Case 336 -- A 38 year-old male with multiple brain masses

Contributed by Yan Peng MD, PhD, Rafael Medina-Flores MD, Clayton Wiley MD, PhD
Published on line in January 2003


The patient was a 38 year-old male who presented with headache for eight weeks and new onset of visual disorientation for several hours. He was afebrile. He had a long history of severe depression. A head MRI showed numerous contrast-enhanced lesions with the largest in the temporal lobe. However, CT scans of chest, abdomen and pelvis were negative. A stereotactic brain biopsy was performed.


Figure 1. MRI of brain: Multiple contrast enhanced lesions are noted in the temporal lobes and the left frontal-parietal parasagittal white matter and cortex. No mass effect is present.


Figure 2. An intraoperative smear shows reactive astrocytosis.
Figure 3. A Creutzfeldt cell (atypical mitotic figure) is present in an intraoperative smear.
Figures 4 and 5. Permanent sections show numerous foamy macrophages and reactive astrocytes with abundant eosinophilic cytoplasm and eccentrically located nuclei.
Figure 6. A permanent section shows infiltrating macrophages and a binucleated astrocyte.
Figure 7. A permanent section shows astrocytic nuclear fragments.
Figure 8. A permanent section shows perivascular lymphocytic cuff.


Figure 9 CD68, a macrophage marker, highlights numerous infiltrating macrophages.
Figure 10 Neurofilament protein stain highlights preserved axons.
Figure 11 Luxol Fast Blue/PAS stain shows severe myelin loss.
Figure 12 CD4, a T- helper lymphocyte marker, is strongly positive in perivascular and parenchymal lymphocytes.
Figure 13 CD8, a T-cytotoxic lymphocyte marker, strongly stains perivascular lymphocytes.
Figure 14 CD20, a B lymphocyte marker, stains occasional perivascular B-lymphocytes.
Figure 15 Glial Fibrillary Acidic Protein stain is strongly positive in reactive astrocytes.


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