1. A 45-Year-Old Man with a
History of Alcohol Abuse and
Rapid Cognitive Decline
Bita Fakhri, MD, MPH
Boston University Medical Center
April/01/14

2. Brain Imaging

3. DDx of Ring Enhancing Lesions on
Brain Imaging

4. DDx of Ring Enhancing Lesions on
Brain Imaging
• Inflammatory (ADEM)
• Vascular (Subacute Infarct)
• Infectious (bacterial, fungal, mycobacterial,
parasitic)
• Neoplastic (primary vs mets)

5. Inflammatory
• ADEM
• MS
• PML
• Radionecrosis
ADEM Radionecrosis

6. Vascular
Enhancing Subacute
Hemorrhagic Stroke

7. Neoplastic
metastasis GBM

8. Infectious
• Bacterial (sinusitis,
otitis media, dental
procedure)
• Fungal
(aspergilloma)
• Mycobacterial
(tuberculoma)
• Parasitic (toxo,
neurocysticercosis)
Abscess

9. Approach to HIV Infected Patients with
CNS Lesions
• CD4 count
• HAART (? Compliance), PPX
• Multifactorial
• CNS Lesions with or without mass effects

10. Approach to HIV Infected Patients with
CNS Lesions
• CNS lesions with mass effect: TE, PCNSL
• CNS lesions without mass effect: PML, HIVE,
CMV encephalitis

11. Toxoplasma
Encephalitis
• Reactivation from prior
infection
• Fever, headache, AMS,
focal neurologic sx, seizure
• Supporting lab data:
presence of IgG Abs and/or
CD4 < 100
• Ring enhancement in
90%
• If solitary lesion > 4 cm 
? PCNSL

12. Primary CNS
Lymphoma
• Confusion, lethargy,
memory loss,
hemiparesis, aphasia,
seizures
• Constitutional sx in
80%
• Irregular, patchy or
diffuse enhancement
• Equally solitary or
multiple

13. PML
• JC virus
• Bilateral, multiple, assymetric areas of demyelination esp.
periventricular
• Generally not contrast enhancing

14. HIV Encephalitis
• Subcortical dementia: memory loss, depressive sx, motor
abnormalities
• Non-enhancing, multiple, “symmetric” lesions (in contrast to
PML)

15. CMV
Encephalitis
• CD4 < 50
• Micronodular or
ventriculoencephalitis

16. Alcoholic Hepatitis
• Hx of heavy alcohol use (>100 g/d) for >= 20
yrs
• Jaundice, anorexia, fever, tender
hepatomegaly
• Labs: moderately elevated transaminases
(<300) with AST/ALT >= 2
• Clinical and lab features are adequate for
establishing dx

17. Mallory-Denk Bodies in Alcoholic
Hepatitis

18. A 45-Year-Old Man with a
History of Alcohol Abuse and
Rapid Cognitive Decline
April/01/14