A case of brain abscess associated with asymptomatic multiple myeloma

A 55-year-old male was admitted to our hospital because of confusion and mild weakness of his left arm and leg. His condition had taken a gradual turn for the worse for several months. Computed tomography (CT) demonstrated a mixed density mass with multiple cysts and massive perifocal edema. Magnetic resonance imaging (MRI) demonstrated an irregular-shaped mass with multiple cysts sized 6 x 4 x 6 cm in the temporal lobe, which manifested mixed signal intensity on both the T1 weighted image and the T2 weighted image. MRI also revealed massive perifocal edema and marked midline shift. Gd-DTPA study showed ring-like enhancement. Angiography showed no tumor stain and a suppressed right posterior cerebral artery. A right extended temporo-occipital craniotomy was performed to extirpate the abscess subtotally. The histological examination showed brain abscess and Gram stain of the pus revealed the presence of gram-positive bacilli. The gram-positive bacillus, Corynebacterium only was subsequently cultured from the pus. After the operation his hemiparesis seemed to disappear. In spite of the treatment with multiple intravenous antibiotics, his hemiparesis worsened again. CT and MRI demonstrated recurrence of the brain abscess in the occipital lobe and marked perifocal edema. The second operation was performed and removed all the infected brain tissue with abscess. After the second operation, otorhinological and cardiovascular examinations were carried out, but no causal disease was found. Immunoelectrophoresis (total protein 12.2 g/d/) revealed the peak of M protein. Bone marrow revealed dysplasia of the plasma cell and he was diagnosed as having multiple myeloma that had made him an immunocompromised host.     

A case of penile malignant melanoma

A 79-year-old male presented in December. In January, 2001, with complaints of black nodules and bleeding from the glans of the penis to the foreskin. Inguinal lymph nodes were palpable bilaterally. Clinical diagnosis was penile malignant melanoma. Cystoscopy and urethrography revealed urethral invasion of malignant melanoma, and magnetic resonance imaging (MRI) of the penis revealed invasion to prostate, and pelvic lymph node metastases in abdominal compuled tomography (CT) but no organ metastases. Total cystectomy, total penectomy, bilateral inguinal and pelvic lymph node dissection and bilateral ureterocutaneostomy were performed in February, 2002. The pathological findings were nodular malignant melanoma, pT4bN2bM1a, and the surgical margin was positive. After these therapies, chemotherapy was performed. Five months later, CT revealed multiple lung and brain metastases, and radiation therapy and chemotherapy were performed. Twelve months after the operation, he died of cancer. Review of the literature revealed that our patient is the thirtieth reported case of penile malignant melanoma in Japan since 1924. In 30 cases, stage III, IV were 20 cases and 16 cases performed operation.     

A case report of ureteropelvic junction obstruction and multiple renal stones associated with nutcracker syndrome

A 20 year-old man presented to emergency room with severe left-sided flank pain. Urinalysis showed hematuria and he was referred to the urology department. KUB, DIP and retrograde pyelography (RP) revealed multiple renal stones, left hydronephrosis (grade 2) and ureteropelvic junction obstruction (UPJO). Abdominal CT revealed shortened nutcracker distance and renal angiography showed left renal vein hypertension. From these findings, diagnosis of nutcracker syndrome was made. Transposition of the left renal vein, dismembered pyeloplasty and left pyelolithotomy were performed simultaneously. 2 months after the procedure, his symptom and hematuria disappeared. 3 months after the procedure, DIP revealed improvement of hydronephrosis (grade 1) and CT showed elongation of nutcracker distance. In 12 months follow-up, there was no recurrence of symptom and hydonephrosis. To the best our knowledge, there has been no report of UPJO associated with nutcracker syndrome and the simultaneous treatment for the both diseases.     

