Dr. Pepe’s Diploma Casebook: Case 2 – SOLVED!

Dear Friends,

Following the usual pattern of an oral examination (mixed cases from all the subspecialities), I challenge you with the following neuro case, below.

Look out for the answer on Thursday. Good luck!

This week’s patient is a 61-year-old immunocompetent male with progressive disorientation and general weakness

Fig. 1

Fig. 2

Fig. 3

Probable diagnosis:

1. Metastases
2. Pyogenic abscess
3. Tuberculosis
4. Multiple Sclerosis

Click here for the answer

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    17 Responses to : Dr. Pepe’s Diploma Casebook: Case 2 – SOLVED!

    1. Guibernau says:

      At least three lesions that restrict in diffusion and have ring heighten after contrast administration. Vasogenic edema is also present.
      Option 2 : Pyogenic abscess.

      In T2-FLAIR hyperintense areas are seen extended in the subcortical white matter of right temporal and left occipital lobes, maybe in relation with encephalitis.

    2. Alejandra says:

      Pyogenic abscess

    3. Mm says:

      I agree. Option 2: pyogenic abscess.

    4. Dr Hesham says:

      TB for immuno competent

    5. Carmen Ursu says:

      Abcese pyogenic.

    6. LL says:

      Does he have fever? It seems to be pyogenic abscess.

    7. Mihai Comsa says:

      2. Pyogenic abscess

    8. san says:


    9. p.s says:


    10. serge says:

      Tuberculosis (with vasculitis ??)

    11. vishal kalia says:

      Pre and post contrast MR axial images showing multiple ring enhancing lesions in right basal ganglia with surrounding edema. These lesions show central hypointensity on T1 and hyperintensity on T2W with peripheral rim appearing isointense on T1 and hypointense on T2W images. The central core shows diffusion restriction.Non enhancing lesion with similar character on T2W is also seen in right frontal region.
      Areas of white matter edema are seen in right posterior temporal and left occipital regions with nodular enhancing lesion in right posterior temporal region. no appreciable enhancing lesions are seen within these areas. no abnormal meningeal or ependymal enhancement is seen. no hydrocephalous seen. the differentials can be -pyogenic or tubercular abscesses.In view of deep seated lesions, lesions in different stages and hypointense rim on T2W images-my first possibility is tubercular.

    12. Kelvin says:

      I agree completely with vishal…however, common things being common, I would place pyogenic abscesses before TB.

    13. Genchi Bari Italia says:

      Ascessi da piogeni: dd con ascessi TBC.La presenza di forme “immature” di cerebrite( aree iperintense a limiti sfocati) depone per ascessi batterici.Gli eventuali test , negativi, per TBC( Mantoux eB-Quantiferon nel siero) ne avvalorano la diagnosi.

    14. Jose caceres says:

      You all did very well! Keep up and you will pass the Diploma easily.