The patient is a 37 year-old man who works as a janitor in a fast food restaurant. In May 1998, a year before the present complaint, a chest radiograph showed massive mediastinal lymphadenopathy, which was diagnosed as stage III nodular sclerosing Hodgkin's Disease. He was treated with alternating MOPP and ABVD chemotherapy for nine cycles without complications. Several months post-chemotherapy, a PET scan revealed an incidental area of decreased activity in the right parietal lobe. Shortly thereafter, the patient had a brief episode of syncope. Other than back pain (a consequence of falling during syncope), he denies any symptoms. Physical examination demonstrated no neuromuscular or other abnormalities. A diagnostic brain biopsy was performed.
MRI examination revealed a focal area of white matter edema in the right parietal lobe. There was no definite mass seen. There was some effacement of the overlying sulci (Figure 1). Following contrast administration, there was some gyriform enhancement, which appeared ring-like on one coronal image. Enhancement was peripheral in the gray matter (Figure 2). No other edema, mass or mass effect was seen. No intracranial hemorrhage was evident.
A second scan two weeks later showed increased thickening of a right parietal gyrus and increasing edema.
DIAGNOSIS AND DISCUSSION