A 41-year-old woman was admitted to the local hospital in November 2011 because of a sudden onset of the left limb weakness which lasted for a few minutes. Brain computed tomography (CT) showed seven heterogeneous haemorrhagic lesions surrounded by edema. The lesions were spread throught both hemispheres - one in the right frontal lobe, one in the right parietal lobe, four in the left parietal lobe and one in the left occipital lobe (Figure 1A). Magnetic resonance imaging (MRI) confirmed the presence of multiple lesions which were surrounded by edema and contained hemosiderin deposits (Figure 1B). They also demonstrated predominantly central contrast enhancement. Those findings were suggestive of neoplasmatic metastases or vascular malformations. MRI angiography was performed. However, apart from hypoplasia of part A1 of the left anterior cerebral artery no other abnormalities were noted. Abdominal ultrasound as well as chest X-ray showed no significant changes. Erythrocyte sedimentation rate was slightly elevated (18 mm after one hour, normal range up to 15 mm). Adequate blood tests excluded the presence of antibodies against Borrelia burgdorferi in M and G classes. Moreover, the Candida, Cryptococcus and Aspergillus antigens were not detected in the serum. Only antibodies against Toxoplasma gondii in G class were positive. In December 2011 the patient was admitted to hospital again due to the right limb weakness. MRI revealed multiple lesions very similar to those reported in November 2011 (Figure 2A, 2B). Similarly to those in the previous study, they were surrounded with edema and showed central contrast enhancement. Chest X-ray was normal. Erythrocyte sedimentation rate was elevated up to 37 mm after one hour. Finally, the patient was qualified to a neurosurgical operation and in January 2012 the tumor from the right frontal lobe was removed. The histopathological assessment revealed hemorrhagic areas with calcifications.
In May 2012 the patient, because of the diagnostic problems, was admitted to the Department of Neurology, Medical University of Warsaw, for the first time. Neurological examination revealed a slight weakness of the right limbs and subtle superficial sensation impairment in the right limbs and chest. Routine blood tests showed anemia (hemoglobin level of 11.1 g%, normal range 12-16 g%), decreased vitamin B12 level (162.3 pg/ml, normal range 191-663 pg/ml) and increased erythrocyte sedimentation rate (33 mm after one hour, normal range up to 12 mm). MRI presented a slight reduction in the size of the lesion in the left parietal lobe. As previously, central contrast enhancement and edema were noted (Figure 3). Based on these findings, vascular abnormality was suspected and therefore digital subtraction angiography (DSA) was performed. However, it showed no abnormalities. Disseminated pathological discharges were detected on electroencephalography. The ophthalmological examination showed irregular deficits in the visual field. There were no symptoms or signs of endometriosis, which may rarely cause intracystic hemorrhages in the central nervous system. The lumbar puncture was performed, and apart from a slightly elevated protein level (62 mg/dl, normal range 15-45 mg/dl), the analysis of the cerebrospinal fluid (CSF) was normal. An additional CSF examination excluded tuberculosis, neuroboreliosis and Cryptococcus infection. The level of thyroid hormones, rheumatoid factor, antibodies against Borrelia spp. in the serum were within normal ranges. Furthermore, the presence of anti-neutrophil cytoplasmic antibodies, antinuclear and anticardiolipin antibodies, lupus anticoagulant, trombophilia, syphilis and HIV infection were excluded by appropriate tests. The antithrombin III level was within normal ranges. The computed tomography of the chest aroused a suspicion of an abnormal mass in the left atrium (Figure 4). Transthoracic echocardiography confirmed the presence of a floating and fragmented mass in the left atrium and based on that the atrial myxoma was recognized. The patient was transferred to the Department of Cardiosurgery and Transplantology, Institute of Cardiology, where at the end of May 2012, heart surgery was performed. Histopathological assessment confirmed the presence of atrial myxoma.
The patient was admitted for the second time to the Department of Neurology in July 2012. Neurological examination showed a slight weakness of the right lower limb and a discrete superficial sensory deficit in the right lower limb and on the left side of the chest. Laboratory tests revealed anemia with iron deficiency and appropriate treatment was introduced. MRI showed reduction in size of the lesion and decreased edema in the left frontal lobe. Other lesions had similar appearance to those previously described. Meanwhile, the histopathological brain sections were examined once again, and chronic inflammation and hemorrhagic process with hemosiderin-laden macrophages, and glial and mesodermal severe reaction with vessel and collagen fiber calcifications were found. There were no signs of fungal infection, neoplastic lesion or cerebral endometriosis.
The third hospitalization in the Department of Neurology took place in January 2013. The neurological examination was comparable with the previous one. The echocardiography showed no signs of myxoma recurrence. Abdominal ultrasound demonstrated no significant abnormalities. The ultrasound of thyroid gland disclosed nodular goiter. Antithyroid antibodies were not detected. MRI of the brain revealed lesions comparable to those already described (Figure 5). Partial resolution of edema surrounding brain lesions was seen on follow-up MRI in July 2013 (Figure 6A, 6B). However, central contrast enhancement was still present (Figure 6C, 6D). There were no new metastases. The neurological examination was similar to the one carried out six months ago. However, further observation and control investigations were recommended.