T1 weighted axial MRI post Gadolinium

Image 41. A 64 year male, two weeks back from 2 months in the Philippines, presented at Central Washington Hospital in Wenatchee, Washington with a progressive two week history of  headache, dysphasia, and right upper extremity weakness and incoordination. He had visited the Philippines many times over the previous 10 years. He had undergone an investigation for fatigue, fever, and 25% eosinophilia nine months before his presenting illness; no cause was discovered and these symptoms and lab findings had cleared.   Stools were O&P negative 2½ months before the present illness. An MRI is shown here. The diagnosis was?     (case and images provided by William Muth MD, Infectious Disease Section, Wenatchee Valley Clinic, Wenatchee, WA)

T2 weighted axial MRI

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Image 41:  A brain biopsy (below) revealed Schistosoma japonicum eggs (75 x 45 µm) within which were viable-looking miracidium, and rectal mucosa biopsies revealed degenerate eggs in granulomas. Schistosoma serology was positive (S. mansoni FAST-ELISA and S. japonicum immunoblot at the CDC) . He had had fresh water exposure many times in the past. He recovered subsequent to treatment with praziquantel and steroids. It is possible that the eosinophilic illness 9 months earlier was a Katayama syndrome (see useful reference: Ropper AH et al. CPC NEJM 345: 126-131; 2001)