This 60-year-old immunocompromised patient presented with a one-week history of progressive right-sided weakness, difficulty concentrating, and impaired word finding ability. Brain MRI showed a 5.5 x 4.0 x 2.7 cm, T2 and FLAIR hyperintense, T1 hypointense, non-contrast enhancing mass involving the white matter of the right frontal lobe.
Based on Figures #1 – #4, what stain would you like to perform to further evaluate this patient’s mass lesion?
A. Polyomavirus IHC
B. IDH1 R132H IHC
C. Cytokeratin IHC
D. AFB stain
Answer: Polyomavirus IHC
Given the presence of morphologic changes of a demyelinating lesion and oligodendrocytes with intranuclear viral cytopathic change, performing a polyomavirus immunohistochemical stain to detect JC virus is the correct choice.
JC virus is the causative agent for Progressive Multifocal Leukoencephalopathy (PML). Please see additional Reference(s) / additional reading.
The nuclear atypia and elevated proliferative fraction, may be mistaken for a neoplastic process.
Reference(s) / additional reading:
Berger JR, Aksamit AJ, Clifford DB, Davis L, Koralnik IJ, Sejvar JJ, Bartt R, Major EO, Nath A. PML diagnostic criteria: consensus statement from the AAN Neuroinfectious Disease Section. Neurology. 2013 Apr 9;80(15):1430-8. doi: 10.1212/WNL.0b013e31828c2fa1. PMID: 23568998; PMCID: PMC3662270.
Atkinson AL, Atwood WJ. Fifty Years of JC Polyomavirus: A Brief Overview and Remaining Questions. Viruses. 2020 Sep 1;12(9):969. doi: 10.3390/v12090969. PMID: 32882975; PMCID: PMC7552028.
Zu Rhein GM. Ultrastructural studies in progressive multifocal leukoencephalopathy, a demyelinating disease of man of probable viral etiology. Int Arch Allergy Appl Immunol. 1969;36:Suppl:463-87. PMID: 4313668.
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