Extracavitary primary effusion lymphoma presenting as a solitary brain mass.

Primary effusion lymphoma (PEL) is an uncommon B-cell lymphoma associated with human herpesvirus 8 and comprises 3-4% of all HIV-related lymphomas. It traditionally presents as a pleural, pericardial, and/or peritoneal effusion, though it can occasionally manifest as an extracavitary or solid mass in the absence of an effusion. The extracavitary or solid variant of primary effusion lymphoma has been reported in the skin, gastrointestinal tract, lung, and lymph nodes. However, very few cases have been reported in the central nervous system. We describe a case of extracavitary or solid variant of primary effusion lymphoma presenting as a brain mass in an HIV-positive man, highlighting the clinicopathologic and immunophenotypic findings of a rare entity.

Primary effusion lymphoma (PEL) is an uncommon and aggressive form of large B-cell lymphoma with a grim outlook, making up less than 1% of all lymphomas. PEL is linked to human herpesvirus 8 and predominantly impacts individuals with HIV or weakened immune systems. The typical presentation of PEL involves cancerous fluid accumulating in the chest or abdominal cavities. Occasionally, PEL can appear as a solid mass outside these cavities, termed extracavitary PEL (EC-PEL). The case we are describing highlights the difficulties in diagnosing PEL/EC-PEL. It is crucial for healthcare providers to consider EC-PEL when dealing with human herpesvirus 8-positive B-cell lymphomas, especially when patients have weakened immune systems and an unusual clinical scenario involving a solid mass, as seen in this case.

Worldwide diversity in mammalian life histories: Environmental realms and evolutionary adaptations.

Mammalian life history strategies can be characterised by a few axes of variation, conforming a space where species are positioned based on the life history strategies favoured in the environment they exploit. Yet, we still lack global descriptions of the diversity of realised mammalian life history and how this diversity is shaped by the environment. We used six life history traits to build a life history space covering worldwide mammalian adaptation, and we explored how environmental realms (land, air, water) influence mammalian life history strategies. We demonstrate that realms are tightly linked to distinct life history strategies. Aquatic and aerial species predominantly adhere to slower life history strategies, while terrestrial species exhibit faster life histories. Highly encephalised terrestrial species are a notable exception to these patterns. Furthermore, we show that different mode of life may play a significant role in expanding the set of strategies exploitable in the terrestrial realm. Additionally, species transitioning between terrestrial and aquatic realms, such as seals, exhibit intermediate life history strategies. Our results provide compelling evidence of the link between environmental realms and the life history diversity of mammals, highlighting the importance of differences in mode of life to expand life history diversity.

A Blast From the Past: Toxoplasmic Encephalitis As the Initial Presentation of HIV/AIDS.

Many opportunistic infections (OIs) seen early in the human immunodeficiency virus (HIV) epidemic receded in prevalence with the advent of antiretroviral therapy (ART). Despite the availability of early detection and treatment of HIV as well as guidelines for near-universal screening, there remains a sizable population of individuals living with HIV who are not yet aware of their HIV status. These individuals are at risk for OIs such as toxoplasmosis, which would otherwise be preventable with ART and appropriate prophylaxis. Toxoplasmic encephalitis (TE) usually occurs in the late stages of HIV with acquired immunodeficiency syndrome (AIDS), but we present a case of a 38-year-old female with TE as the initial presentation of HIV/AIDS. Testing for the presence of an immunocompromising condition such as HIV is important in patients presenting with focal brain lesions as the differential diagnosis will change, and proper workup may spare invasive procedures such as a brain biopsy.

The Use of Induction Sensors and Helmet-Based Shielding Technology to Identify Differences in Electromagnetic Fields in Patients With Cranial Neurological Disease Versus Healthy Controls.

