LAUSR

The patient is a 78yearold male with a history of multiple cutaneous and soft tissue squamous cell carcinomas of the face and ear statuspost resection and a right parotid gland tumor statuspost parotidectomy (diagnosis unknown). He works on a ranch with horses and cows on a property with freshwater ponds. He originally presented with flank pain and weakness. Computed tomography of the chest demonstrated soft tissue disease and lymphadenopathy involving the left axilla and anterior mediastinum, bilateral adrenal masses, and a large pleuralbased mass. To evaluate for malignancy, biopsies of a right adrenal nodule and right pleuralbased mass were performed and demonstrated granulomatous inflammation. He was stabilized clinically and discharged. Five months later, he was admitted because of a multiple month history of subacute mental status changes and inability to ambulate. Magnetic resonance imaging of the head demonstrated numerous enhancing intracranial lesions involving both cerebral hemispheres with prominent adjacent edema, the largest measuring 3.6 cm in the right occipital lobe (Figure 1A– C). He was treated with wholebrain radiation for presumed metastases. Histoplasma PCR and serology, tuberculosis PCR, and evaluation for lymphoma were negative. He continued to decline clinically and underwent an open biopsy of a left frontal brain lesion (Box 1). Received: 12 October 2021 | Accepted: 21 February 2022