xiii reunion gtno de la senec juan camilo hernandez mir neurocirugia hupm - cadiz
TRANSCRIPT
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XIII REUNION GTNO DE LA SENEC
JUAN CAMILO HERNANDEZMIR NEUROCIRUGIA
HUPM - CADIZ
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CASO CLINICO
• Varón - 42 años
• Antecedentes Personales:- Ex-ADVP- VIH- VHC
• Consulta por cefalea, crisis y disminución de conciencia, desde hace 15 días. No fiebre.
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EXPLORACION
• Conciente, desorientado y somnoliento. - GCS 14/15 - TA 120/70 - Afebril - SatO2 98%
• Sin otros hallazgos…..
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LEUCOCITOS: 3410 (31% NT, 1100 LF)
TCD4: 86 cel/ul
PCR: 5.47
PRUEBAS COMPLEMENTARIAS
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TAC CRANEAL
CON CONTRASTE
CON CONTRASTESIN CONTRASTE
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TAC CRANEAL
CON CONTRASTE
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INGRESO PARA ESTUDIO
• Tto empírico: - Sulfadiazina/pirimetamida. - Dexametasona. - Antirretrovirales.
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T1 T2 FLAIR
T1 GDDIFUSION
RNM CEREBRAL
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RNM CEREBRAL
T1 GADOLINIO
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RNM CEREBRAL
T2
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TAC TORAX
VORICONAZOL, COTRIMOXAZOL, CEFTRIAXONA
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PRUEBAS COMPLEMENTARIAS
• ECOGRAFÍA ABDOMINAL• COLONOSCOPIA• BIOPSIA M. ÓSEA• ANA, ANCA • TAC CERVICAL• TAC ABDOMEN• MICROBIOLOGIA• CITOMETRIA DE FLUJO• COLANGIORM
• FIBROBRONCOSCOPIA (BAS, BAL y Cepillado) Ausencia de células neoplásicas, material inflamatorio y necrótico de uno de los nódulo, estudio microbiológico e histológico negativo.
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EVOLUCION
• 2 semanas: No mejoría.
• Serología TXP negativa.
• Consulta a Neurocirugía para Biopsia Cerebral.
• Se retrasa Biopsia por:– COLANGITIS – ENTEROCOLITIS– FALLO HEPÁTICO
• AG P 65 + para CMV.• Ganciclovir (3 semanas).
INFECCION AGUDA POR CMV
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Biopsia cerebral #1
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LCA
CD3
CD5
IHQ
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CD20
TOXOPLASMA
Ki67
IHQ
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• CD 30• CD 15• CD 68• MUM 1• Bcl 6• VEB • GFAP
IHQ
NO CONCLUYENTE POR NECROSIS
OTRAS TECNICAS HISTOQUIMICAS DESCARTARON AGENTES PATÓGENOS
OTRAS TECNICAS HISTOQUIMICAS DESCARTARON AGENTES PATÓGENOS
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Biopsia cerebral #2
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Resección tumor
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Resección tumor
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RETICULINA
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RETICULINA
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DIAGNOSTICO SUGESTIVO…
Linfoma de fenotipo B necrosado
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GRANULOMATOSIS LINFOMATOIDE????