case_images: PMC11301807_01
case_images: Radiologic findings: (a-c) Pre-surgery magnetic resonance imaging (MRI); (d-f) MRI postoperative. (a-c) Preoperative MRI: (a) T2 axial, (b) T1 axial, and (c) T1 post-contrast axial (A large heterogenous appearing lesion involving the right temporal and frontal lobe with surrounding vasogenic edema. The lesion is iso- to hypointense on T1 and hyperintense on T2, with heterogeneous enhancement noted on the contrast sequence. The lesion is also causing a mass effect and midline shift to the contralateral side). (d-f) MRI status post-surgery: (d) T2 axial, (e) T1 axial, (f) T1 post-contrast axial status post-surgery (right temporal resection cavity is evident with vasogenic edema in the right temporal region extending into the right parieto-occipital lobe. On T1 post-contrast, no enhancing residual component of the lesion was noted).
case_images: SNI-15-238-g001.jpg
case_images: PMC11301807_01_SNI-15-238-g001.jpg
case_images: F1
case_images: Magnetic resonance imaging (MRI) brain showed a large heterogenous enhancing lesion involving the right temporal and frontal lobes with surrounding vasogenic edema and midline shift, as shown in Figure 1. She developed no new postoperative deficits, postoperative MRI showed gross total resection of the lesion [Figure 1], and she was shifted out of the special care unit.
case_images: Histopathologic findings: (a and b) leptomeningitis and encephalitis, (c and d) necrotizing vasculitis with aggregation of amebic organisms around the blood vessel, (e) vasculitis, (f) rare multinucleated giant cells.
case_images: SNI-15-238-g002.jpg
case_images: PMC11301807_01_SNI-15-238-g002.jpg
case_images: F2
case_images: The larger size of the putative organism favored Balamuthia or Acanthamoeba as the culprit, as shown in Figure 2.
case_images: (a) Multiple patchy T2 hyperintensity along areas involving the cerebellum, bilateral temporal lobes, frontal lobes and left parietal lobe, posterior margins of resection cavity, brainstem, and right basal ganglia showing patchy diffusion restriction. (b and c) There is also interval development of basal meningeal enhancement noted. (d) On T1 contrast sagittal view, tonsillar herniation is evident with resultant mass effect on the brainstem. (e and f) Heterogeneous perfusion signals were noted in the brain parenchyma. Most of the areas of the brain were showing significantly reduced blood volume and flow, there was elevated time to peak and mean transit time.
case_images: SNI-15-238-g003.jpg
case_images: PMC11301807_01_SNI-15-238-g003.jpg
case_images: F3
case_images: Her MRI brain was repeated, which revealed multifocal areas of infarction and abnormal patchy hyperintensities with tonsillar herniation [Figure 3].