Presentation
Right-sided weakness and fever.
Patient Data
Large intra-axial mass/collection with peripheral enhancement in the left frontal and parietal lobe, involving the left basal ganglia, with areas of calcification in the medial aspect. Perilesional vasogenic edema involving the frontal, parietal, and temporal lobes, crossing the midline in the frontal region. There is compression of the left lateral ventricle and effacement of the third ventricle. There is midline shift and resultant right ventricular hydrocephalus. Edema extends to the upper part of the brainstem.
The patient went on to have a resection.
Macroscopic appearance
Multiple large masses of white to yellowish cheese-like appearance indicate caseous necrosis.
Histology
Serial sections examined from the specimen received reveal pieces of tissue showing multiple variable-sized granulomata. Each granuloma is formed of epithelioid macrophages, lymphocytes, and a few Langerhans giant cells. There are wide areas of caseous necrosis. No evidence of malignancy in the serial sections examined.
Case Discussion
A large mass lesion in the left cerebral hemisphere with marked adjacent vasogenic edema simulates a tumoral mass. The thin, regular peripheral wall enhancement generally argues against a tumor, favoring infection. Calcification can be seen in both tumors and infectious lesions.
Tuberculomas (confirmed pathologically) are usually smaller but can be this large.
Acknowledgements: Dr Ali Shraf Al-dine & Dr Yousif Al-madani (neurosurgeon), Dr Abdulatif Magram (radiology specialist), Dr Wael Al-Absi (pathology specialist)
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