A Giant (Cell) Mistake - Slides

The Patient was sent for an urgent brain and orbit MRI with contrast, which suggested a soft tissue lesion in the right orbital apex, extending in the right cavernous sinus. A dedicated orbital MRI the next day (October 1, 2015) was reported as: Better visualization workup of the already seen the right orbital apex lesions. Based on the contrast enhancement and the extension into the cavernous sinus and the nasal cavity there are multiple differential diagnoses possible. These include lymphoma manifestation or metastatic lesion. Nerve sheath tumor is less likely. The asymmetry of the lacrimal gland has a dimension. The infiltration of e.g. lymphoma cannot be excluded. In her follow up visit after MRI on Oct 5, 2015 she was still on high dose oral prednisone and was found to have more vision loss in the right eye. Neuro-ophthalmic exam showed: VA: LP OD, 20/20 OS. Neuro exam showed reduced pinprick sensation over the right V1 face area. General exam showed a 5cmX5cm skin lesion over the back. She was admitted to hospital with diagnosis of right orbital apex syndrome likely cause by an infiltrative disease such as lymphoma versus metastasis from her old breast cancer. As part of cancer workup a chest CT scan was done which was reported as: Significant increase in the nodular pulmonary opacities in the short interval since the prior study, in a miliary distribution. The dominant pulmonary lesion demonstrates increased cavitation. The rapid rate of progression is suggestive of atypical infection such as TB. A lung biopsy with bronchoscopy was first refused because it was thought but thoracic surgery service that the diagnosis was metastatic lung cancer and therefore the patient received one dose of radiation treatment. Neuro-Ophthalmology insisted on biopsy that showed Blastomycosis. Unfortunately, the patient died in ICU because of respiratory complications.