Background and objective Electromagnetic fields (EMFs) stemming from neural circuits have been evaluated in healthy human subjects by using non-invasive induction sensor technologies with adjunctive shielding constrained to a helmet constructed of Mu-metal and copper mesh. These EMF measurements have been analyzed and discerned to alter physiological states of movement, thoughts of movement, emotional thoughts, and planned activities. However, these technologies have not yet been investigated as a diagnostic tool in patients with cranial neurological pathology to evaluate differences in patterns in the pathologic state compared to healthy controls. In light of this, we conducted this study to address this scarcity of data. Methods An observational study was conducted in which patients at a single center with cranial neurological disease of all causes were eligible to enroll; they had real-time non-invasive continuous EMF measurements obtained using induction sensors and a shielded helmet. These measurements were obtained in the resting state and then compared to previously obtained measurements in healthy volunteers. Post-processing analysis was conducted to evaluate the derivatives of these EMFs to identify changes in patterns. Results Fourteen patients with traumatic injury, stroke, and neoplasm with ages ranging from 14 to 81 years underwent successful analysis and post-processing of their cortically generated EMF waves. Patterns of EMF waves were compared to previously obtained data from four healthy controls. It was identified that there was less variation in the EMF measurements in patients with neurological disease compared to healthy controls. This was identified based on differences in derivatives of the EMF waves and decreased numbers of peaks and valleys in the EMF waves. Conclusions Novel induction sensors with an engineered, layered Mu-metal and copper mesh helmet for shielding with Mu-metal EMF channels appear to be efficient in measuring neural circuit-driven EMF non-invasively, in real-time, and continuously and can discern differences in EMF patterns between healthy volunteers and patients with neural circuit pathology. The decreased variability in EMF measurements in patients with neural pathology and greater decreases in slope within low-frequency measurements may be correlated with disrupted neural signaling from dysfunctional neurons and abnormalities in spatial and temporal summation. Some EMF changes in ill individuals correspond to changes in the experimentally induced lesions in the animal model. Further studies are warranted to devise models of disease and healthy states to improve these technologies as a diagnostic modality.

Evolutionary and genomic perspectives of brain aging and neurodegenerative diseases.

This chapter utilizes genomic concepts and evolutionary perspectives to further understand the possible links between typical brain aging and neurodegenerative diseases, focusing on the two most prevalent of these: Alzheimer's disease and Parkinson's disease. Aging is the major risk factor for these neurodegenerative diseases. Researching the evolutionary and molecular underpinnings of aging helps to reveal elements of the typical aging process that leave individuals more vulnerable to neurodegenerative pathologies. Very little is known about the prevalence and susceptibility of neurodegenerative diseases in nonhuman species, as only a few individuals have been observed with these neuropathologies. However, several studies have investigated the evolution of lifespan, which is closely connected with brain size in mammals, and insights can be drawn from these to enrich our understanding of neurodegeneration. This chapter explores the relationship between the typical aging process and the events in neurodegeneration. First, we examined how age-related processes can increase susceptibility to neurodegenerative diseases. Second, we assessed to what extent neurodegeneration is an accelerated form of aging. We found that while at the phenotypic level both neurodegenerative diseases and the typical aging process share some characteristics, at the molecular level they show some distinctions in their profiles, such as variation in genes and gene expression. Furthermore, neurodegeneration of the brain is associated with an earlier onset of cellular, molecular, and structural age-related changes. In conclusion, a more integrative view of the aging process, both from a molecular and an evolutionary perspective, may increase our understanding of neurodegenerative diseases.

Transcranial ultrasonography to detect intracranial pathology: A systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Transcranial ultrasonography (TCU) can be a useful diagnostic tool in evaluating intracranial pathology in patients with limited or delayed access to routine neuroimaging in critical care or austere settings. We reviewed available literature investigating the diagnostic utility of TCU for detecting pediatric and adult patient's intracranial pathology in patients with intact skulls and reported diagnostic accuracy measures. METHODS: We performed a systematic review of PubMed® , Cochrane Library, Embase® , Scopus® , Web of Science™, and Cumulative Index to Nursing and Allied Health Literature databases to identify articles evaluating ultrasound-based detection of intracranial pathology in comparison to routine imaging using broad Medical Subject Heading sets. Two independent reviewers reviewed the retrieved articles for bias using the Quality Assessment of Diagnostic Accuracy Studies tools and extracted measures of diagnostic accuracy and ultrasound parameters. Data were pooled using meta-analysis implementing a random-effects approach to examine the sensitivity, specificity, and accuracy of ultrasound-based diagnosis. RESULTS: A total of 44 studies out of the 3432 articles screened met the eligibility criteria, totaling 2426 patients (Mean age: 60.1 ± 14.52 years). We found tumors, intracranial hemorrhage (ICH), and neurodegenerative diseases in the eligible studies. Sensitivity, specificity, and accuracy of TCU and their 95% confidence intervals were 0.80 (0.72, 0.89), 0.71 (0.59, 0.82), and 0.76 (0.71, 0.82) for neurodegenerative diseases; 0.88 (0.74, 1.02), 0.81 (0.50, 1.12), and 0.94 (0.92, 0.96) for ICH; and 0.97 (0.92, 1.03), 0.99 (0.96, 1.01), and 0.99 (0.97, 1.01) for intracranial masses. No studies reported ultrasound presets. CONCLUSIONS: TCU has a reasonable sensitivity and specificity for detecting intracranial pathology involving ICH and tumors with clinical applications in remote locations or where standard imaging is unavailable. Future studies should investigate ultrasound parameters to enhance diagnostic accuracy in diagnosing intracranial pathology.