Adenocarcinoma of the rete testis. A case report

Adenocarcinoma of the rete testis is a rare malignant tumor with a poor prognosis. About 60 cases of this adenocarcinoma have been reported in the literature. The diagnosis is often difficult and made incidentally. Herein, we report a case of adenocarcinoma of the rete testis and review the literature. Our patient was an 80-year-old man who presented with painless scrotal swelling for 2 years. Physical examination revealed an enlarged, hard mass of the left scrotum. The serum markers alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (beta-HCG), and carcinoembryonic antigen (CEA) were negative. Magnetic resonance imaging (MRI) showed a left hydrocele with central necrosis of the testis. After 4 months, the patient presented with appetite loss, general fatigue, and pain in the left scrotum. Positron emission tomography (PET) was performed in another hospital, and the patient was referred for a left testicular tumor, multiple lung metastases, and para-aorta lymph node metastasis. The patient underwent left high inguinal orchiectomy. Pathological examination revealed a hard whitish mass around the testis involving the epididymis and tunica vaginalis and spreading under the subcutaneous tissue. Histological examination revealed adenocarcinoma in the hilum of the testis, which extended to the subcutaneous tissue but not to the surface of the scrotum. The tunica albuginea was intact, and no invasion of carcinoma in the testis was seen. After the histological diagnosis of adenocarcinoma of the rete testis was confirmed, computed tomography (CT) was performed and showed multiple pulmonary nodules and para-aortica lymph node swelling of 3 cm diameter. Because the patient did not wish to receive chemotherapy or other aggressive treatment, he has been followed-up with palliative care since his diagnosis. Although local recurrence has occurred 4 months later, he is still alive for 8 months since his diagnosis.     

A case report of simultaneous multiple intracerebral hematomas

A case of multiple spontaneous intracerebral hematomas is presented. A 67-year-old man with 7 years history of hypertension had sudden clumsiness in his right hand and an hour later dysarthria appeared. A CT scan taken 3 hours after the onset revealed two well demarcated high density areas in the left putamen and in the parietal subcortex. A diagnosis of multiple intracerebral hematomas was made. On neurological examination he was midly stuporous (13 points of Glasgow Coma Scale). Dysarthria, right hemiparesis and right extensor plantar response were seen. CT scan of 6 hours later disclosed the same findings as the previous study. He recovered well and neurologically free in a few days. On the following CT scans both hematomas were isodense 2 weeks later, and ring-like enhancement effect was noted. CT scan showed normal appearance 7 weeks later. On MRI using 0.5 T unit t-1 and t-2 weighted spin echo images of these hematomas also showed the similar chronological changes. The history, these CT and MRI studies suggest that two hematomas of this case occurred almost simultaneously in one cerebral hemisphere. No causative factors such as blood dyscrasias, AVM, angioma, septicemia, malignancies or sinus thrombosis was identified. We consider that a hypertensive intracerebral hematoma of the putamen was followed by the parietal intracerebral hematoma within a few hours, although amyloid angiopathy was not completely excluded because no cerebral biopsy of the lesion was performed.     

A case of encapsulated intracerebral hematoma mimicking metastatic brain tumor

We report a case of encapsulated intracranial hematoma (EIH) mimicking metastatic brain tumor. A 77-year-old male with a medical history of prostate cancer was admitted to our hospital presenting with progressive left hemiparesis. Previous head CT scan and MRI findings during 3 weeks before admission revealed a subcortical acute to subacute hematoma under the right precentral gyrus with growing perifocal brainedema. The Head DSA showed tumor-stain with vascular compression corresponding to the hemorrhagic mass, and Tl-201 SPECT study revealed high L/N ratio (3.0) and high L/E ratio (0.8). The preoperative diagnosis was metastatic brain tumor originating from prostate cancer, and total removal of the mass was undergone with the postoperative diagnosis of EIH. Neither tumoral component nor vascular malformation was found even by detailed pathological study. EIH is a rare variant of intracranial hemorrhage and most of cases in past reports are preoperatively misdiagnosed as malignant brain tumor. In our case, even Tl-201 SPECT and DSA, which are reported as key studies for distinguishing EIH from other brain tumors, demonstrated brain tumor-like findings. It is necessary to consider the possibility of EIH when we encounter hemorrhagic mass in the brain parenchyma even with brain tumor-like radiographical images.     

