Presentation
Emergency department presentation with a one-week history of an intense headache without any additional neurological complaint. Serology for human immunodeficiency virus was positive with a CD4-count of 70 cells/mm3.
Patient Data
Selected MRI images demonstrate a large ring-enhancing lesion located in the parietal white-matter of the right hemisphere in contact with the ependimal surface of the lateral ventricle. There is significant perilesional edema and mass effect with partial collapse of the right ventricle. On T2-weighted image there is a peripheral hypointense rim and a nodular hypointense component in the lateral aspect of the lesion. There is high signal in DWI but a heterogeneous behavior on ADC maps with true restricted diffusion only in some areas within the lesion. Contrast-enhanced axial images show other two small lesions involving frontal and parietal subcortical white matter.
Selected CT images demonstrate multiple intraaxial lesions with significant perilesional edema and mass effect on the midline and on the lateral ventricle. Contrast-enhanced axial images show three lesions involving frontal, parietal and temporal lobes at the right hemisphere, the largest one with ring enhancement.
Case Discussion
This 35-year-old woman from Bolivia was admitted to the Emergency Department with an intense headache without any additional neurological complaint. Serology for human immunodeficiency virus was positive with a CD4-count of 70 cells/mm3. There was a history of several previous opportunistic infections such as toxoplasma, pneumocystis pneumonia, oral candidiasis, and asymptomatic chronic Chagas disease without adherence to treatment.
CT scan images demonstrated multiple intra-axial rim-enhancement lesions with perilesional edema and mass effect, which were confirmed at MRI.
Imaging features were non-specific and cerebral abscess of an unknown origin was suggested. Other differential diagnoses, including high-grade glioma, metastasis, toxoplasmosis, and cerebral lymphoma were less probable according to laboratory results (which showed IgG positive, PCR and microhematocrit concentration method positive for Trypanosoma cruzi and PCR negative for Toxoplasma Gondii).
After complete treatment for Chagas disease, PCR and microhematocrit concentration method for T. Cruzi became negative and follow-up images showed improvement of the cerebral lesions, with progressive decrease in size. Due to good clinical and radiological evolution and to avoid potential complications, brain biopsy was not considered and cerebral chagoma was assumed as the most likely diagnosis.
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