case_images: PMC10613972_01
case_images: CT thorax and abdomen at diagnosis: (A) tumor dorsolateral in the right lower lobe and (B) multiple lesions in the liver at diagnosis. After four cycles of combined chemotherapy/immunotherapy showing response to therapy: (C) Reduction in size of nodule in right lower lobe to 4 mm, and (D) considerable reduction in size of liver lesions compared to before therapy.
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case_images: The largest pulmonary lesions were 3x1.5 cm and 2x2 cm, respectively ( Figure 1A ). CT abdomen showed multiple liver metastases; the largest with a diameter of 5.5 cm ( Figure 1B ). After the 4th cycle, the pulmonary lesions were smaller, with a remaining 4 mm nodule in the right lower lobe ( Figure 1C ) and reduced size of the liver metastases ( Figure 1D ), and serum neuron-specific enolase (NSE) was normalized.
case_images: MRI images (FLAIR, 3 T) of the brain showing pre-PLEX treatment situation (A, B) and situation five weeks later after PLEX (C, D). (A) Transverse section and (B) coronal section through temporal lobes and hippocampi showing clear hyperintense signal in temporal lobe and hippocampus on the left side (with some minor hyperintensity also on the right side). (C) and (D) show same sections after PLEX treatment with reduced hyperintensity signal in the same regions. Arrows depict hyperintense areas in left hemisphere (filled arrows) and right hemisphere (un-filled arrows).
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case_images: Brain MRI on day 4 after admission showed high T2/FLAIR signal and increased volume in the left temporal lobe and hippocampus with no gadolinium contrast enhancement ( Figures 2A, B ), which suggested limbic encephalitis, possibly paraneoplastic. Three days after final PLEX treatment, EEG revealed no focal epileptic activity, and 6 days after PLEX, brain MRI showed improvement in the left hippocampus but remaining high signal in the anterior left hippocampus and amygdala, with reduced edema ( Figures 2C, D ).
case_images: Representative images of the reaction of antibodies from the patients' serum with cells that express GABABR (A) and GAD65 (B).
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case_images: A neuro-immunological paraneoplastic and encephalitis panel analysis was positive for antibodies in serum against both gamma-aminobutyric acid type beta receptor 1 (GABABR1) and glutamic acid decarboxylase 65 (GAD65) ( Figure 3 ), while CSF analysis was positive only for GABABR1 ( Table 1 ).