AHLE has a fulminant course requiring accurate and rapid diagnosis. Successful therapy requires aggressive management of intracranial pressure and immunosuppression. Two other reports of AHLE document successful management with TPE. Each of these patients survived with minimal neurologic impairments. Given the likely immune-mediated nature of this disease, combined treatment of steroids, surgery, and TPE may lead to shorter hospital stays and improved neurologic outcomes. Clinical studies are needed to further study the effect of TPE on neurologic outcome in AHLE.

Cokeromyces recurvatus is a dimorphic zygomycete with histologic morphology similar to Coccidioides immitis. A 66-year-old man who was status-post bone marrow transplantation for chronic myelogenous leukemia was hospitalized with new onset rash, nausea, and vomiting and subsequently expired. A sputum culture collected on the day of death revealed heavy growth of C. recurvatus 6 days after collection. At autopsy, microscopic examination of the lungs revealed numerous thick-walled, nonbudding spherules ranging in size from 40 to 80 µm. Initial immunohistochemical staining of the formalin-fixed lung tissue was positive for Coccidioides. Additional immunoperoxidase staining revealed the organisms were consistent with a zygomycete fungus, compatible with C. recurvatus infection. Polymerase chain reaction using panfungal primers was attempted on the formalin-fixed tissue but was inconclusive. This case highlights the potential for misdiagnosing Cokeromyces as Coccidioides when the diagnosis is based on histology and immunohistochemical staining.

The cytologic findings of a paratracheal metastasis from a malignant sex cord tumor with annular tubules (SCTATs) diagnosed by endoscopic ultrasound guided fine needle aspiration are described. Cytologic features of SCTATs include the presence of highly cellular aspirates forming simple and complex rosette-like structures around central rounded hyaline material, small nucleoli, and prominent nuclear grooves. These cytologic findings are clearly distinct from the poorly formed rosette-like structures of granulosa-cell tumors and are reminiscent of the low-power appearance of the cribriform variant of adenoid cystic carcinoma. The fine needle aspiration cytologic features of only two other cases have been previously described and, to the best of our knowledge, this is the first case reporting the cytologic diagnosis of a distant metastasis of a SCTATs by endoscopic ultrasound-guided fine needle aspiration. In this case, the distinctive and characteristic cytologic features have allowed the proper diagnosis of a distant metastasis of SCTATs.

A 59-year-old woman with a history of refractory acute myelomonocytic leukemia with normal karyotype showing NPM1 mutation (FAB classification M4) experienced fever, progressive weakness, fatigue, and fluctuating levels of consciousness about 1.5 months after haplomatched NK cell infusion, followed by peripheral blood stem cell transplant. The patient was originally from Russia, but had been living in the United States for almost 30 years and had recently undertaken a trip to China. Pretransplant serologies included positive IgG titers for CMV, HSV, VZV, and EBV. Serologies for HIV, hepatitis B, and C virus, Treponema pallidum and Trypanosoma cruzi were negative. Pretransplant serologies for Toxoplasma gondii were not performed.The patient's post hematopoietic stem cell transplant (HSCT) course was complicated by neutropenia, profound immunosuppression, and multiple systemic infections including positive blood cultures for vancomycin-resistant Enterococcus faecium, Escherichia coli, and HHV6 viremia. The patient was treated prophylactically or preemptively with antiviral agents (Acyclovir), multiple antifungals (caspofungin, voriconazole), and antibacterial agents (meropenem, levofloxacin, quinupristin/dalfopristin). Pentamidine was given by nebulizer once monthly for Pneumocystis prophylaxis.On post transplant day 48, the patient developed highgrade fevers and an acute decline in mental status. Brain MRI demonstrated new confluent punctate areas of T2 signal change involving the periventricular white matter of both cerebral hemispheres, predominantly in a subarachnoid location, and white matter changes in both cerebellar hemispheres. Lumbar puncture demonstrated a CSF white blood cell count of 36/ll (reference range 0-5), with 100% neutrophils, a red blood cell count of 3/ll (reference range 0-2), glucose of 49 mg/dl (reference range 40-70), and total CSF protein 107 (reference range 15-60 mg/dl) with increased IgG and albumin levels. No blasts were identified cytologically or by flow cytometry. CSF cultures for bacteria and fungi were negative. CSF PCR tests for HHV6, HSV1, HSV2, and VDRL testing were negative. Gram stain demonstrated neutrophils with multiple ovoid intracytoplasmic inclusions. Chemiluminescent immunoassay showed the presence of T. gondii IgG antibodies (14 IU/ml, reference range 6 IU/ml or less) but not of T. gondii IgM antibodies (0.27 IV, reference range 0.89 IV or less). Cytologic examination of Wright-stained cytospin preparations and Papanicolaou-stained Surepath 1 preparations of the CSF demonstrated intracellular and extracellular ovoid to crescent or banana-shaped organisms measuring 2-3 by 6 micron [ Fig. C-1], with an illdefined eccentric nucleus, best seen in the Wright-stained preparation [ Fig. C-2]. Extracellular organisms were best defined in the Papanicolaou-stained preparation and were frequently seen in close contact with the cytoplasmic membrane or within invaginations of neutrophils. Intracellular organisms were sometimes surrounded by a thin halo and were more rounded, mea...