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A 16-year-old Japanese girl presented with left hemiparesis and coma, following a 2-day history of headache and fever. She had been previously well and no history of a skin wound. MR scan of the brain showed a 6 cm lesion in the right frontal white matter with mass effect and slight edge enhancement (figure 1). A craniotomy was performed for external decompression and brain biopsy. The intraoperative finding was of white matter necrosis rather than tumour or abscess. An interim biopsy showed prominent neutrophil infiltration and fibrinoid necrosis in small vessels but no evidence of a specific pathogen. We suspected either a central nervous system infection or an autoimmune disease such as acute disseminated encephalomyelitis, and so started antibiotics and pulsed corticosteroids in the intensive care unit.
Contributors YO: conception and design of the study, interpretation of data, drafting the manuscript for intellectual content. IY: acquisition and analysis of the data, revision of the manuscript for intellectual content. NO: acquisition and analysis of the data. AK: acquisition and analysis of the data. HK: acquisition and analysis of the data. MS: acquisition and analysis of the data. MU: conception and design of the study, critical revision of the manuscript for important intellectual content, drafting the manuscript for intellectual content, final approval of the published version.
Funding Intramural research fund of Shiga University of Medical Science.
Competing interests None declared.
Provenance and peer review Not commissioned. Externally peer reviewed by Nick Davies, London, UK.