Her medications include fosinopril, hydroxychloroquine and mycophenolate, with Keppra added following the seizure. She was on prednisone until February 2016 when this was discontinued, and steroids have not been prescribed since.

Material submitted:

Virtual slide of the stereotactic biopsy

Question:

Differential diagnosis?