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Case quiz
Kathleen M. Sakamoto, MD PhD, Mattel Children’s Hospital UCLA
An 18-year-old WF with a history
of Senior-Løken syndrome
(characterized by retinitis pigmentosa
and polycystic kidney disease)
received a living related renal
transplant 17 years ago and has
been treated with immunosuppressive
drugs, including prednisone, cellcept,
and cyclosporine. She has had
migraines in the past; however,
2 days prior to admission, she
complained of a worsening left-sided
headache, dizziness, right-arm
and -leg tingling and numbness,
and slurred speech. Upon physical
examination, she had a right facial
droop. She was also hypertensive
with episodes of disorientation
and emesis. The patient was transferred
to the intensive care unit, and
magnetic resonance imaging (MRI)
of her head showed multiple enhancing
masses involving all lobes of
the cerebrum, the corpus callosum,
and ependyma of the occipital
horns of the lateral ventricles.
Some of the lesions had ring enhancement
with surrounding edema and occasional
hemorrhages (Figure 1).
Figure 1. Head MRI results with T2 Image on left and T1 Image on
right (permission obtained from parents)
The differential diagnosis includes
1. infection (fungal, bacterial, viral)
2. stroke
3. malignancy
4. posterior reversible encephalopathy syndrome (PRES), secondary to
cyclosporine.
Based on the history and MRI, in what order would you rank these?
| | A. 4, 3, 1, 2 |
| | B. 1, 4, 3, 2 |
| | C. 3, 1, 4, 2 |
| | D. 1, 3, 2, 4 |
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