case_images: PMC10794512_01
case_images: Diffusion-weighted brain MRIs (DWI). On day 2 of admission, hyperintensity was noted in the bilateral deep white matter and the corpus callosum splenium (A,D). On days 3 (B,E) and 6 (C,F), the hyperintensities were attenuated gradually.
case_images: fneur-14-1322302-g001.jpg
case_images: PMC10794512_01_fneur-14-1322302-g001.jpg
case_images: fig1
case_images: DOC did not improve. Diffusion-weighted brain magnetic resonance imaging (MRI) on day 2 of hospitalization showed hyperintensity in the symmetrical cerebral white matter and corpus callosum (Figures 1A,D). Brain MRI was performed on days 3 and 6, which revealed gradual attenuation of hyperintensity in these areas (Figures 1B,C,E,F).
case_images: Apparent diffusion coefficient maps brain MRI on day 2 of admission. Hypointensity was in the bilateral deep white matter (A) and the corpus callosum (B). This hypointensity was consistent with DWI hypointensity areas.
case_images: fneur-14-1322302-g002.jpg
case_images: PMC10794512_01_fneur-14-1322302-g002.jpg
case_images: fig2
case_images: Brain MRI apparent diffusion coefficient (ADC) images showed hypointensity in the areas consistent with hyperintensity by diffusion-weighed images (Figures 2A,B).
case_images: Pathology of the corpus callosum splenium. Pathological changes in the area of myelin pallor (A,C,E,G,I,K) are compared to those in the unaffected area of myelin unpallor (B,D,F,H,J,L) in corpus callosum splenium. Kluver-Barrera stain (A,B). Myelin is much paler (A) than that in the unaffected area (B). H&E stain (C,D). Intramyelinic edema is noticed (C). Immunoperoxidase for neurofilaments (E,F). Axons with phosphorylation are clearly visible (E,F). Immunoperoxidase for HLA-DR (G,H). Microglia increase in number and size (G). Immunoperoxidase for glial fibrillary acidic protein (GFAP) (I,J). Fibrous astrocytes decrease in number (I). Immunoperoxidase for CD8 (K,L). CD8-positive lymphocytes are infiltrated (K).
case_images: fneur-14-1322302-g003.jpg
case_images: PMC10794512_01_fneur-14-1322302-g003.jpg
case_images: fig3
case_images: Kluver-Barrera staining showed uneven myelin pallor in the SCC (Figure 3A) and deep white matter. I K) were compared with those in the areas without myelin pallor (Figures 3B D F H J L) in the SCC. In the area of the myelin pallor, eosin staining for myelin showed pallor as well as vacuolization in myelin sheaths (Figure 3C). Immunohistochemical analysis showed that neurofilaments were preserved in the myelin sheaths and were more clearly positive (Figure 3E) than in the regions without pallor (Figure 3F), possibly due to myelin loss. Microglia evaluated by the anti-HLA-DRA antibody was in the activated form with swollen cytoplasm and increased in number (Figure 3G). In contrast, some astrocytes evaluated by the anti-glial fibrillary acidic protein (GFAP) antibody were lost (Figure 3I) in the demyelinated area. CD8-positive lymphocytes were scattered throughout the parenchyma (Figure 3K).
case_images: Pathology of the deep white matter. H & E stain (A). Vacuolization is marked. Kluver-Barrera stain (B). Myelin is pale. Immunoperoxidase for HLA-DR (C). Microglia increase in number and size. Immunoperoxidase for GFAP (D). Astrocytes decrease in number.
case_images: fneur-14-1322302-g004.jpg
case_images: PMC10794512_01_fneur-14-1322302-g004.jpg
case_images: fig4
case_images: In the white matter of the cerebrum, Kluver-Barrera staining also showed myelin pallor (Figure 4A). Vacuolization was marked (Figure 4B), and immunohistochemical studies also showed preserved myelin sheaths, active microglia (Figure 4C), and a reduction of astrocytes (Figure 4D) in the white matter.