case_images: PMC5797606_01
case_images: Clinical, therapeutic, and radiological course. Abbreviations: CSF cerebrospinal fluid; d, days; EEG, electroencephalography; GE, gadolinium-enhancement; IVIG, intravenous immunoglobulin; JCV-PCR John Cunningham virus-polymerase chain reaction; MP, methylprednisolone; MRI, magnetic resonance imaging; NCSE, non-convulsive status epilepticus.
case_images: fimmu-09-00108-g001.jpg
case_images: PMC5797606_01_fimmu-09-00108-g001.jpg
case_images: F1
case_images: A 67-year-old woman was diagnosed with squamous NSCLC 1 year before the current admission, details of the subsequent clinical course are outlined in Figure 1. Second-line treatment with nivolumab in the standard dosage of 3 mg/kg was subsequently initiated and details of the course are shown in Figure 1.
case_images: Neuroimaging. Brain CT in the postoperative course after the patient developed nausea, vomiting, and generalized weakness. The red arrows point at revealing wide-spread bilateral hypodensities in the subcortical white matter of the frontal, parietal, and occipital lobe (A,B). Brain MRI findings on day 14 of month 1 of the first nivolimab course. Fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) showing multiple bilateral hyperintensities in gray cerebellar matter [(C), red arrows]. (D) T1-contrast enhanced images on the same level as image [(A) (red arrow)]. (D) MRI FLAIR images showing bilateral thalamic hyperintensities with corresponding T1-contrast enhancement left [(F), red arrow]. FLAIR MRI images showing confluent cortical hyperintensities (G) T1 contrast-enhancement showing pial gyriform pattern of enhancement [(H), red arrows].
case_images: fimmu-09-00108-g002.jpg
case_images: PMC5797606_01_fimmu-09-00108-g002.jpg
case_images: F2
case_images: Brain CT revealed wide-spread bilateral hypodense lesion in the subcortical white matter of the frontal, parietal, and occipital lobe (Figures 2A,B), which had vanished on follow-up 8 days later. Brain MRI 44 days showed multiple and confluent cortical and subcortical FLAIR hyperintensities within both cerebral hemispheres, as shown in Figures 2C,E,G. A pial and gyriform contrast enhancement was observed in some lesion (Figures 2D,F,H).
case_images: Histological examination of the brain. Microscopic examination disclosed necrotic tissue damage in the right thalamus [(A), H&E], and reactive astrogliosis in the cortex [(B), H&E]. Normal appearing white matter [(C), H&E]. Further stainings of the thalamus included LFB (D), MBP (E), and PLP (F). Additional findings were vascular wall hyalinosis (G) with presence of CD3-positive T-cells in the perivascular space (H), reactive astro and microgliosis [(I,J), respectively]. Abbreviations: GFAP Glial fibrillary acid protein, LFB Luxol fast blue, MBP Myelin basic protein, PLP Proteolipid protein.
case_images: fimmu-09-00108-g003.jpg
case_images: PMC5797606_01_fimmu-09-00108-g003.jpg
case_images: F3
case_images: Microscopic analysis revealed generalized mild edematous changes as well as hypoxic neuronal changes (Figure 3).