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What’s the Diagnosis?

Case of the Month

The New Physician November-December 2014

The case below is followed by a choice of diagnoses. Select the answer choice that best describes this patient’s condition.

A 42-year-old woman is referred to the neurosurgery outpatient department with a gradual-onset headache that is constant and located in the right half of her head. She has also had frequent, repetitive, nonprojectile vomiting not related to meal intake for three to four months. In addition, the patient has had cognitive defects for the last three to four months, especially a reduction of what she describes as “thinking power.” She underwent enucleation of her left eye in a different hospital eight years ago, the details of which the patient could not recall. No other significant medical history is known. The first-degree family members also report no significant medical or surgical history.

On examination, the right pupil is reactive to light. No localized lesions are found in the enucleated left orbital fossa. The hematologic parameters of the patient are noted as follows: Hb, 9.8 g/dL; total leukocyte count, 15,000/μL; and platelet count, 190 x 103/μL. Her erythrocyte sedimentation rate (ESR) is 36 mm/hr. The peripheral blood smears show no abnormal morphology. Her biochemical parameters are also within normal physiological limits. The patient’s vital signs are a pulse rate of 90 bpm, blood pressure of 138/86 mm Hg, and a respiratory rate of 18 breaths/min, and she is afebrile. Her abdominal organs are not palpable. X-ray of the chest does not reveal any acute findings.

Sagittal T1-weighted magnetic resonance imaging (MRI) of the brain shows a hyperintense lesion in the superficial cortex of the posterior frontal region, with surrounding edema (Figure 1). A sagittal T2-weighted MRI scan of the brain reveals a hypointense lesion in the posterior frontal region, with surrounding edema that appears hyperintense. The lesion is excised; a postoperative noncontrast computed tomography (CT) scan of the head shows no evidence of residual tumor, with mild cerebral edema. On histopathologic examination, a tumor is noted in the cerebral cortex infiltrating into the Virchow-Robbins spaces. Subpial spread of the cells is seen, as well as marked nuclear pleomorphism and prominent nucleoli. Frequent mitotic activity is detected (Figure 4).

What is the diagnosis?

A. Glioblastoma

B. Choroid plexus papilloma

C. Retinoblastoma

D. Metatastic melanoma

Hint: Note the site of the lesion, the characteristic histologic findings, and the history of ocular enucleation.

Go to the answer page


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