The patient was a 21-year-old male non-smoker without significant past medical history other than alcohol drinking (150 g/day). One week before admission, the patient developed a swelling headache without obvious inducement. The headache progressively intensified, accompanied by minor coughs without hemoptysis or other neurological symptoms. Two days before admission, the patient was admitted to a local hospital for head trauma and found to have multiple intracranial space-occupying lesions on a head CT scan. He was transferred to our hospital for further diagnosis and treatment.
On admission, the patient's vital signs were stable, mental status normal and physical examinations unremarkable. Laboratory tests showed WBC 11.42 x 109/L, neutrophil 8.18 x 109/L and eosinophil 0.51 x 109/L, normal coagulation tests, normal tumor markers (CEA and AFP), and negative PPD test. Plain and enhanced head MRI revealed bilateral multiple intracranial lesions suggesting tuberculosis or possible metastatic tumors (Figure 1A). An enhanced CT scan of the chest showed bilateral pulmonary patchy infiltrates, most prominent in the left lower lobe dorsal segment, and an enlarged mediastinal lymph node (about 2.5 x 1.6 cm) without pleural effusion (Figure 2A). The patient was treated with intracranial pressure lowering agents and seizure prophylaxis as well as anti-tuberculosis agents and other antibiotics. One month later, patient's headache and cough remained unchanged, while repeat CT scan showed that both intracranial and pulmonary lesions had progressed significantly. The patient then underwent a bronchoscopy, which displayed bronchial inflammation and hemorrhage in the left lower lobe basal segment, as were consistent with bronchial biopsy results. No cancer cells were detected in the lavage. Considering the duration of treatment, the patient was advised to continue anti-tuberculosis and seizures prophylaxis as an outpatient.
The patient continued suffering from intermittent headache, cough with phlegm and occasional hemosputum. When he returned for follow-up 1 month later, his head MRI showed bilateral lesions wider than those of the previous one (Figure 1B). Chest CT indicated bilateral scattered lesions, with the lesion in the left lower lobe and the mediastinal lymph node larger than before and associated with high density lesions in the lower left oblique fissure (Figure 2B). Additionally, spinal tap was performed, and examination of cerebrospinal fluid revealed colorless, transparent fluid without clots, negative for Pan's test, total protein 0.55 g/L, glucose 4.12 mmol/L, and no cells or acid-fast bacilli found. While the patient continued to receive treatment for brain edema, anti-infection and seizure prophylaxis, his condition deteriorated progressively with worsening headache, frequent convulsions, hypotension, leading to coma and death. With the consent of the patient's family, an autopsy was performed, and it revealed multiple nodular lesions in the lungs and brain (Figure 3), no tumor in other organs. Immunohistochemistry of the lungs and brain displayed CK (-), Ki-67 (-), CD31 (+), CD34 (+), EMA (-) and GFAP (-). Histopathology of the lesions confirmed the diagnosis of PPA with brain metastasis (Figure 4).