CNS path q

[MudPhud20XX]

A 48-year-old woman has experienced headaches for the past week. On physical examination her temperature is 37.6° C (99.7° F), pulse 73 bpm, respirations 16 bpm, and blood pressure 130/85 mmHg. She has a lumbar puncture performed. The cerebrospinal fluid (CSF) opening pressure is 220 mm H2O, the CSF protein 60 mg/dL, and the CSF glucose 75 mg/dL (serum glucose 105 mg/dL). A CT scan shows the findings in the image. Biopsy of the mass reveals gliosis and fibrosis with necrosis, neutrophils, and lymphocytes. Which of the following is the most likely diagnosis?

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[worldbeater]

Just a guess, but would these be considered "ring enhancing lesions" so Toxoplosma gondii, from the feces of a cat?

 

[MudPhud20XX]

Just a guess, but would these be considered "ring enhancing lesions" so Toxoplosma gondii, from the feces of a cat?

yes absolutely that is one of the diff diagnosis... here are the answer choices

A. cerebral abscess
B. Gioblastoma (GBM)
C. Herpes simlex type II encephalitis
D. Subacute infarction
E. Vascular malformation

 

[MudPhud20XX]

A 70-year-old man dies from aspiration pneumonia. At autopsy he has bilateral symmetrical cerebral cortical atrophy involving mainly the frontal, parietal, and temporal lobes. There is ex vacuo cerebral ventricular dilation. Cerebral arteries at the base of the brain show no atherosclerosis. The cerebral cortex microscopically shows the findings in the image. Which of the following physical examination findings was most likely to have been present in this man prior to death?

 

[suarad32]

Why would anyone do a lumbar puncture on patient with a supratentorial mass? Anyway, abscesses are ring-enhancing too, although parasagittal is an unusual location for an abscess (usually temporal lobes secondary to chronic suppurative otitis media). And meningeal involvement with abscesses is rare, which explains why it's not particularly abnormal. GBM? Maybe, but I'm sure they would say that the biopsy showed pseudopalisading necrosis.
HSV encephalitis would give you RBCs in CSF. Subacute infaraction would not enhance and an AVM would show up as a bleed, not as an enhancing mass.

For the second question, since I have no idea how to interpret the histopath, I would presume they mean Alzheimer's (hydrocephalus ex vacuo + "occipital sparing", since they're being so specific).

 

[MudPhud20XX]

Why would anyone do a lumbar puncture on patient with a supratentorial mass? Anyway, abscesses are ring-enhancing too, although parasagittal is an unusual location for an abscess (usually temporal lobes secondary to chronic suppurative otitis media). And meningeal involvement with abscesses is rare, which explains why it's not particularly abnormal. GBM? Maybe, but I'm sure they would say that the biopsy showed pseudopalisading necrosis.
HSV encephalitis would give you RBCs in CSF. Subacute infaraction would not enhance and an AVM would show up as a bleed, not as an enhancing mass.

For the second question, since I have no idea how to interpret the histopath, I would presume they mean Alzheimer's (hydrocephalus ex vacuo + "occipital sparing", since they're being so specific).

yeah not sure, but with high temp and headache they thought the pt might have meningitis? not sure...
the answer is the cerebral abscess.

The necrosis with fibrosis is typical for an abscess with an organizing wall. Neovascularization around the organization produces the ring-enhancing effect on CT scan with contrast, and leads to adjacent cerebral edema, increasing the mass effect.

Herpetic lesions are more often temporal, and fibrosis is usually not present.

 

[MudPhud20XX]

Why would anyone do a lumbar puncture on patient with a supratentorial mass? Anyway, abscesses are ring-enhancing too, although parasagittal is an unusual location for an abscess (usually temporal lobes secondary to chronic suppurative otitis media). And meningeal involvement with abscesses is rare, which explains why it's not particularly abnormal. GBM? Maybe, but I'm sure they would say that the biopsy showed pseudopalisading necrosis.
HSV encephalitis would give you RBCs in CSF. Subacute infaraction would not enhance and an AVM would show up as a bleed, not as an enhancing mass.

