Presentation Time: 0945-1000

B. Joseph MD, J. Maguire MB, BCh, BAO.

Division of Neuropathology, Dept. of Pathology and Laboratory Medicine, Vancouver General Hospital, University of British Columbia


Case 4: A Clinical Calamity

Presentation: 29 year old female presented with headache, seizures, partial facial droop, dysarthria and hemiparesis.

Laboratory investigations: reported as being within normal limits.  

Past Medical History:

1 month before: stiffness in knee, headache and sinus pain for five weeks. Treated with azithromycin for sinusitis for 5 days. 

4 months before: maculopapular skin rash for 4 weeks, arthralgia, low-grade fever.

Reported negative testing for syphilis, HIV, throat swab negative for Strep group A.   Rash disappeared.

2 years before: Multiple sclerosis diagnosed, relapsing remitting type. Presented with ataxia, bilateral lower limb numbness then involving upper limbs, hands, and fingers. Had presumed imaging negative transverse myelitis. Subsequent MRI demonstrated a cervical lesion. Treated with Ocrelizumab infusions, had no further attacks.   

Family history: positive for rheumatoid arthritis and multiple sclerosis

Travel history: Tunisia for 2 months, 14 years ago. Stayed in a tent in the desert mainly. One month after she came back she developed diffuse neck swelling. No palpable lymph nodes or hepatosplenomegaly. Very high fever with malaise, no vomiting/hematemesis. Clinical impression was mononucleosis, treated conservatively. She later developed a progressive maculopapular rash over her palms and soles, with progression to her trunk and back. Experienced intermitted fevers and chills, headache, generalized myalgia, arthralgia. Routine laboratory investigations normal, except for a mildly elevated CRP. Comprehensive panel of infective serology was negative.

Imaging:   CT scan: 2.2cm left frontal parietal rim enhancing cortical lesion with edema, right frontal 1.2cm enhancing extra-axial dural based lesion. MRIs of brain and spine shown.

The cortical lesion was biopsied.


What is your differential diagnosis?

What definitive laboratory investigations would you request, and what would they show?

Materials submitted:

1. MRI images of head (T2 FLAIR) and cervical spine (T1 and T2).
2. One H&E stained slide.

Reveal Diagnosis

To be added after the meeting.