Case 37-1996

Abstract

A 51-year-old man was admitted to the hospital because of visual "instability" and an intracranial mass.The patient was an accountant. He had been well until six years earlier, when he began to have difficulty fixating on the proper line when reading pages with columns of figures. The problem was bilateral but appeared to be worse in the left eye. Five years before admission, he noticed a progressive loss of vision in the left eye. Two years later, he experienced anosmia and had urinary frequency and urgency, with nocturia five times nightly. Several days before admission to this hospital, the patient entered another hospital, where a cranial magnetic resonance imaging (MRI) scan ( Fig. 1 and 2) showed a densely enhancing extraaxial subfrontal mass, 5.5 cm by 2.2 cm by 1.7 cm on T 2 -weighted images. The mass, which was isointense on T 1 -weighted images and hypointense on T 2 -weighted images, extended along the falx into the interhemispheric fissure, along the inferior surface of the left basal ganglia and hypothalamus, and into the suprasellar region, where it surrounded the left optic chiasm and abutted the left aspect of the pituitary stalk. The frontal lobes were involved, with extensive vasogenic edema in the white matter of the inferior frontal lobes and in the external capsules. The mass encased and narrowed the distal left internal carotid artery, the proximal portions of both anterior cerebral arteries, and the left middle cerebral artery. Scattered, nonspecific hyperintense areas were seen in the periventricular white matter. There was a retention cyst in the right maxillary sinus, with mucosal thickening in the left maxillary and bilateral ethmoid sinuses. The patient was referred to this hospital.He had worked as a paint stripper 15 years earlier, with prolonged exposure to solvents. There was a six-year history of sinusitis with chronic, clear postnasal drip. He had smoked a pipe and cigars in the past but did not smoke cigarettes; he drank small amounts of alcohol. There was no history of diplopia, headache, dizziness, dysarthria, dysphagia, epistaxis, risk factors for human immunodeficiency virus (HIV) infection, foreign travel, intolerance of heat or cold, changes in sexual function, impaired judgment, or altered personality. There was a history of parkinsonism in his father but no family history of other neuromuscular disease or cancer. The temperature was 37.2°C, the pulse was 68, and the respirations were 18. The blood pressure was 150/90 mm Hg.On physical examination, no rash or lymphadenopathy was found. The head was normal, and the neck supple. The lungs, heart, abdomen, and extremities were normal; no evidence of arthritis was found. The rectal examination was normal except for slight prostatic enlargement without nodules.