Contributed by Tanner Freeman MD, PhD and Scott Kulich MD, PhD
The patient is a woman in her 60's presenting with a month-long history of altered mental status, expressive aphasia and confusion. The patient has a past medical history significant for an orthotopic liver transplant due to end-stage liver disease secondary to nonalcoholic steatohepatitis four years prior to the current presentation. The patient is currently taking tacrolimus and mycophenolate.
During the patient's initial work-up, an CT of the brain was obtained which showed an abnormality in the left frontal lobe, followed by an MRI of the brain showing a 3cm left frontal, contrast-enhancing lesion with significant surrounding edema (see below).
Despite approximately one week of extensive, inpatient workup, the etiology of this mass remained unclear which prompted a direct cortical biopsy of the mass by the neurosurgery team. The neuropathology team was called for intraoperative consultation.
The smear preparation demonstrated an acute and chronic inflammatory reaction with vascular proliferation and multiple foci of necrosis. On closer inspection of the viable tissue, multiple thin walled cystic structures were apparent which contained numerous crescent to elongated basophilic structures.