Brain Pathology Case of the Month - March 2019

Contributed by Dai-Zhong Wang1, Li Yao1, Tao Zhang2, Tie-Yan Wang1, Rui-Juan Zhu1, Xue-Qiang Chen3, Xian-Bin Tang1
Departments of 1Pathology, 2Neurosurgery, 3Radiology, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China


A 55-year-old male presented to our institution in October, 2016 with a 4-week history of intermittent slight fever and 3-week headache, accompanied by dizziness as well as fatigue, nausea, tinnitus, vision rotation, standing instability and blurred vision. Physical examination revealed no focal neurological deficit. MRI showed a flaky and nodular lesion involving the right cerebellar hemisphere and cerebellar vermis. The lesion was isointense on T2 weighted images, high signal intensity on T1 weighted images with nodular gadolinium enhancement (Figures 1a, 1b). Laboratory investigations revealed a white-cell count of 9780 per mm3 (reference range, 3500 to 9500), and an absolute eosinophil count of 1660 per mm3 (reference range, 20 to 500). A biopsy of the lesion was performed. .


Microscopic examination showed a granulomatous lesion (CD68 positive) (Figure 1c), with several eggs deposited in the center of coagulative necrosis , with reactive gliosis in the cerebellar parenchyma by GFAP (Figure 1d). Multinucleated giant cells and eosinophils could be also found in the lesion (frozen section) (Figure 1e). Formalin-fixed paraffin-embedded tissue showed that the well-preserved eggs were oval in outline with a slightly birefringent, brown in color (Figure 1g). They stained with Ziehl-Neelsen stain . No spine was found on the shell. Some of the eggs were crenated and distorted, while multiple small nuclei was found inside the eggs. What is your diagnosis?


International Society of Neuropathology