A case of cardiac myxoma with multiple brain hemorrhage]

A case of cardiac myxoma with multiple brain hemorrhage is reported. A 57-year-old male had complained of lower abdominal pain, diarrhea and fever for 3 days. On admission, he was in a condition of disseminated intravascular coagulation and sepsis. An abdominal CT scan showed infarction in the right kidney and spleen and an echocardiogram also showed myxoma in the left atrium. Although he presented no neurological symptoms, the brain CT showed multiple brain hemorrhage in the bilateral brain hemispheres. Total resection of the tumor was carried out for the improvement of the patient's general condition. Vimentin, S-100 protein and neuron specific enolase was positive in immunological staining and the pathological diagnosis was myxoma. Postoperative recovery of consciousness was poor and left hemiparesis developed. CT showed the increase of hematoma but angiography showed no cerebral aneurysm. The symptoms improved with conservative therapy. However the enhanced lesion remained in the right parietal lobe and an operation was performed 5 months later. The myxoma cell could not be found in the pathological examination, so tumor embolism, cerebral infarction, hemorrhagic infarction due to DIC, hematoma enlargement caused by heparinization during operation were suspected to have occurred in this order without tumor growth.     

Can CT scanner and MRI predict capsular invasion of local cancer of the prostate? A study of 20 radical prostatectomies

Spread beyond the capsule is a poor prognosis factor in clinically localized carcinomas of the prostate; preoperative diagnosis is difficult and clinical evaluation usually underestimates tumor spread. This prospective study was undertaken to confront results of the conventional workup (rectal examination, transrectal ultrasonography and PSA) and of CT scan and MRI findings with findings upon the pathologic study of operative specimens following radical prostatectomy. Results show that the conventional workup remains the diagnostic gold standard and that CT scan yields no additional information. Technically faultless MRI with sections in the three planes is a good means for analyzing the capsule of the prostate.     

Malignant lymphoma of the prostate: a case report]

A case of a primary malignant lymphoma of the prostate is presented. An 82-year-old man visited our hospital complaining of anal pain. Digital rectal examination revealed an enlarged prostate gland, which caused a rectal stricture. A computed tomographic scan and magnetic resonance imaging (MRI) showed a large mass arising from the prostate and protruding to the rectum. According to the Working Formulation, he was diagnosed with non-Hodgkin's lymphoma of B-cell origin, diffuse, mixed, small and large cell. The results of bone marrow puncture and imaging studies led to the diagnosis of primary malignant lymphoma of the prostate. Because of poor performance status deriving from severe anal pain, radiation therapy was performed to control the pain. After improvement of his performance status, he received combination chemotherapy consisting of cyclophosphamide, adriamycin, vincristine and predonisone (CHOP regimen). His prostate markedly diminished in size, but pneumonia developed. His respiratory condition rapidly deteriorated, and he died of respiratory failure about two and a half months after the onset of his illness. Malignant lymphoma involving the prostate, whether primary or secondary, is very rare. In our understanding, this case is thought to be the 28th clinical case of a malignant lymphoma of the prostate in Japan.     

