A 45-Year-Old Man with a History of Alcohol Abuse and

Rapid Cognitive Decline

Bita Fakhri, MD, MPHBoston University Medical Center

April/01/14

Brain Imaging

DDx of Ring Enhancing Lesions on Brain Imaging

DDx of Ring Enhancing Lesions on Brain Imaging

• Inflammatory (ADEM)• Vascular (Subacute Infarct)• Infectious (bacterial, fungal, mycobacterial,

parasitic)• Neoplastic (primary vs mets)

Inflammatory

• ADEM• MS• PML• Radionecrosis

ADEM Radionecrosis

Vascular

Enhancing Subacute Hemorrhagic Stroke

Neoplastic

metastasis GBM

Infectious• Bacterial (sinusitis, otitis media, dental procedure)

• Fungal (aspergilloma)• Mycobacterial (tuberculoma)• Parasitic (toxo, neurocysticercosis)

Abscess

Approach to HIV Infected Patients with CNS Lesions

• CD4 count• HAART (? Compliance), PPX• Multifactorial• CNS Lesions with or without mass effects

Approach to HIV Infected Patients with CNS Lesions

• CNS lesions with mass effect: TE, PCNSL• CNS lesions without mass effect: PML, HIVE,

CMV encephalitis

Toxoplasma Encephalitis

• Reactivation from prior infection• Fever, headache, AMS, focal neurologic sx, seizure• Supporting lab data: presence of IgG Abs and/or CD4 < 100• Ring enhancement in 90%• If solitary lesion > 4 cm ? PCNSL

Primary CNS Lymphoma• Confusion, lethargy, memory loss, hemiparesis, aphasia, seizures• Constitutional sx in 80%• Irregular, patchy or diffuse enhancement• Equally solitary or multiple

PML

• JC virus• Bilateral, multiple, assymetric areas of demyelination esp. periventricular• Generally not contrast enhancing

HIV Encephalitis

• Subcortical dementia: memory loss, depressive sx, motor abnormalities• Non-enhancing, multiple, “symmetric” lesions (in contrast to PML)

CMV Encephalitis• CD4 < 50• Micronodular or ventriculoencephalitis

Alcoholic Hepatitis

• Hx of heavy alcohol use (>100 g/d) for >= 20 yrs

• Jaundice, anorexia, fever, tender hepatomegaly

• Labs: moderately elevated transaminases (<300) with AST/ALT >= 2

• Clinical and lab features are adequate for establishing dx

Mallory-Denk Bodies in Alcoholic Hepatitis

A 45-Year-Old Man with a History of Alcohol Abuse and

Rapid Cognitive Decline

April/01/14