For the second question, since I have no idea how to interpret the histopath, I would presume they mean Alzheimer's (hydrocephalus ex vacuo + "occipital sparing", since they're being so specific).

correct, it is Alzheimer, for me the biggest clue for me was cortical atrophy. I really have no idea how to interpret the histopath either... is it amyloid plaque or neurofibillary tangle? anyone has any idea?

 

[MudPhud20XX]

A 44-year-old man has noted progressive, symmetrical muscular weakness for the past 3 years. He has no myalgias or arthralgias. His mental status is unchanged. There is no history of traumatic injury. Within the past two months he has had increasing difficulty with swallowing and speaking. On physical examination, fasciculations of the tongue are noted. A deltoid biopsy is obtained. Which of the following microscopic findings involving myofibers is most likely to be seen?





A 23-year-old man undergoes bone marrow transplantation for acute myelogenous leukemia. He has failure of engraftment by day 20. He becomes febrile. Laboratory studies show Hgb 6.8 g/dL, platelet count 51,400/µL, and WBC count 897/µL. He then becomes comatose. A CT scan reveals several areas from 1 to 4 cm in size in the cerebral hemispheres that suggest necrosis with hemorrhage. Which of the following microscopic findings is most likely to be present in his cerebral cortex?

 

[kagman]

yeah not sure, but with high temp and headache they thought the pt might have meningitis? not sure...
the answer is the cerebral abscess.

The necrosis with fibrosis is typical for an abscess with an organizing wall. Neovascularization around the organization produces the ring-enhancing effect on CT scan with contrast, and leads to adjacent cerebral edema, increasing the mass effect.

Herpetic lesions are more often temporal, and fibrosis is usually not present.

Yea why would anyone wanna do a LP ? Anyways I started thinking its not a Bact cause since CSF glucose is N. Only high prot and pressure.. so was thinkign of non-bacterial causes...

 

[kagman]

correct, it is Alzheimer, for me the biggest clue for me was cortical atrophy. I really have no idea how to interpret the histopath either... is it amyloid plaque or neurofibillary tangle? anyone has any idea?

Looks like a plaque to me... but I was going towards pick disease(fronto-temporal) but yea there is no parietal involvement... or would have been spherical tau protein

but what PE findings would we find none the less ?

 

[usmleswot]

There you go

 

[seminoma]

Why would anyone do a lumbar puncture on patient with a supratentorial mass? Anyway, abscesses are ring-enhancing too, although parasagittal is an unusual location for an abscess (usually temporal lobes secondary to chronic suppurative otitis media). And meningeal involvement with abscesses is rare, which explains why it's not particularly abnormal. GBM? Maybe, but I'm sure they would say that the biopsy showed pseudopalisading necrosis.
HSV encephalitis would give you RBCs in CSF. Subacute infaraction would not enhance and an AVM would show up as a bleed, not as an enhancing mass.

For the second question, since I have no idea how to interpret the histopath, I would presume they mean Alzheimer's (hydrocephalus ex vacuo + "occipital sparing", since they're being so specific).

She doesn't have encephalitic signs and HSV is almost always temporal lobe, plus it's usually HSV1, not HSV2. She's too old for an AVM. GBM wouldn't give neutrophils. Has to be abscess.
Edit: Oh, answer already posted. My bad.

Looks like a plaque to me... but I was going towards pick disease(fronto-temporal) but yea there is no parietal involvement... or would have been spherical tau protein

but what PE findings would we find none the less ?

PE findings would be signs of delirium (alzheimer + pneumonia == high delirium likelihood). Are there answer choices for that question? My guess is that they would have "wet, wobbly, wacky" type of stuff in at least one of the answer choices to make sure you know ex vacuo isn't NPH.

A 44-year-old man has noted progressive, symmetrical muscular weakness for the past 3 years. He has no myalgias or arthralgias. His mental status is unchanged. There is no history of traumatic injury. Within the past two months he has had increasing difficulty with swallowing and speaking. On physical examination, fasciculations of the tongue are noted. A deltoid biopsy is obtained. Which of the following microscopic findings involving myofibers is most likely to be seen?