Intracerebral xanthogranuloma with specific MRI features: a case report

We report a case of a 47-year-old male who had a left frontal lobe mass with specific magnetic resonance imaging (MRI). Four years previous to his admission to our hospital, he developed acute myelocytic leukemia and he was implanted with peripheral blood stem cell transplantation. One month before his admission, he was unable to walk due to right leg motor weakness. MRI revealed a round mass lesion at the left frontal lobe. Initial diagnosis was a brain abscess, so he was administered some antibacterial drug. However, his neurological symptoms kept getting worse with increase of mass size on MRI. T1-weighted MR images showed the mass as a low intensity lesion with incomplete ring-like Gd-enhancement. T2-weighted images showed the mass as a high intensity lesion with many linear shadows inside the mass. Diffusion weighted images showed the mass as a low intensity lesion. MR spectroscopy revealed an elevation of choline and lactate peak. Differential diagnosis was glioma or demyelinating disease. At the operation, the mass was light yellow and seen to be rich with vessels. The pathological diagnosis was xanthogranuloma in the brain. Postoperative course was uneventful. The frontal residual mass lesion decreased in size and Gd-enhancement.     

A case of giant transitional cell carcinoma of the prostate

A 69-year-old man presented with a complaint of pollakisuria, dysuria and anal pain. Digital rectal examination, transrectal ultrasonography and tumor marker of the prostate indicated a giant benign prostate hypertrophy (BPH), but urethrocystogram and magnetic resonance imaging (MRI) of the prostate was not typical of BPH. A diagnosis of giant BPH was made by transrectal needle biopsy of the prostate. However, symptoms of dysuria and anal pain became severe and then a catheter was indwelt into his bladder. A biopsy performed, 3 months later revealed transitional cell carcinoma in the specimens, but he suddenly died of pulmonary infarction.     

Case report of malignant sertoli cell tumor

Malignant sertoli cell tumor is a rare disease and only a few cases have been described previously. We report a terminal case of malignant sertoli cell tumor. A 38-year-old male visited a hospital with a complaint of swelling his left testis. He underwent high left orchiectomy. His pathologic diagnosis was suspected seminoma, and all tumor markers (LDH, HCG, AFP) were negative, and CT imaging confirmed clinical stage 1 (pT1N0M0S0). One year later, a CT scan showed a small retroperitoneum lymph node swelling. Four months later, these lesions increased to 55 x 45 x 70 mm in diameter. He received 3 courses of chemotherapy with BEP (bleomycine, etoposide, cisplatin), but, lymph node size did not change. After he underwent a CT guided lymph node biopsy, his pathologic diagnosis was viable embryonal carcinoma. He then came to our hospital. We selected CPT-11 and nedaplatin for his salvage chemotherapy, but lymph node lesions did not change. After he received 3 courses of chemotherapy, we performed retroperitoneal lymphadenectomy. His pathologic diagnosis was viable sertoli cell tumor, malignant type. After 30 days, he had multiple liver metastases ane died 27 months after orchiectomy. All tumor markers were negative in his all clinical courses.     

Prostate small cell carcinoma: report of two cases that differed in treatment responsiveness

Case 1 : A 76-year-old man with a chief complaint of dysuria had an elevated prostate specific antigen (PSA) level of 24.9. He underwent a transperineal needle biopsy of the prostate, and the histopathological diagnosis was prostatic small cell carcinoma. The cancer was clinically diagnosed as T3bN1M1 with multiple lung metastases. He started receiving hormonal therapy. After three months of hormonal therapy, the multiple lung metastases disappeared. Thereafter, the serum PSA level and the tumor volume increased and he died 12 months from the start of therapy. Case 2: A 79-year-old man was referred to our hospital with a chief complaint of dysuria. The serum level of PSA was elevated to 10.4. Transperineal prostate biopsy revealed prostatic small cell carcinoma. The cancer was clinically diagnosed as T3bN1M1, and hormonal therapy was started. Subsequently, although his serum PSA level declined, his condition worsened rapidly and he died five months after the start of therapy.     

