The patient is a 40-year-old Haitian man who presented with progressive right-sided weakness, dysesthesias, and headaches. He denies any symptoms of dizziness, vision changes, nausea, vomiting, or neck stiffness. His neurological exam showed upper motor neuron pattern weakness (4 out of 5) in the right upper and lower extremities, increased sensitivity to temperature in his right upper and lower extremities, and gait abnormalities in his right lower extremity. All reflexes were intact and no cranial nerve abnormalities were detected. Computed tomography (CT) scan of the head without contrast showed widespread cystic lesions in the cerebral region of the brain. MRI brain showed numerous bilateral intraparenchymal cystic enhancing lesions, some of which demonstrated internal hemorrhagic components (Figure 1). The largest cystic lesion was in the left paramedian frontoparietal lobe measuring 5.0 x 3.4 x 4.0 cm. It also demonstrated a significant mass effect leading to distortion of the body of the corpus callosum and the body of the left lateral ventricle. Another lesion was found in the left caudate nucleus head region measuring 2.1 x 3.0 x 1.6 cm. A left basal ganglia lesion posterior to the left caudate nucleus lesion had a prominent rim of hemorrhagic products. The septum pellucidum was shifted approximately 5 mm to the right at the level of the frontal horns of the lateral ventricles. On the right, one of the lesions was centered in the white matter of the right superior frontal gyrus measuring 1.8 x 1.5 x 1.6 cm. CT chest and abdomen did not show any primary or metastatic masses. Syphilis serology was nonreactive, and the Quantiferon test was reactive. The patient had no history of latent tuberculosis (LTBI) therapy. Cerebrospinal fluid (CSF) analysis showed a cell count of 10 WBC per mm3, protein 69 g/L, and glucose 70 mmol/L. CSF cytology was significant for atypical cells, raising concern for malignancy. Other infectious workup including venereal disease research laboratory (VDRL), routine blood cultures, acid-fast bacillus (AFB), and serum Cryptococcus antigen was negative. Human immune deficiency (HIV) virus, galactomannan, Fungitell, and toxoplasmosis serology were negative.
The patient experienced worsening right lower extremity weakness three days after his admission. His hemiparesis had progressed to a full right lower extremity paralysis. CT head without contrast demonstrated hyperdense material layered within a cystic structure, likely representing blood products. The fundoscopic examination did not report evidence of retinal or subretinal parasites. The patient was started on dexamethasone 4 mg every 6 hours for vasogenic edema, which slightly improved his right-sided hemiparesis and lower extremity paralysis. Despite cysticercosis antibodies being tested negative, the patient was also initiated on albendazole, praziquantel, and levetiracetam for the empiric treatment of neurocysticercosis and seizure prophylaxis. Due to high suspicion of brain tuberculoma, the patient was treated for latent tuberculosis.
On day eighteen, the patient had a right-sided open resection craniotomy with biopsy and left-sided stereotactic cyst drainage. The pathology of the specimen showed high-grade, nonlymphoid neoplasm favoring glioblastoma with undifferentiated small cell components (Figure 2) with O-methylguanine-DNA-methyltransferase (MGMT) promoter methylated. Next-generation sequencing with glioma panel detected mutation in PTEN and APC with wild-type IDH1 and wild-type IDH2. The patient was deemed unfit for surgery and was initially offered enrollment in clinical trial at Memorial Sloan Kettering Cancer Center; however, he was not interested. The patient ultimately elected to be treated with the standard of care of concurrent chemotherapy with radiotherapy followed by adjuvant chemotherapy with temozolomide based on the Stupp trial. His treatment was modified to a shorter course of radiotherapy with concurrent temozolomide followed by adjuvant chemotherapy based on the study by Perry et al.. The patient received a total dose of 40.05 Gy, given in 15 daily fractions over three weeks, along with concurrent temozolomide (75 mg/m2) for twenty-one days. Interval CT of the head without contrast 10 days after initial treatment showed decreased size of the brain lesions. The patient did not receive adjuvant temozolomide (150-200 mg/m2) for five consecutive days of a twenty-eight-day cycle for up to 12 cycles as he decided to return to Haiti.