Post-transplantation primary central nervous system lymphoma: A case report and review of the literature

Isolated primary CNS lymphoma after liver transplantation for autoimmune hepatitis: a case report

Post-transplantation primary central nervous system lymphoma (PT-PCNSL) is a rare neoplasm that occurs in immunocompromised patients. It can manifest months or years after transplantation, presenting with various neurological symptoms. A 64-year-old woman, who had received a liver transplant due to autoimmune hepatitis, presented with generalized weakness, headache, and confusion. Further investigation revealed multiple ring-enhancing lesions in the right frontal and temporoparietal regions on brain MRI. A brain biopsy confirmed the diagnosis of PT-PCNSL. This case underscores the importance of considering PT-PCNSL in the differential diagnosis of contrast-enhancing brain lesions in post-transplant patients. Timely recognition of PT-PCNSL is crucial for appropriate management and improved outcomes. To the best of our knowledge, this report describes the first instance of isolated CNS lymphoma in a liver transplant recipient, due to autoimmune hepatitis, successfully brought to complete remission with a rituximab-methotrexate regimen.

Primary central nervous system post-transplantation lymphoproliferative disorder: A case report and systematic review of imaging findings

Primary central nervous system post-transplant lymphoproliferative disease (PCNS-PTLD) is a rare subset of post-transplant lymphoproliferative disorder (PTLD) isolated to the CNS without nodal or extra-nodal organ involvement [1,2]. PCNS-PTLD occurs primarily in patients following either solid organ transplants or hematopoietic stem cell transplants and tends to be monomorphic DLBCL. The development of PCNS-PTLD is commonly associated with EBV infection [3]. Many intracranial pathologies can resemble the imaging appearance of PCNS-PTLD, including primary CNS lymphoma, glial tumors, metastatic disease, and intracranial abscesses. The purpose of this systematic review is to identify the most common imaging characteristics of PCNS-PTLD. Our review included 97 sources that describe the imaging appearance of PCNS-PTLD. Based on our review, PCNS-PTLD lesions are typically multifocal, ring-enhancing and diffusion-restricting. PCNS-PTLD lesions typically demonstrate focal FDG avidity. Despite advancement in medical imaging, PCNS-PTLD remains a diagnostic challenge due to its rare incidence. Limited data is available on advanced imaging with regards to PTLD, but techniques including DCE-MRI and fMRI demonstrate promising results that may help further delineate PCNS-PTLD.

Central Nervous System Infections in the Immunocompromised Adult Presenting to the Emergency Department

Over the past 2 decades, the population of immunocompromised patients has increased dramatically in the United States. These patients are at elevated risk for both community-acquired and opportunistic central nervous system infections. We review the most common and serious central nervous system pathogens affecting these patients and outline a diagnostic and therapeutic approach to their management in the emergency department. We recommend a broad diagnostic evaluation, including neuroimaging and cerebrospinal fluid studies where appropriate, empiric antimicrobial therapy, and early involvement of subspecialists to provide comprehensive care for these complex patients.

Multiple Brain Biopsies for Epstein-Barr Virus-Positive Diffuse Large B-Cell Lymphoma with Extensive Necrosis in a Posttransplant Patient

BACKGROUND

Epstein-Barr virus (EBV)-positive diffuse large B-cell lymphoma (DLBCL) in an immunocompromised patient with organ transplantation demonstrated unusual brain magnetic resonance imaging (MRI) findings. Recognition of EBV-positive DLBCL by radiologists on MRI may prevent unnecessary neurosurgical resection, and it could be important to obtain viable cells for accurate diagnosis on stereotactic biopsy because of extensive necrosis.

CASE DESCRIPTION

A 62-year-old woman presented to the emergency department with left hemiparesis grade III and dysarthria lasting for 3 weeks. She underwent kidney transplantation in 2007 and was taking immunosuppressants and had hypothyroidism. Brain MRI showed a 3.8-cm peripheral enhancing lesion with extensive central necrosis in association with marked perilesional edema. The irregular ringlike enhancing lesion showed diffusion restriction and mildly increased regional cerebral blood volume in the rim portion of the mass. 11C-Methionine positron emission tomography revealed slightly increased uptake in the peripheral lesion. The provisional diagnosis was a high-grade glioma. Stereotactic multiple biopsies were performed for the central necrotic area and peripheral enhancing lesion. The nonenhancing areas showed only necrotic material, without viable cells, and the enhancing portion showed viable cells for an accurate diagnosis in a frozen biopsy specimen. The pathologic diagnosis was EBV-positive DLBCL with extensive necrosis. Positron emission tomography of the chest, abdomen, pelvis, and neck soft tissues ruled out systemic diseases. She underwent whole-brain radiotherapy at a dose of 30.6 Gy. Eight months later, her neurologic symptoms had improved, with a stable brain lesion and improved perilesional edema.