Dissecting vertebral aneurysm with subarachnoid hemorrhage after ischemic onset on the same day: a case report

We report a case of a dissecting vertebral aneurysm with subarachnoid hemorrhage (SAH) after ischemic onset on the same day. A 48-year-old man had abrupt vertigo and nausea. CT & MRI on admission showed no abnormality, but he complained of left hemiparesis after admission. Twelve hours after the ischemic onset he suddenly complained of severe headache and his consciousness deteriorated. The follow-up CT showed diffuse SAH. Cerebral angiography showed occlusion of the right vertebral artery at the origin of the posterior inferior cerebellar artery (PICA) and segmental stenosis of the left vertebral artery at the portion distal to the vertebral PICA junction. We treated the patient conservatively. Four days later, he suddenly fell into a coma, but CT showed no bleeding. Because of this we suspected brain stem ischemia due to deterioration of vertebral dissection. The patient died 8 hours after the ischemic reattack. We report difficulty of treatment of a dissecting vertebral aneurysm with simultaneous ischemia and subarachnoid hemorrhage.     

Case with cardiac myxoma causing cerebral metastasis after cardiac tumor resection

We report a case of cardiac myxoma causing cerebral metastasis after cardiac tumor resection. A 68-year-old man with a cerebral infarction was admitted to our hospital. A cardioembolic source was suspected and echocardiography was performed. In that examination, a cardiac tumor was found in the left atrium. Tumor resection was performed urgently and his postoperative course was uneventful. After the operation he had no new episodes of cerebral deficit. However 6 months after the operation, he complained of headaches. The brain computed tomography (CT) showed there were multiple high-density areas. One of the tumors was resected and the tumor was diagnosed pathologically as metastasis of cardiac myxoma. Brain metastases were treated with 40.8 Gy whole-brain radiation therapy. As the result the tumors were effectively treated and reduced.     

Acute abducens nerve palsy following prostatitis due to prostate biopsy

This is a case of repeated acute abducens nerve palsy following prostatitis due to prostate biopsy. A 64-year-old man came to our hospital because of high prostate specific antigen (PSA; 25 ng/ml) on routine medical examination. Transrectal prostate needle biopsy revealed atypical small acinar proliferations in two cores taken from the apex of the prostate. One day after biopsy, the patient presented with chills and a fever. Prostatitis due to prostate biopsy was diagnosed, and hydration and intravenous antibiotics were administered. Although he showed signs of improvement, seven days after biopsy, he complained of double vision in the left gaze. Upon referral to the neurology, head MRI and CSF examination showed no particular abnormality. He was thus diagnosed with post-infection abducens nerve palsy and treated with steroid therapy. His symptoms gradually ameliorated. One year after biopsy, his PSA level was still high, although follow-up prostate biopsy was benign. One day after follow-up biopsy, he presented again with chills and a fever. He was retreated with hydration and intravenous antibiotics. Six days after follow-up biopsy, he complained of double vision in the left gaze as in the previous year. With the diagnosis of post-infection abducens nerve palsy, he was retreated with steroid therapy.     

A total removal case of cavernous angioma at the lateral wall of the third ventricle with interhemispheric trans-lamina terminalis approach

A case of cavernous angioma at the lateral wall of the third ventricle which was totally removed with interhemispheric trans-lamina terminalis approach is reported. A 40-year-old male had a slowly progressive onset of partial diabetes insipidus and headache with no neurological deficit . CT scan revealed a high density area at anterior third ventricle. The tumor was diagnosed ectopic pinealoma because of CT findings and clinical symptoms. Irradiation and chemotherapy ( RAFP therapy) was performed to this lesion. After two months, his clinical symptoms disappeared. CT scan showed decrease of the density of the region at this point. He was discharged with no symptom. After a half year, he suddenly complained of right homonymous hemianopsia with headache. CT scan showed that the high density area became larger to left posterior than that of half year before. Left carotid angiogram showed no mass lesion and no abnormal vessel. Operation was performed with interhemispheric trans-lamina terminalis approach using bifrontal craniotomy. Operative findings revealed that the tumor situated at the lateral wall of the third ventricle, had rough surface with reddish colour, and old and fresh blood clots inside the tumor. The tumor was carefully dissected without brain damage and was totally removed. The histological findings was compatible with cavernous angioma. Post-operative CT scan showed no high density area. He was discharged with no neurological deficit without right homonymous hemianopsia. Cavernous angioma of anterior third ventricle is very rare.(ABSTRACT TRUNCATED AT 250 WORDS)     

