Rojbin Ceylan Tekin

A 28-year-old man presented to the emergency department with a 5-week history of severe headache, dizziness, and weakness in the right arm. Neurological examination revealed 3/5 strength in the right arm. Brain magnetic resonance imaging (MRI) of the brain showed a large hypointense lesion with thick peripheral contrast enhancement in the left periventricular area. The solid components appeared hyperintense after contrast enhancement, and microabscesses were observed in the basal ganglia, subcortical white matter, and left anterior thalamic area. On T2-weighted images, the large hypointense lesion caused a minimal mass effect, which was accompanied by significant peripheral edema ( Figure 1). Diffusion-weighted imaging revealed several diffusely localized lesions with restricted diffusion in both hemispheres and the cerebellum ( Figure 2). Multivoxel MR spectroscopy revealed significant elevation in lipid and lactate levels, indicating an abscess. A brain biopsy was performed and pathological examination confirmed the diagnosis of Aspergillus infection ( Figure 3, arrowheads). The patient was treated with intravenous liposomal amphotericin B but died despite a 57-day course of antifungal therapy. Intracranial Aspergillus infection is a rare condition that is difficult to diagnose because of the lack of specific imaging features¹ 1. Brun S, Fekkar A, Busse A, Seilhean D, Lecsö M, Adler D, et al. Aspergillus flavus brain abscesses associated with hepatic amebiasis in a non-neutropenic man in Senegal. Am J Trop Med Hyg. 2009;81(4):583-6. 2. Lange N, Wantia N, Jörger AK, Wagner A, Liesche F, Meyer B, et al. J. Fungal brain infection-no longer a death sentence. Neurosurg Rev. 2021;44(4):2239-44. ^-3 3. Dal T, Tekin A, Tekin R, Deveci O, Fırat U, Mete M, et al. Soft Tissue Abscess Caused by Aspergillus Fumigatus in an Immunosuppressive Patient. Eur J Gen Med. 2013;10(2):118-22. .

A 23-year-old male patient reported experiencing pain in his right thigh for 2 days along with swelling in the same area for the past 5 months. Upon physical examination, his thigh was found to be mildly painful. Magnetic resonance imaging (MRI) revealed T1-weighted hypointense and T2-weighted fat-suppressed series hyperintense lesions in the semimembranosus muscle ( Figure 1a,b). The MRI further indicated a rupture of a muscular hydatid cyst, as evidenced by the “water lily sign” produced by the detachment of the germinal membrane of the endocyst ( Figure 1c,d arrow). The MRI also confirmed the intramuscular location of the lesion in the semimembranosus muscle, which exhibited significant edematous signal changes in the surrounding muscle structures and between the fascia planes. Based on the clinical, laboratory, and radiological findings, the patient was diagnosed with a ruptured muscular hydatid cyst. A wide resection of the right thigh was performed, ensuring adequate margins of healthy tissue were maintained around the associated soft-tissue cystic components ( Figure 2). The diagnosis of hydatid disease was confirmed through a histopathological examination ( Figure 3). The patient was prescribed 400 mg of oral albendazole daily. The spontaneous rupture of muscular hydatid cysts is an extremely rare condition. The rupture of hydatid cysts into the muscle poses a considerable challenge for surgeons. Pericystectomy is the primary treatment for the muscular rupture of hydatid cysts, with medical treatment typically administered postoperatively¹ 1. Tekin R, Avci A, Tekin RC, Gem M, Cevik R. Hydatid cysts in muscles: Clinical manifestations, diagnosis, and management of this atypical presentation. Rev Soc Bras Med Trop. 2015;48(5):594-8. ^,2 2. Tekin R, Onat S, Tekin RC. Ruptured Pulmonary Hydatid Cyst Complicated by COVID-19. Am J Trop Med Hyg. 2022;107(1):6-7. . It is important to consider hydatid disease in the differential diagnosis of cystic swelling in a musculoskeletal region³ 3. Tekin R, Özkul E, Ulus SA. Hydatid Cyst of the Tibia. Rev Soc Bras Med Trop . 2022;55:e00822022. .