Metastatic adenocarcinoma of the prostate presenting as a solitary cystic brain mass.

Carcinoma prostate is the second most common cancer in men after skin cancer. It is the most common visceral malignancy in the United States of America. Like any other cancerous lesion, it has the propensity to metastasize to any part of the body; the most common locations being bones, lymph nodes, liver, and thoracic organs. However, it rarely metastasizes to the brain. It is even rarer for brain metastases to manifest as cystic lesions. We describe an unusual case of a metastatic prostate carcinoma presenting as a cystic brain mass.

Large and expensive brain comes with a short lifespan: The relationship between brain size and longevity among fish taxa.

Vertebrates show substantial interspecific variation in brain size in relation to body mass. It has long been recognized that the evolution of large brains is associated with both costs and benefits, and it is their net benefit which should be favoured by natural selection. On one hand, the substantial energetic cost imposed by the maintenance of neural tissue is expected to compromise the energetic budget of organisms with large brains and their investment in other critical organs (expensive brain framework, EBF) or important physiological process, such as somatic maintenance and repair, thus accelerating ageing that shortens lifespan, as predicted by the disposable soma theory (DST). However, selection towards larger brain size can provide cognitive benefits (e.g., high behavioural flexibility) that may mitigate extrinsic mortality pressures, and thus may indirectly select for slower ageing that prolongs lifespan, as predicted by the cognitive buffer hypothesis (CBH). The relationship between longevity and brain size has been investigated to date only among terrestrial vertebrates, although the same selective forces acting on those species may also affect vertebrates living in aquatic habitats, such as fish. Thus, whether this evolutionary trade-off for brain size and longevity exists on a large scale among fish clades remains to be addressed. In this study, using a global dataset of 407 fish species, I undertook the first phylogenetic test of the brain size/longevity relationship in aquatic vertebrate species. The study revealed a negative relationship between brain size and longevity among cartilaginous fish confirming EBF and DST. However, no pattern emerged among bony fish species. Among sharks and rays, the high metabolic cost of producing neural tissue transcends the cognitive benefits of evolving a larger brain. Consequently, my findings suggest that the cost of maintaining brain tissue is relatively higher in ectothermic species than in endothermic ones.

A Case of Neuroparacoccidioidomycosis in Houston, Texas.

Paracoccidioidomycosis is a systemic fungal disease caused by the dimorphic Paracoccidioides species endemic to South America. Infection classically presents with pulmonary, mucosal, or reticuloendothelial involvement, though other organs can be involved. Central nervous system involvement is rare, and almost universally reported within the endemic area for the fungus. We present a 60-year-old Brazilian male who complained of occipital headache, ataxia, dysmetria, and dysarthria for two months, diagnosed with neuroparacoccidioidomycosis in Houston, Texas. The patient had a cerebellar mass and a left pulmonary spiculated apical mass suspicious for a lung metastatic malignancy and a preliminary histological report consistent with invasive cryptococcosis. The patient's work and travel history were paramount in achieving the final diagnosis.

Brain Tumor/Mass Classification Framework Using Magnetic-Resonance-Imaging-Based Isolated and Developed Transfer Deep-Learning Model.

With the advancement in technology, machine learning can be applied to diagnose the mass/tumor in the brain using magnetic resonance imaging (MRI). This work proposes a novel developed transfer deep-learning model for the early diagnosis of brain tumors into their subclasses, such as pituitary, meningioma, and glioma. First, various layers of isolated convolutional-neural-network (CNN) models are built from scratch to check their performances for brain MRI images. Then, the 22-layer, binary-classification (tumor or no tumor) isolated-CNN model is re-utilized to re-adjust the neurons' weights for classifying brain MRI images into tumor subclasses using the transfer-learning concept. As a result, the developed transfer-learned model has a high accuracy of 95.75% for the MRI images of the same MRI machine. Furthermore, the developed transfer-learned model has also been tested using the brain MRI images of another machine to validate its adaptability, general capability, and reliability for real-time application in the future. The results showed that the proposed model has a high accuracy of 96.89% for an unseen brain MRI dataset. Thus, the proposed deep-learning framework can help doctors and radiologists diagnose brain tumors early.

