Yonsei Med J.  2009 Apr;50(2):284-288.

A Case of Cerebral Gumma Presenting as Brain Tumor in a Human Immunodeficiency Virus (HIV)-Negative Patient

• Lee CW
• Lim MJ
• Son D
• Lee JS
• Cheong MH
• Park IS
• Lim MK
• Kim E
• Ha Y

Abstract

Syphilis, along with the recent increase of human immunodeficiency virus (HIV) patients, has also been on the rise. It has a broad spectrum of clinical manifestations, among which cerebral gumma is, a kind of neurosyphilis, however, it is rare and can be cured by penicillin. Thus, cerebral gumma needs to be differentially diagnosed from other brain masses that may be present in syphilis patients. We have experienced a case where the patient was first suspected of brain tumor, but confirmed by surgery to be cerebral gumma due to neurosyphilis. This is the first such case encountered in Korea, therefore, we report it here in. A 40-year old woman complaining of headaches was found to have a brain mass on her CT scans and MRI. Suspecting a brain Tumor, a resection was performed on the patient, and histological results revealed that the central portion of the mass contained necrotic material and the peripheral region was infiltrated with plasma cells. Warthin-Starry staining of the region revealed spirochetes, and the patient was thus diagnosed as brain gumma. Venereal Disease Research Laboratory (VDRL) of cerebrospinal fluid (CSF) was reactive. After an operation, penicillin-G at a daily dose of 24x10(6) U was given for 10 days from post-operative day 10, and thereafter, the mass disappeared.

Keyword

Brain tumor; cerebral gumma; neurosyphilis; sexually transmitted disease; syphilis

MeSH Terms

Adult
Brain Neoplasms/*diagnosis/pathology/radiography
Female
HIV Infections/*diagnosis/radiography
Humans
Magnetic Resonance Imaging
Neurosyphilis/*diagnosis/pathology/radiography
Tomography, X-Ray Computed

Figure

• 

  Fig. 1 MR images of the patient(A-D). (A) T1-weighted sagittal image shows a round mass-like lesion with isointensity in the peripheral and hypointensity in the central portion of the left temporal lobe (arrow). (B) T2-weighted coronal images show the lesion with isointensity in the peripheral and hyperintensity in the central portion with severe vasogenic edema in the surrounding region. (C) Diffusion-weighted image of the central portion of the lesion shows high signal intensity, which suggests brain abscess or necrotic tumor. (D) Contrast-enhanced, T1-weighted image demonstrates peripheral enhancement of the lesion with no enhancement of the central portion. (E) MR spectroscopic image shows small inverted lactate peaks (doublet peak at 1.3 ppm, white arrow) and slightly higher choline peaks (open arrow). This suggests the presence of a tumor rather than an abscess.

• 

  Fig. 2 (A) High-power view of the mass shows small arterioles with lymphocytic and plasma cell infiltration in the adventitia and media, concentric collagenous thickening of the intima, and occlusion of the lumen (×400, H & E stain). (B) In the central area, one thinly coiled microorganism, Treponema pallidum, is observed (×1,000, Warthin-Starry stain).

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