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Images of Memorable Cases: Case 107

Module by: Herbert L. Fred, MD, Hendrik A. van Dijk

http://rup.rice.edu/memcases-button.jpg

Case_107-pres1-1.jpg

Contrast-enhanced cranial CT scan of a 42-year-old HIV-positive man with numbness and weakness in his left hand. He denied headaches, fever, mental change, visual difficulty, or speech disturbance. His spinal fluid had 21 leukocytes per mm 3 mm 3 size 12{ ital "mm" rSup { size 8{3} } } {} , 118 mg/dL of protein, and a VDRL reactive 1:4. Various stains and cultures of the fluid were negative.

107. Cerebral gumma

The ring-enhancing lesion with surrounding edema in the right parietal lobe was consistent with neoplasm, opportunistic infection, and pyogenic abscess. But the spinal fluid findings indicated active neurosyphilis with probable gumma formation. Accordingly, the patient received high-dose penicillin intravenously for 21 days. On day 16 of therapy, a repeat CT scan showed that the brain lesion had all but disappeared. And by day 21, the patient was asymptomatic with a normal physical examination.

Despite their relative rarity, cerebral gummata deserve consideration in patients who have one or more brain masses and laboratory evidence of syphilis. On CT scan, the cerebral gumma typically appears as a peripherally located, contrast-enhancing lesion, with or without surrounding edema. Therefore, it can be easily mistaken for neoplasm, abscess, opportunistic infection, or infarct.

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