A case of brain metastasis from gastric cancer involving bilateral middle cerebellar peduncles

A case with brain metastasis involving bilateral middle cerebellar peduncles (bMCP) was reported. A 71-year-old male with gastric cancer was treated for multiple brain metastasis by gamma knife radiosurgery (GKR) in September, 2004. Two months after the initial GKR, MRI showed asymmetrical enhanced lesions involving bMCP. A few months later, MRI revealed an expansional infiltration of bMCP lesions. The patient had presented with headache loss of appetite, cerebellar ataxia, diplopia and slight dysmetria. PET showed 2-deoxy-2- [18F] fluoro-D-glucose (FDG) uptake of the bMCP lesions. The lesions were diagnosed as brain metastasis of gastric cancer. The patient underwent his second GKR (marginal dose : 19Gy, maximum dose 38Gy) MRI revealed the disappearance of the tumors 3 months after the second GKR. One year later, the patient showed no evidence of recurrence. For the last time, our case was diagnosed as brain metastasis from gastric cancer without meningeal carcinomatosis. It was suggested that FDG-PET can provide additional information about the lesion of bMCP. GKR may be useful to treat the tumor in bMCP.     

Metastatic malignant lymphoma of the skull with extradural and extracranial extension. Case report

A 72-year-old male was hospitalized because of a steadily growing mass (4 x 4 x 2 cm) in the frontal region, noticed following head injury. Six months earlier, he had declined treatment for malignant lymphoma (small non-cleaved cell type), discovered upon evaluation of a subcutaneous mass in his forearm. Neurological examination on admission was negative. Plain skull films revealed a large, osteolytic lesion with an irregular margin. Bone scintigraphy disclosed no uptake other than in the frontal bone. Computed tomography (CT) showed a large, homogeneously enhanced mass with both extradural and extracranial extension, which had destroyed the left frontal bone. The skull tumor was totally resected, and the diagnosis was malignant lymphoma, large cell, immunoblastic and plasmacytoid type. Postoperative combined chemotherapy with vincristine, cyclophosphamide, prednisolone, and adriamycin resulted in the complete disappearance of liver metastases. The patient was readmitted 2 months later, however, because of headache and gradually progressive impairment of consciousness. A CT scan disclosed brain metastasis in the paraventricular region. Radiation therapy (20 Gy) was administered but no further treatment was given. Skull metastasis is not uncommon in cases of malignant lymphoma, but a large mass with both extradural and extracranial extension is rare. Although aggressive chemotherapy was effective, prophylactic irradiation of the brain should have been considered in this case.     

The usefulness of MRI around the tentorial incisura for determining the mechanism of brain stem injury: a case report

We report a case of isolated brain stem injury caused by the tentorium cerebelli. A 17-year-old male was admitted to our hospital. Thirty minutes before admission, he was struck by another motorcycle while driving his own motorcycle. The Glasgow Coma Scale (GCS) was 10. He had no extremity weakness and his pupils were normal. CT scan showed no evidence of intracranial lesions except for facial bone fractures. His consciousness level improved to GCS 13 at 6 hours after admission. Follow-up CT scan was normal, however MRI 3 days after admission showed a contusion at the left lateral midbrain. He was discharged without any neurological deficits on 6 days after admission. Analysis of the distance between the brain stem and the tentorial margin using MR cisternography showed that the left side was shorter than the right side. We presumed that an isolated lateral brain stem injury was caused by the direct impact of the tentorium cerebelli. Typically the location of this type of lesion is present in the same side as that of impact. However in this case the orientation was opposite to that. We considered that the distance between the brain stem and the tentorial margin affected the mechanism of this lesion.