A Nod to the Nodule

Identifier walsh_2022_s3_c3
Title A Nod to the Nodule
Creator Natalie Brossard; Kirill Zaslavski; Laila Al-Shafai; David Munoz; Edward Margolin
Affiliation (NB) University of Toronto, Toronto, Canada
Subject Autoimmune Diseases; CNS Vasculitidies; Meningo-encephalitis; Optic Radiations; Visual Field Testing
Description This patient presented with acute onset of neurological abnormalities and was found to have a mass lesion in left parieto-occipital lobe with surrounding edema. Neoplastic process was suspected, however, diffusion restriction, loss of gray/white matter differentiation and decreased perfusion of the lesion led to conclusion that subacute infarction is the most likely diagnosis. MRI performed a month later showed abnormal nodular/irregular leptomeningeal enhancement at the borders of the lesion thus question of neoplastic or infectious process was raised. Presence of extensive parenchymal microhemorrhages on subsequent MR suggested possibility of inflammatory amyloid antipathy. CT perfusion study 2 months later showed preservation of gray matter and continued effacement of hemispheric sulci along convexity, findings not expected at this stage of chronic infarct. Thus, lack of expected for infarct evolution of the lesion, leptomeningeal enhancement and worsening of vasogenic edema on subsequent MR made initial diagnosis of stroke very unlikely thus a decision was made to proceed with brain biopsy. Unexpectedly, it demonstrated histolytic palisade around areas of bland necrosis, typical for a rheumatoid nodule. The diagnosis of rheumatoid leptomeningitis producing mass-like lesion was made and treatment with oral corticosteroids commenced. This led to remarkable improvement of patient's cognition and improvement in right-sided weakness. Rheumatoid arthritis (RA) can very rarely involve central nervous system(1). The spectrum of the CNS involvement includes meningitis, encephalitis and occasionally rheumatoid nodules in the brain. Mass-like presentation has only been reported once in a literature. The most common clinical presentation is with recurrent stroke-like episodes, ataxia, headache and seizures, often accompanied by constitutional symptoms(2-4). MRI usually demonstrates leptomeningeal or pachymeningeal hyperintensities with contrast enhancement. Mass-like presentation has only been described once. The characteristic pathologic findings are histiocytic palisades around a site of necrosis devoid of inflammatory cell infiltrates.
History A 67-year-old man presented to emergency department in March'21 with 6hours h/o fever, headache, confusion, right- sided weakness and urinary incontinence. He had h/o hypertension, rheumatoid arthritis, spinal stenosis and was taking etanercept/leflunomide/sulfasalazine. Non-contrasted CT showed left frontoparietal lesion with surrounding edema, thought to be either mass lesion or subacute stroke.
Disease/Diagnosis Rheumatoid nodule and leptomeningitis presenting as a brain mass
Date 2022-02
References 1 Atzeni, F. et al. Central nervous system involvement in rheumatoid arthritis patients and the potential implications; of using biological agents. Best Practice and Research: Clinical Rheumatology vol. 32 (2018).; 2. Bathon, J. M., Moreland, L. W. & DiBartolomeo, A. G. Inflammatory central nervous system involvement in; rheumatoid arthritis. Seminars in Arthritis and Rheumatism 18, 258-266 (1989).; 3. Nesbitt, C., Willshire, L., Quan, D., Shaw, C. & Batchelor, P. Leptomeningeal rheumatoid nodules: diagnosis and; failed therapeutics. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia 22, 425-428; (2015).; 4. Takahashi, M. et al. Multiple intracranial nodules associated with rheumatoid arthritis: case report. Neurologia; medico-chirurgica 54, 317-320 (2014).; 5. Kim, R. C. & Collins, G. H. The neuropathology of rheumatoid disease. Human Pathology 12, (1981).
Language eng
Format video/mp4
Type Image/MovingImage
Source 54th Annual Frank Walsh Society Meeting
Relation is Part of NANOS Annual Meeting 2022
Collection Neuro-Ophthalmology Virtual Education Library: Walsh Session Annual Meeting Archives: https://novel.utah.edu/Walsh/
Publisher North American Neuro-Ophthalmology Society
Holding Institution Spencer S. Eccles Health Sciences Library, University of Utah
Rights Management Copyright 2022. For further information regarding the rights to this collection, please visit: https://NOVEL.utah.edu/about/copyright
ARK ark:/87278/s6y2kscq
Setname ehsl_novel_fbw
ID 2192230
Reference URL https://collections.lib.utah.edu/ark:/87278/s6y2kscq
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