CASE HISTORY
45 YEAR OLD MALE
Presenting compaints: Patient presented with lower back pain since 5 years; right leg numbness and tingling since 6 months and acute onset urinary incontinence
Past history and comorbidities : H/o pulmonary TB and TB meningitis 15 years ago, completed ATT; Hypertensive since 1 year , on medication.
Physical examination: Unremarkable, with a full range of motion of the cervical and lumbar spine with no pain elicited on movement.
Full strength in both legs with diminished sensation to touch in the right leg and foot in a non-dermatomal distribution.
Reflexes were elevated at the lower extremities bilaterally, but no clonus or Babinski sign was detected.
Workup: Patient was referred for a lumbar spine MR
CASE CONTRIBUTED BY
Dr. MEGHANA KANCHARLA, SENIOR RESIDENT, ST JOHNS MEDICAL COLLEGE AND HOSPITAL
Dr. STALLON SEBASTIAN, ASSISTANT PROFESSOR, ST JOHNS MEDICAL COLLEGE AND HOSPITAL
SAGITTAL T2
AXIAL T2
SAGITTAL T1
CORONAL T2 STIR
DWI
ADC
T1 PRE CON
T1 POST CON
FAT PHASE
CT
HISTOPATHOLOGY REPORT
Clinical diagnosis:
L2 L3 IDEM
? Lipoma
Gross Description:
Bottle contains 1 irregular piece of grey white soft tissue measures 4×1.8×0.5cm
2 bits embed all – A
Bottle contains <0.25gms of grey white soft tissue
<0.25gms embed all – B
Grossed By – Dr. Deepthi Benny
Microscopy:
A – Section shows portions of cyst lined by stratified squamous epithelium. Cyst wall is composed of
fibrocollagenous tissue and lymphoplasmacytic infiltrate, admixed with pigment-laden macrophages. Also
noted are areas of calcification and congested blood vessels.
B – Section shows lamilated keratin flakes
Impression:
Consistent with epidermoid cyst, L2L3 IDEM
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