A 23-year-old man undergoes bone marrow transplantation for acute myelogenous leukemia. He has failure of engraftment by day 20. He becomes febrile. Laboratory studies show Hgb 6.8 g/dL, platelet count 51,400/µL, and WBC count 897/µL. He then becomes comatose. A CT scan reveals several areas from 1 to 4 cm in size in the cerebral hemispheres that suggest necrosis with hemorrhage. Which of the following microscopic findings is most likely to be present in his cerebral cortex?

1. ALS (age, progressive, no neuro deficits (mental status)); grouped atrophy because of muscle group denervation.
2. Aspergillus (immunosuppressed, hemorrhage because of angioinvasion). branching, 45*, septate, whatever else.

 

[MudPhud20XX]

A 47-year-old man has become increasingly fatigued with routine activities over the past year. On examination he has spastic paraparesis, sensory ataxia, and marked paresthesias of the legs. Laboratory studies show Hgb 8.9 g/dL, platelet count 222,200/µL, and WBC count 8190/µL. MR imaging of the brain shows optic nerve atrophy. Which of the following diseases is most likely to produce these findings?

 

[MudPhud20XX]

A 27-year-old man comes to his physician because of recurrent headaches, averaging one episode per week for the past 2 months. He describes a slowly building, dull, aching, bandlike pain accompanied by tight neck muscles. The pain lasts for 4 to 10 hours. Exertion does not worsen the headache. On physical examination there are no abnormal findings. Which of the following types of headache is the most likely diagnosis?

 

[MudPhud20XX]

An 8-year-old girl has had generalized tonic-clonic seizures for the past 3 years. Her seizures are poorly controlled by medications. Her cognitive development is slowed and she is placed in special education classes. On examination she has four hypomelanotic skin macules, a shagreen patch, and a subungual fibroma. Echocardiography reveals an interventricular mass. MR imaging of her brain shows multiple cortical and subependymal masslike lesions that are isointense or hypointense with T1-weighting. An abdominal CT scan shows multiple circumscribed 1- to 4-cm solid masses with dark areas of attenuation in both kidneys, as well as cysts in liver, kidneys, and pancreas. She is most likely to have a spontaneous new mutation involving which gene?

 

[MudPhud20XX]

based on the clinical vignette, what do you guys think the pt have?

A 29 yr old Caucasian female complains of decreased vision and pain around her eye, which is aggravated by eye movement. Several months later she is found to have an intention tremor of her left arm.

 

[NeuroLAX]

A 47-year-old man has become increasingly fatigued with routine activities over the past year. On examination he has spastic paraparesis, sensory ataxia, and marked paresthesias of the legs. Laboratory studies show Hgb 8.9 g/dL, platelet count 222,200/µL, and WBC count 8190/µL. MR imaging of the brain shows optic nerve atrophy. Which of the following diseases is most likely to produce these findings?

B12 deficiency

An 8-year-old girl has had generalized tonic-clonic seizures for the past 3 years. Her seizures are poorly controlled by medications. Her cognitive development is slowed and she is placed in special education classes. On examination she has four hypomelanotic skin macules, a shagreen patch, and a subungual fibroma. Echocardiography reveals an interventricular mass. MR imaging of her brain shows multiple cortical and subependymal masslike lesions that are isointense or hypointense with T1-weighting. An abdominal CT scan shows multiple circumscribed 1- to 4-cm solid masses with dark areas of attenuation in both kidneys, as well as cysts in liver, kidneys, and pancreas. She is most likely to have a spontaneous new mutation involving which gene?

TSC1: hamart1n
TSC2: 2berin

A 27-year-old man comes to his physician because of recurrent headaches, averaging one episode per week for the past 2 months. He describes a slowly building, dull, aching, bandlike pain accompanied by tight neck muscles. The pain lasts for 4 to 10 hours. Exertion does not worsen the headache. On physical examination there are no abnormal findings. Which of the following types of headache is the most likely diagnosis?