Molecular markers of brain cholesterol homeostasis are unchanged despite a smaller brain mass in a mouse model of cholesteryl ester storage disease.

Lysosomal acid lipase (LAL), encoded by the gene LIPA, facilitates the intracellular processing of lipids by hydrolyzing cholesteryl esters and triacylglycerols present in newly internalized lipoproteins. Loss-of-function mutations in LIPA result in cholesteryl ester storage disease (CESD) or Wolman disease when mutations cause complete loss of LAL activity. Although the phenotype of a mouse CESD model has been extensively characterized, there has not been a focus on the brain at different stages of disease progression. In the current studies, whole-brain mass and the concentrations of cholesterol in both the esterified (EC) and unesterified (UC) fractions were measured in Lal-/- and matching Lal+/+ mice (FVB-N strain) at ages ranging from 14 up to 280 days after birth. Compared to Lal+/+ controls at 50, 68-76, 140-142, and 230-280 days of age, Lal-/- mice had brain weights that averaged approximately 6%, 7%, 18%, and 20% less, respectively. Brain EC levels were higher in the Lal-/- mice at every age, being elevated 27-fold at 230-280 days. Brain UC concentrations did not show a genotypic difference at any age. The elevated brain EC levels in the Lal-/- mice did not reflect EC in residual blood. An mRNA expression analysis for an array of genes involved in the synthesis, catabolism, storage, and transport of cholesterol in the brains of 141-day old mice did not detect any genotypic differences although the relative mRNA levels for several markers of inflammation were moderately elevated in the Lal-/- mice. The possible sites of EC accretion in the central nervous system are discussed.

Brain Mass (Energy) Resistant to Hyperglycaemic Oversupply: A Systematic Review.

Cerebral energy supply is determined by the energy content of the blood. Accordingly, the brain is undersupplied during hypoglycaemia. Whether or not there is an additional cerebral energy demand that depends upon the energy content of the brain is considered differently in two opposing theoretical approaches. The Selfish-Brain theory postulates that the brain actively demands energy from the body when needed, while long-held theories, the gluco-lipostatic theory and its variants, deny such active brain involvement and view the brain as purely passively supplied. Here we put the competing theories to the test. We conducted a systematic review of a condition in which the rival theories make opposite predictions, i.e., experimental T1DM. The Selfish-Brain theory predicts that induction of experimental type 1 diabetes causes minor mass (energy) changes in the brain as opposed to major glucose changes in the blood. This prediction becomes our hypothesis to be tested here. A total of 608 works were screened by title and abstract, and 64 were analysed in full text. According to strict selection criteria defined in our PROSPERO preannouncement and complying with PRISMA guidelines, 18 studies met all inclusion criteria. Thirteen studies provided sufficient data to test our hypothesis. The 13 evaluable studies (15 experiments) showed that the diabetic groups had blood glucose concentrations that differed from controls by +294 ± 96% (mean ± standard deviation) and brain mass (energy) that differed from controls by -4 ± 13%, such that blood changes were an order of magnitude greater than brain changes (T = 11.5, df = 14, p < 0.001). This finding confirms not only our hypothesis but also the prediction of the Selfish-Brain theory, while the predictions of the gluco-lipostatic theory and its variants were violated. The current paper completes a three-part series of systematic reviews, the two previous papers deal with a distal and a proximal bottleneck in the cerebral brain supply, i.e., caloric restriction and cerebral artery occlusion. All three papers demonstrate that accurate predictions are only possible if one regards the brain as an organ that regulates its energy concentrations independently and occupies a primary position in a hierarchically organised energy metabolism. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=156816, PROSPERO, identifier: CRD42020156816.

Giant tuberculoma of the corpus callosum, the unforeseen diagnosis.

OBJECTIVE: Isolated intracranial tuberculomas are rare, especially in adults and it is not uncommon that they are easily confused with other diseases. To address this issue, we reported a case of a tuberculoma of the corpus callosum focusing on clinical characteristics, diagnostic clues, and outcome. CONCLUSIONS: Intracranial masses are frequently targeted as neoplastic pathology with surgical treatment in most cases. It is important to distinguish between neuro tuberculoma and brain tumors because of their different management and prognosis. Therefore even in absence of a known history of primary TB and in immunocompetent patients, tuberculoma must be in the differential diagnosis of solitary intracranial lesions also in countries where TB is not endemic.

