[Skip to Content]
[Skip to Content Landing]

A 24-Year-Old Man With a Left Frontal Brain Mass

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A healthy 24-year-old man presented with 1 week of headache, gait imbalance, and coordination difficulties. His mother reported that he had experienced personality changes. He denied any fevers, chills, night sweats, or weight loss. He reported smoking marijuana and denied tobacco and intravenous drug use. He is sexually active, with multiple male partners.

On examination, he was alert and oriented, with a temperature of 36.3°C, blood pressure of 131/90 mm Hg, heart rate of 94/min, respiratory rate of 18/min with pulse oximetry of 98% on ambient air, and a body mass index of 28.1 (calculated as weight in kilograms divided by height in meters squared). Neurologic examination was significant for hyperreflexia in all extremities, bilateral shoulder weakness, and right-sided pronator drift. Laboratory results showed a white blood cell count of 3600/μL (73.5% neutrophils, 16.4% lymphocytes, 7.8% monocytes, 1.4% eosinophils, 0.6% basophils); the remainder of the complete blood cell count and comprehensive metabolic profile was unremarkable. The result of a human immunodeficiency virus (HIV) type 1 antibody test was positive, and CD4 cell count was 73/mm3. Results of serologic testing for Toxoplasma gondii IgG were negative. Computed tomography (CT) imaging of the brain showed a left caudate nucleus and lentiform nucleus lesion with mass effect on the left lateral ventricle (Figure, left panel). Fluid-attenuated inversion recovery magnetic resonance imaging (MRI) of the brain confirmed the presence of an aggressive mass lesion extending through the corpus callosum (Figure, right panel). CT of the chest, abdomen, and pelvis and spinal MRI were unremarkable.

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

Primary CNS lymphoma (PCNSL)

B. Obtain a brain biopsy

The key to the diagnosis in this case was an imaging finding of an aggressive solitary lesion suggesting malignancy. The most common malignant brain mass in patients with AIDS is PCNSL, particularly in individuals with CD4 cell counts less than 100/mm3. Brain tumors arising from CNS tissue and metastatic malignancies are possible but less likely. Since PCNSL is an Epstein-Barr virus (EBV)–associated B-cell lymphoma, a positive CSF polymerase chain reaction (PCR) assay is highly suggestive of the diagnosis. In this case, a lumbar puncture (option C) was contraindicated because of imaging consistent with increased intracranial pressure. Other causes of brain mass in patients with human immunodeficiency virus (HIV) are toxoplasma encephalitis and progressive multifocal leukoencephalopathy. The latter does not manifest with a mass effect as seen in this case, but toxoplasma encephalitis can present as a solitary, aggressive mass on MRI. This patient had a negative toxoplasma IgG serologic status, making toxoplasmosis unlikely. Had he presented subacutely, had multiple ring-enhancing lesions on MRI, and/or had a positive toxoplasma serologic status, a treatment trial with 10 to 14 days of sulfadiazine and pyrimethamine for toxoplasmosis would be reasonable before considering a brain biopsy (option D). However, the rapid progression, lack of above-mentioned features, and possibility of PCNSL required more urgent diagnosis and treatment. Antiretroviral therapy (ART) is clearly indicated and was given to the patient (option A); outcomes with PCNSL improve when the viral load declines and CD4 cells recover. However, confirming the diagnosis (option B) is vital before initiating antitumor therapy.

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

Corresponding Author: N. Cary Engleberg, MD, Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, 3119P Taubman Center Box 5378, 1500 E Medical Center Dr, Ann Arbor, MI 48109 (cengleb@med.umich.edu)

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Additional Contributions: We thank the patient’s mother for providing permission to share the patient’s information.

References
1.
Gopal  S, Patel  MR, Yanik  EL,  et al.  Temporal trends in presentation and survival for HIV-associated lymphoma in the antiretroviral therapy era.  J Natl Cancer Inst. 2013;105(16):1221-1229.PubMedGoogle ScholarCrossref
2.
Antinori  A, Ammassari  A, De Luca  A,  et al.  Diagnosis of AIDS-related focal brain lesions: a decision-making analysis based on clinical and neuroradiologic characteristics combined with polymerase chain reaction assays in CSF.  Neurology. 1997;48(3):687-694.PubMedGoogle ScholarCrossref
3.
Corr  P.  Imaging of neuro-AIDS.  J Psychosom Res. 2006;61(3):295-299.PubMedGoogle ScholarCrossref
4.
Corcoran  C, Rebe  K, van der Plas  H, Myer  L, Hardie  DR.  The predictive value of cerebrospinal fluid Epstein-Barr viral load as a marker of primary central nervous system lymphoma in HIV-infected persons.  J Clin Virol. 2008;42(4):433-436.PubMedGoogle ScholarCrossref
5.
Antinori  A, De Rossi  G, Ammassari  A,  et al.  Value of combined approach with thallium-201 single-photon emission computed tomography and Epstein-Barr virus DNA polymerase chain reaction in CSF for the diagnosis of AIDS-related primary CNS lymphoma.  J Clin Oncol. 1999;17(2):554-560.PubMedGoogle Scholar
6.
Lee  AM, Bai  HX, Zou  Y,  et al.  Safety and diagnostic value of brain biopsy in HIV patients.  J Neurol Neurosurg Psychiatry. 2016;87(7):722-733.PubMedGoogle ScholarCrossref
7.
Rosenow  JM, Hirschfeld  A.  Utility of brain biopsy in patients with acquired immunodeficiency syndrome before and after introduction of highly active antiretroviral therapy.  Neurosurgery. 2007;61(1):130-140.PubMedGoogle ScholarCrossref
8.
Koralnik  IJ. Approach to HIV-infected patients with central nervous system lesions. http://www.uptodate.com/contents/approach-to-hiv-infected-patients-with-central-nervous-system-lesions. Accessed November 28, 2016.
9.
Rubenstein  JL, Gupta  NK, Mannis  GN,  et al.  How I treat CNS lymphomas.  Blood. 2013;122(14):2318-2330.PubMedGoogle ScholarCrossref
10.
Holdhoff  M, Ambady  P, Abdelaziz  A,  et al.  High-dose methotrexate with or without rituximab in newly diagnosed primary CNS lymphoma.  Neurology. 2014;83(3):235-239.PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Topics
State Requirements