Tension

based on the clinical vignette, what do you guys think the pt have?

A 29 yr old Caucasian female complains of decreased vision and pain around her eye, which is aggravated by eye movement. Several months later she is found to have an intention tremor of her left arm.

MS

 

[MudPhud20XX]

B12 deficiency



TSC1: hamart1n
TSC2: 2berin



Tension



MS

Hey Nuero, thanks for the reply. For the last one, don't you think it's a bit stretch to say MS? I feel like the clinical vignette should give more info. Could you explain why you came up with MS?

 

[pathologyDO]

A 47-year-old man has become increasingly fatigued with routine activities over the past year. On examination he has spastic paraparesis, sensory ataxia, and marked paresthesias of the legs. Laboratory studies show Hgb 8.9 g/dL, platelet count 222,200/µL, and WBC count 8190/µL. MR imaging of the brain shows optic nerve atrophy. Which of the following diseases is most likely to produce these findings?

Was going to say MS, BUT, the low Hgb lends credence to subacute combined degeneration of the spinal cord from B12 deficiency

 

[MudPhud20XX]

Was going to say MS, BUT, the low Hgb lends credence to subacute combined degeneration of the spinal cord from B12 deficiency

you got it exactly... the answer was actually pernicious anemia which leads to B12 def

 

[NeuroLAX]

Hey Nuero, thanks for the reply. For the last one, don't you think it's a bit stretch to say MS? I feel like the clinical vignette should give more info. Could you explain why you came up with MS?

There are a ton of clues, which all lead to MS.

based on the clinical vignette, what do you guys think the pt have?

A 29 yr old Caucasian female complains of decreased vision and pain around her eye, which is aggravated by eye movement (optic neuritis). Several months later she is found to have an intention tremor of her left arm.

 

[MudPhud20XX]

There are a ton of clues, which all lead to MS.

with regard to the intention tremor, I always thought this was a cerebellum sign, so in MS cerebellum is affected I guess, right? thank you.

 

[seminoma]

How do you know it's B12 and not VitE? Signs are exactly the same except Vit E = hemolytic anemia, B12= megaloblastic.

 

[MudPhud20XX]

How do you know it's B12 and not VitE? Signs are exactly the same except Vit E = hemolytic anemia, B12= megaloblastic.

also, just want to add that VIt E is an antioxidant, thus with Vit E def, increased oxidative stress leads to hemolytic anemia

 

[pathologyDO]

A 12 y/o boy presented to your office with recurrent headaches. On CT it was found that he has a small mass on the wall of the right lateral ventricle. Microscopy confirmed the mass as a subependymal giant cell astrocytoma. What else could this patient present with?

A. Schwannoma of CN 8
B. Lisch Nodules
C. Cafe-au-lait spots
D. Renal Angiomyolipomas
E. Hemangioblastoma

 

[MudPhud20XX]

D right?

 

[pathologyDO]

Yep! Good job. This patient has tuberous sclerosis which presents with multiple hamartomous lesions of the skin, CNS and other organs. Cardiac rhabdomyomas and renal angiomyolipomas are both seen as well.

 

[MudPhud20XX]

Yep! Good job. This patient has tuberous sclerosis which presents with multiple hamartomous lesions of the skin, CNS and other organs. Cardiac rhabdomyomas and renal angiomyolipomas are both seen as well.

thanks man. keep posting questions. these are really helpful man. i will do so too.

 

[NeuroLAX]

D right?

Yeah that would be my answer (Tuberous Sclerosis). A-C represent NF-1, and E was trying to making you think VHL.

Woops, didn't see that the answer was already posted.

 

[pathologyDO]

A 5 y/o girl presents to the ER with headache and vomiting for the past week. She has bilateral papilledema. MRI shows the following enhancing mass in the cerebellum:



Which of the following is the most likely cause?

