case_images: PMC11089811_01
case_images: MRI images from a patient with NEMO deficiency and MAC infection. A 40-year-old man with NEMO deficiency and disseminated MAC infection. Images were obtained following a generalized seizure and show T2-FLAIR hyperintense signal in the bilateral occipital lobes (A) and the hippocampi (B), initially considered to be posterior reversible encephalopathy syndrome vs. a post-ictal etiology due to the atypical distribution and restriction of some lesions on DWI (C,D), but a post-mortem analysis of the brain showed microglial activation and nodules in the hippocampi, with tissue culture positive for MAC. DWI, diffusion-weighted imaging; FLAIR, fluid-attenuated inversion recovery; MAC, Mycobacterium avium complex; NEMO, Nuclear factor-kappa B Essential Modulator; PRES, posterior reversible encephalopathy syndrome.
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case_images: PMC11089811_01_fneur-15-1360128-g001.jpg
case_images: fig1
case_images: In addition, there was diffuse hyperintensity with restricted diffusion involving the right pulvinar nucleus, right hippocampus, and amygdala, possibly suggesting seizure-induced changes (Figures 1A-D).
case_images: PMC11089811_02
case_images: MRI images from a patient with NEMO deficiency and Mycobacterium haemophilum infection. A 28-year-old man with NEMO deficiency and Mycobacterium haemophilum infection with multiple enhancing lesions and associated edema on postcontrast T1 images from the brainstem (A) and upper cervical cord (B). Despite treatment, he had persistent rhomboencephalitis on postcontrast T2-FLAIR 5 months later (C,D), eventually leading to his death. FLAIR, fluid-attenuated inversion recovery; NEMO, Nuclear factor-kappa B Essential Modulator.
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case_images: PMC11089811_02_fneur-15-1360128-g002.jpg
case_images: fig2
case_images: MRI of the brain showed multiple nodular and ring-enhancing lesions of the brainstem (Figure 2A) and upper cervical cord (Figure 2B) with associated edema, in addition to one focus of enhancement in the left frontal lobe. FLAIR (Figure 2D) with subtle enhancement. Following a 5-month hospitalization, he developed profound hypotension with tachycardia and died.
case_images: PMC11089811_03
case_images: A 58-year-old man with untreated HIV and Mycobaterium avium subspecies paratuberculosis infection. A large enhancing lesion in the left midbrain [(A) - postcontrast T1], with a center of hypointensity on susceptibility-weighted imaging (not shown). In addition, multiple small enhancing lesions were noted in the left frontal lobe (not shown) and deep gray matter (B). On PET-FDG (C), the lesion had high FDG uptake in the periphery (maximal standardized uptake value = 12.8) with an area of decreased uptake centrally that corresponds to the area of hemorrhagic transformation. Tissue from a stereotactic left midbrain biopsy was positive on the auramine-rhodamine stain (D). PET-FDG, positron emission tomography with fluorodeoxyglucose.
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case_images: PMC11089811_03_fneur-15-1360128-g003.jpg
case_images: fig3
case_images: Brain MRI showed a large enhancing lesion in the left midbrain (Figure 3A) with central hypointensity on susceptibility-weighted imaging. Additionally, other small enhancing lesions were present in the left frontal lobe and deep gray matter (Figure 3B). The left midbrain lesion showed high FDG uptake in the periphery (maximal standardized uptake value = 12.8, Figure 3C) with an area of decreased uptake centrally that corresponded to the area of hemorrhagic transformation seen on MRI. Eventually, a stereotactic left midbrain biopsy was performed, and histologic sections showed a fibrinous matrix containing numerous neutrophils and few admixed mononuclear cells, with stains positive for numerous AFB and a positive auramine-rhodamine stain (Figure 3D).
case_images: PMC11089811_04
case_images: MRI images from two patients with neurological manifestations of nontuberculous mycobacteria. MRI images from a 56-year-old man with Mycobacterium abscessus isolated from a lumbosacral epidural abscess with sacral osteomyelitis and arachnoiditis [(A) - postcontrast T1, (B)- STIR], and a 39-year-old man with sarcoidosis and IRF-8 variant with a cerebellar enhancing lesion at presentation (C) and an encephalomalacia years after resection of left frontal and right parietal lesions due to Mycobacterium avium complex (D). IRF8, Interferon Regulatory Factor 8; STIR, short tau inversion recovery.
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case_images: PMC11089811_05_fneur-15-1360128-g004.jpg
case_images: fig4
case_images: Serial brain MRI scans showed an enlarging right cerebellar lesion (Figure 4C) without hydrocephalus. The patient improved clinically over the next few months, and a follow-up brain MRI showed post-operative changes (Figure 4D) with a stable appearance of a left posterior parasagittal enhancing nodule, which was not resected.
case_images: PMC11089811_05
case_images: MRI images from two patients with neurological manifestations of nontuberculous mycobacteria. MRI images from a 56-year-old man with Mycobacterium abscessus isolated from a lumbosacral epidural abscess with sacral osteomyelitis and arachnoiditis [(A) - postcontrast T1, (B)- STIR], and a 39-year-old man with sarcoidosis and IRF-8 variant with a cerebellar enhancing lesion at presentation (C) and an encephalomalacia years after resection of left frontal and right parietal lesions due to Mycobacterium avium complex (D). IRF8, Interferon Regulatory Factor 8; STIR, short tau inversion recovery.
case_images: fneur-15-1360128-g004.jpg
case_images: PMC11089811_05_fneur-15-1360128-g004.jpg
case_images: fig4
case_images: Serial brain MRI scans showed an enlarging right cerebellar lesion (Figure 4C) without hydrocephalus. The patient improved clinically over the next few months, and a follow-up brain MRI showed post-operative changes (Figure 4D) with a stable appearance of a left posterior parasagittal enhancing nodule, which was not resected.
case_images: PMC11089811_06
case_images: MRI images from a 31-year-old woman with anti-IFN-gamma autoantibodies and Mycobacterium avium infection. Brain MRI images showing a left post-auricular lesion with erosion through the bone [(A) - postcontrast FLAIR] and a right frontal epidural collection [(B) - postcontrast T1], later also extending into right frontal parenchyma [(C) - postcontrast FLAIR, (D)- postcontrast T1]. FLAIR, fluid-attenuated inversion recovery; IFN, interferon.
case_images: fneur-15-1360128-g005.jpg
case_images: PMC11089811_06_fneur-15-1360128-g005.jpg
case_images: fig5
case_images: Brain MRI showed a 3 cm X 2 cm left post-auricular lesion with erosion through the bone (Figure 5A), as well as a right frontal extra-axial convexity lesion (Figure 5B). She initially had worsening headaches and altered mental status, with a brain MRI showing an extension of epidural abscess into the right frontal parenchyma (Figures 5C,D).