Geographic patterns in seasonal changes of body mass, skull, and brain size of common shrews.

Some small mammals exhibit Dehnel's Phenomenon, a drastic decrease in body mass, braincase, and brain size from summer to winter, followed by a regrowth in spring. This is accompanied by a re-organization of the brain and changes in other organs. The evolutionary link between these changes and seasonality remains unclear, although the intensity of change varies between locations as the phenomenon is thought to lead to energy savings during winter.Here we explored geographic variation of the intensity of Dehnel's Phenomenon in Sorex araneus. We compiled literature on seasonal changes in braincase size, brain, and body mass, supplemented by our own data from Poland, Germany, and Czech Republic.We analyzed the effect of geographic and climate variables on the intensity of change and patterns of brain re-organization.From summer to winter, the braincase height decreased by 13%, followed by 10% regrowth in spring. For body mass, the changes were -21%/+82%, respectively. Changes increased toward northeast. Several climate variables were correlated with these transformations, confirming a link of the intensity of the changes with environmental conditions. This relationship differed for the decrease versus regrowth, suggesting that they may have evolved under different selective pressures.We found no geographic trends explaining variability in the brain mass changes although they were similar (-21%/+10%) to those of the braincase size. Underlying patterns of change in brain organization in northeastern Poland were almost identical to the pattern observed in southern Germany. This indicates that local habitat characteristics may play a more important role in determining brain structure than broad scale geographic conditions.We discuss the techniques and criteria used for studying this phenomenon, as well as its potential presence in other taxa and the importance of distinguishing it from other kinds of seasonal variation.

Thinking Outside Malaria: A Rare Case of Disseminated Cysticercosis With Cardiopulmonary Involvement From Urban Tanzania.

Dissemination of the cysticerci throughout the body with cardiopulmonary involvement represents a very rare occurrence and an uncommon form of cysticercosis manifestation. We report a rare case of a 48-year-old African male from urban Tanzania who was, at first, referred to our radiology department for a coronary computed tomography angiography (CCTA), but incidentally on further evaluation of the patient revealed a history of recurrent convulsions, loss of consciousness, a single episode of temporary loss of vision and recent skin nodules. The value of a full clinical and radiological evaluation of the patient presenting with adult-onset seizures cannot be overemphasized for the diagnosis of this disease. Management of disseminated cysticercosis is complex and, therefore, should be tailored to fit the individual cases and focus on clinical manifestations.

The role of brain size on mammalian population densities.

The local abundance or population density of different organisms often varies widely. Understanding what determines this variation is an important, but not yet fully resolved question in ecology. Differences in population density are partly driven by variation in body size and diet among organisms. Here we propose that the size of an organism' brain could be an additional, overlooked, driver of mammalian population densities. We explore two possible contrasting mechanisms by which brain size, measured by its mass, could affect population density. First, because of the energetic demands of larger brains and their influence on life history, we predict mammals with larger relative brain masses would occur at lower population densities. Alternatively, larger brains are generally associated with a greater ability to exploit new resources, which would provide a competitive advantage leading to higher population densities among large-brained mammals. We tested these predictions using phylogenetic path analysis, modelling hypothesized direct and indirect relationships between diet, body mass, brain mass and population density for 656 non-volant terrestrial mammalian species. We analysed all data together and separately for marsupials and the four taxonomic orders with most species in the dataset (Carnivora, Cetartiodactyla, Primates, Rodentia). For all species combined, a single model was supported showing lower population density associated with larger brains, larger bodies and more specialized diets. The negative effect of brain mass was also supported for separate analyses in Primates and Carnivora. In other groups (Rodentia, Cetartiodactyla and marsupials) the relationship was less clear: supported models included a direct link from brain mass to population density but 95% confidence intervals of the path coefficients overlapped zero. Results support our hypothesis that brain mass can explain variation in species' average population density, with large-brained species having greater area requirements, although the relationship may vary across taxonomic groups. Future research is needed to clarify whether the role of brain mass on population density varies as a function of environmental (e.g. environmental stability) and biotic conditions (e.g. level of competition).

Diagnostic value of real-time PCR of brain mass lesion in HIV-associated toxoplasmic encephalitis: a case series.