A. Lung abscess
B. Bacterial Meningitis
C. Viral Meningitis
D. Otitis Media
E. Bacterial Conjunctivitis

 

[bobsanchez123c]

A 5 y/o girl presents to the ER with headache and vomiting for the past week. She has bilateral papilledema. MRI shows the following enhancing mass in the cerebellum:

View attachment 186595

Which of the following is the most likely cause?

A. Lung abscess
B. Bacterial Meningitis
C. Viral Meningitis
D. Otitis Media
E. Bacterial Conjunctivitis

Is the answer D?

 

[pathologyDO]

Correct! Most commonly a cerebellar abscess in a child would be caused by spread from otitis media infection. In children the infections are usually S. pneumoniae and H. influenza.

 

[MudPhud20XX]

A 50-year-old man experiences a sudden grand mal seizure. On examination he has papilledema on funduscopic examination of the right eye. MR imaging of his brain shows a large irregular mass with surrounding edema in the posterior frontal lobe. What is the form of intracranial hemorrhage is most likely to complicate this man’s clinical course?

 

[MudPhud20XX]

A 57-year-old man has noted a swelling increasing in size on the right side of his face for the past year. For the last 3 months he has experienced pain in this area. On physical examination there is an irregular 4-cm firm and tender mass involving the right parotid region. Surgical excision is performed and on microscopic examination the lesion is extensively invading surrounding structures, including the facial nerve. What neoplasm is this man most likely to have?

 

[MudPhud20XX]

A 42-year-old man with HIV infection has had headaches for the past month. He has noted difficulty with movement of his right arm for the past 2 weeks. On physical examination he is afebrile. There is flaccid paralysis of his right arm. Laboratory studies show an HIV-1 RNA of 5630 copies/mL. Brain MR imaging reveals four periventricular 1- to 3-cm masses. A stereotaxic biopsy is performed and on microscopic examination shows a monoclonal proliferation of cells with large nuclei and scant cytoplasm. What is the most likely diagnosis?

 

[MudPhud20XX]

A 23-year-old man undergoes bone marrow transplantation for acute myelogenous leukemia. He has failure of engraftment by day 20. He becomes febrile. Laboratory studies show Hgb 6.8 g/dL, platelet count 51,400/µL, and WBC count 897/µL. He then becomes comatose. A CT scan reveals several areas from 1 to 4 cm in size in the cerebral hemispheres that suggest necrosis with hemorrhage. What microscopic finding is most likely to be present in his cerebral cortex?

 

[MudPhud20XX]

A 5-year-old child appeared normal at birth following an uncomplicated term pregnancy. He developed normally through infancy. During the past year, he has exhibited progressive loss of neurologic function. On physical examination there is no hepatosplenomegaly or lymphadenopathy. A bone marrow biopsy shows no abnormalities. The child dies 3 years later. This child was most likely to have a deficiency of what enzyme?

 

[MudPhud20XX]

A 33-year-old HIV positive man has had increasing difficulty performing activities of daily living for the past 4 months. On examination he is afebrile and there are no localizing neurologic signs. A head CT scan shows multifocal 0.5- to 1-cm white matter lesions. Laboratory studies shown total WBC count 6000/µLwith differential count 77 segmented neutrophils, 3 band neutrophils, 8 lymphocytes, 10 monocytes, and 2 eosinophils. What infection is he most likely to have?

 

[pathologyDO]

A 33-year-old HIV positive man has had increasing difficulty performing activities of daily living for the past 4 months. On examination he is afebrile and there are no localizing neurologic signs. A head CT scan shows multifocal 0.5- to 1-cm white matter lesions. Laboratory studies shown total WBC count 6000/µLwith differential count 77 segmented neutrophils, 3 band neutrophils, 8 lymphocytes, 10 monocytes, and 2 eosinophils. What infection is he most likely to have?

