A 32-year-old Tunisian woman presented with 2 years history of headaches. The patient's past medical history was no significant. She did not have a history of sinusitis, nasal deformity, or oral ulcers. she was not on any regular medications. Routine laboratory tests including renal function were normal. Chest x-ray showed neither lung lesions, nor mediastinal lymphadenopathy.
After an initial CT scan showed a left temporal lobe mass, he was referred to neurosurgery. A follow-up Magnetic resonance neuro-imaging studies (MRI), with and without contrast, identified a left temporal globular mass involving the lenticular nucleus and the internal capsule with edema and signal intensities suggestive of glial neoplasm (Figure 1, Figure 2). Administration of gadolinium resulted in significant enhancement in clods. The patient underwent a left subtemporal craniotomy with complete resection of the mass.
Pathological examination revealed neuroglial tissue heavily involved with multiple granulomas (Figure 3). These lesions consisted of focal areas of fibrinoid necrosis, surrounded by a rim of mononuclear cells (Figure 4). The latter often had either oval-shaped or elongated irregular and indented nuclei. Most cells also had a generous amount of pink cytoplasm (epithelioid cells) (Figure 5). Intermixed with the epithelioid histiocytes were a modest number of lymphocytes and plasma cells, although acute inflammatory infiltrates including segmented neutrophils or eosinophils were not seen. Fibrosis surrouding granulomas was highlighted with Masson Trichrome staining (Figure 6). There was no definitive vasculitis, although some vessels had inflammatory cells around them. Sections were stained with periodic acid-Schiff and did not reveal any fungal organisms. Stain for mycobacteria (Zeihl-Neilsen) was negative.
Based upon the histopathology of the resected mass lesion, the two main differential diagnostic considerations were a mycobacterial infection (likely tuberculosis) and sarcoidosis. However, negative special stains, negative skin test for tuberculosis and normal Chest x-ray, nearly ruled out an infectious aetiology.
Postoperatively, the patient underwent corticotherapy. She had a partial motor deficiency of the right hemibody due to the achievement of the internal capsule. She is currently being retraining and she will have a fruther control.