BACKGROUND: Toxoplasmic encephalitis (TE) is a leading cause of brain mass lesions (BML) in human immunodeficiency viruses (HIV)-infected patients. Yet, so far, no accurate diagnostic approach for TE has been developed. Herein, we presented a case series (9 HIV-infected patients with TG confirmed by RT-PCR of BML) to assess the diagnostic value of reverse transcription-polymerase chain reaction (RT-PCR) on TE. METHODS: A total of 9 HIV-infected patients with TE confirmed by RT-PCR of BML were included in this study. Clinical data, including clinical symptoms, blood and CSF analysis, neuroimaging features, histopathological characteristics, treatment, and prognosis, were assessed in all patients. According to the results of RT-PCR of BML, all the patients received oral administration of trimethoprim-sulfamethoxazole combined with antiretroviral therapy (ART). Patients were followed up by telephone or outpatient service. RESULTS: There were 8 male and 1 female patients; their age ranged from 26 to 56 years-old. The main symptom was intracranial hypertension (6/9). Six patients presented multiple brain lesions, which were mainly located in the supratentorial area (7/9). CD4+ count ranged from 11 to 159 cells/µl (median 92 cells/µl), and serological HIV viral load 0-989190 copies/ml (median 192836 copies/ml). IgG and IgM against serum TG were positive in 7 and 1 patients, respectively. Moreover, regarding CSF, IgG against TG was positive in 3 patients, while all patients were negative for IgM. The neuroimaging features on MRI showed no specificity. Four patients were diagnosed with TE by histopathological findings. After receiving anti-Toxoplasma therapy, 8 (8/9) patients improved clinically to a considerable extent. CONCLUSIONS: The application of RT-PCR of BML, together with conventional methods, may significantly improve the diagnostic efficiency of TE.

Do Different Methods Yield Equivalent Estimations of Brain Size in Birds?

The ratio of brain size to body size (relative brain size) is often used as a measure of relative investment in the brain in ecological and evolutionary studies on a wide range of animal groups. In birds, a variety of methods have been used to measure the brain size part of this ratio, including endocranial volume, fixed brain mass, and fresh brain mass. It is still unclear, however, whether these methods yield the same results. Using data obtained from fresh corpses and from published sources, this study shows that endocranial volume, mass of fixed brain tissue, and fresh mass provide equivalent estimations of brain size for 48 bird families, in 19 orders. We found, however, that the various methods yield significantly different brain size estimates for hummingbirds (Trochilidae). For hummingbirds, fixed brain mass tends to underestimate brain size due to reduced tissue density, whereas endocranial volume overestimates brain size because it includes a larger volume than that occupied by the brain.

Primary Angiitis of the Central Nervous System Presenting as a Cerebral Mass Lesion: A Case Report and Literature Review.

Primary angiitis of the central nervous system (PACNS) is a rare form of vasculitis and is confined entirely to the central nervous system (CNS)without systemic involvement. We report a rare case of PACNS in a 39-year-old female with new onset seizures and a right frontal enhancing mass. Initially the patient was thought to have a high-grade glioma and thus underwent a right frontal craniotomy for resection of right frontal mass. Intraoperatively, two fresh tissue samples were sent for intraoperative consultation. Sample 1 showed predominantly necrotic tissue and scant glial cells while sample 2 revealed glial tissue favoring gliosis versus low-grade neoplasm with necrosis and a few acute inflammatory cells. Final pathological diagnosis was consistent with PACNS. Postoperatively, the patient recovered well from surgery with no neurological deficits and was discharged on postoperative day 3. Two weeks after surgery the patient was started on cyclophosphamide and prednisone by Rheumatology. At one month follow up, the patient remained asymptomatic and seizure free.

A case report: pause and consider the late complications of heart transplantation.

BACKGROUND: A 75-year-old woman with a past medical history significant for non-ischaemic cardiomyopathy status post orthotopic heart transplant, type II diabetes mellitus, hypertension, chronic kidney disease stage III, chronic anaemia, and chronic diarrhoea presented with nausea, vomiting, and an unexplained fall 23 years after original transplantation. CASE SUMMARY: During her hospital stay, she had multiple episodes of sinus arrest with syncope, preceded by seizure like activity. She was stabilized, and broad work up revealed an occult brain mass that was ultimately resected and consistent with post-transplant lymphoproliferative disease. DISCUSSION: Features that make this case study unique include the late onset and location of the malignancy, the absence of Epstein-Barr virus involvement, and asystole that was potentially neurologically mediated and induced by a brain space occupying mass. This case offers insight into potential late parasympathetic reinnervation of transplanted hearts, adds to the growing literature regarding the connection between the brain and the heart, and reviews potential complications in patients with a remote history of heart transplantation.