Im confused by infection but being afebrile. I know he has HIV, and that a focal brain abscess would most commonly be from Toxoplasmosis. That's what I have to go with

 

[Gdl88]

A 33-year-old HIV positive man has had increasing difficulty performing activities of daily living for the past 4 months. On examination he is afebrile and there are no localizing neurologic signs. A head CT scan shows multifocal 0.5- to 1-cm white matter lesions. Laboratory studies shown total WBC count 6000/µLwith differential count 77 segmented neutrophils, 3 band neutrophils, 8 lymphocytes, 10 monocytes, and 2 eosinophils. What infection is he most likely to have?

There are multifocal lesions......JC virus?

 

[pathologyDO]

There are multifocal lesions......JC virus?

I see no reason why that wouldn't be a good answer. I think that you're probably right. After reading a bit it looks like JC virus can infect the brain without causing a fever as well which fits the bill.

 

[MudPhud20XX]

There are multifocal lesions......JC virus?

correct! This is the typical set of findings with progressive multifocal leukoencephalopathy (PML), a disease found in immunocompromised patients. Note the lymphopenia in this man typical for AIDS.

 

[Instatewaiter]

A 48-year-old woman has experienced headaches for the past week. On physical examination her temperature is 37.6° C (99.7° F), pulse 73 bpm, respirations 16 bpm, and blood pressure 130/85 mmHg. She has a lumbar puncture performed. The cerebrospinal fluid (CSF) opening pressure is 220 mm H2O, the CSF protein 60 mg/dL, and the CSF glucose 75 mg/dL (serum glucose 105 mg/dL). A CT scan shows the findings in the image. Biopsy of the mass reveals gliosis and fibrosis with necrosis, neutrophils, and lymphocytes. Which of the following is the most likely diagnosis?

This looks like an abscess. Notice the center is a different houndsfeld unit than the normal parenchyma of the brain. These will sometims have air fluid levels inside them.

high opening pressure makes you think crypto but it doesn't look like crypto.

 

[MudPhud20XX]

yup, it is brain abscess. good job.

 

[pathologyDO]

32 y/o male comes into your office with a known immunocompromised state with marked reduction in CD4+ T-cells, below 50. The patient complains that he has had a respiratory infection that has gotten progressively worse, and that he has had recurring headaches too. You notice that the patients eyes look inflamed from afar. Fundoscopic exam reveals the following:

After thinking, you ask your physician for tips. He tells you that this disease is common in healthy people too, and can cause serious CNS problems in neonates if the mother catches it during pregnancy.

Diagnosis? What findings on microscopy?

 

[MudPhud20XX]

CMV? retinitis? that's my guess.

 

[MudPhud20XX]

A 34-year-old man has polydipsia and polyuria. With the patient fasting, a 24-hour urine sample shows a volume of 7.8 L and osmolality of 135.0 mOsmol/kg, while the plasma osmolality is 270.0 mOsmol/kg. His urine is negative for red blood cells, leukocytes, protein, and glucose. His blood pressure and heart rate are both normal. What is a likely cause of polyuria in this patient?

 

[MudPhud20XX]

A 72-year-old woman visits a neurologist for follow-up two weeks after suffering an ischemic stroke. A careful examination of her vision reveals complete blindness in the upper and lower nasal quadrants of the visual field of her left eye, and the upper and lower temporal quadrants of the visual field of her right eye. Central vision was spared in both eyes. Occlusion of which artery produces these symptoms?

 

[MudPhud20XX]

A chest film of a 53-year-old man shows a tumor in the left apical lung area (see figure). It has spread to the parietal pleura and has invaded structures in his neck. Patient with Pancoast tumor develops Horner syndrome. Which of the following signs and symptoms indicates a condition other than Horner syndrome is most likely to result from direct extension of the tumor into the stellate ganglion?

 

[pathologyDO]

I'm feeling December/January area for Uworld.

CMV? retinitis? that's my guess.

Right you are. This is a case of CMV, which causes retinitis with lots of hemorrhaging in HIV patients. It causes mono like symptoms, including respiratory infections, sore esophagus, etc. If a mother has not had CMV but gets it during pregnancy, the baby can come out with serious CNS defects.

On microscopy you would see giant cells from the virus emerging. Looks like an owl eye

Great job.