CONCLUSIONS

We report an immunocompromised patient with EBV-positive DLBCL, which showed atypical MRI findings, including extensive necrosis. Multiple biopsies were required for final diagnosis.

Primary central nervous system post-transplant lymphoproliferative disorders: the spectrum of imaging appearances and differential

OBJECTIVE

Central nervous system post-transplant lymphoproliferative disorder (CNS-PTLD) is a rare disease that presents with non-specific signs and symptoms. The purpose of this article is to present the imaging appearances of CNS-PTLD by magnetic resonance imaging. We highlight the differential diagnostic considerations including primary central nervous system lymphoma, glioblastoma, cerebral abscess, and metastatic disease. This is an important topic to review since in daily practice the diagnosis of CNS-PTLD is often not initially considered when present due to its rarity and the lack of radiologists' familiarity with the disease.

CONCLUSION

Knowing the unique imaging features of CNS-PTLD narrows the differential diagnosis, facilitates the diagnostic work-up, and optimizes making the diagnosis. Advanced MRI data for CNS PTLD is limited but is promising for helping with narrowing the differential diagnosis.

Acute Brain Damage in a 56-Year-Old Woman With a 20-Year-Old Transplanted Kidney as a Complicated Differential Diagnostic Process: A Case Report

INTRODUCTION

Acute central nervous system (CNS) damage in a patient who has received organ transplant is an extremely difficult and complex clinical issue that spans a wide spectrum of differential diagnoses with ischemia, post-transplant lymphoproliferative disorders (PTLDs), infections, lymphomas, and progressive multifocal leukoencephalopathy (PML). PTLDs are a clinically and histopathologically heterogeneous group of diseases that most often occur in heavily immunocompromised populations after solid organ transplantation (SOT), probably related to the infection or reactivation of Epstein-Barr virus (EBV) infection, whereas PML is an infectious disease caused by the John Cunningham virus (JCV).

CASE DESCRIPTION

A 56-year-old female, 20 years after renal transplantation from a deceased donor, was admitted to the hospital as an emergency due to sensory aphasia and memory disorders. Computed tomography (CT) examination revealed a diffuse expansive process in the temporo-parieto-occipital and left frontal area. Magnetic resonance imaging (MRI) results suggested changes associated with PML; however, JCV was not found in the cerebrospinal fluid. The disorders progressed quickly, both clinically and radiologically-the patient developed central facial palsy, paresis of limbs, and positive Babinski sign on the left. A second radiological examination (CT) also suggested PML. Due to the rapid deterioration of the patient's general condition, further diagnostic examinations (magnetic resonance with contrast and brain stereotactic biopsy) could not be performed. After almost 2 months of the commencement of the diagnostic process, the patient died. Autopsy revealed that the cause of death was acute CNS damage in the course of monomorphic PTLD (CNS-PTLD).

CONCLUSION

Rapid deterioration of mental status can be the first symptom of CNS-PTLD, a dangerous and life-threatening condition in immunocompromised patients after solid organ transplantation.

Susceptibility-weighted imaging and diffusion-weighted imaging findings in central nervous system monomorphic B cell post-transplant lymphoproliferative disorder before and after treatment and comparison with primary B cell central nervous system lymphoma

The purpose of this article is to review the MRI features of monomorphic central nervous system post-transplant lymphoproliferative disorder (CNS PTLD), including diffusion-weighted and susceptibility-weighted sequences before and after treatment and to compare the imaging findings with those of primary central nervous system B cell lymphoma (PCNS BCL). Retrospective review of the brain MRI characteristics in patients with pathology proven monomorphic CNS PTLD and PCNS BCL was performed. In particular, the enhancement, diffusion-weighted, susceptibility-weighted MRI characteristics of the lesions were evaluated. In addition, the diffusion-weighted, susceptibility-weighted MRI features after treatment for CNS PTLD were evaluated. A total of 12 lesions in six patients with CNS PTLD and 12 lesions in nine patients with PCNS BCL were identified on MRI. Among the CNS PTLD lesions with post-contrast images, 80 % demonstrated peripheral enhancement. All of the CNS PTLD lesions contained foci of intratumoral susceptibility signal (ITSS) and the average mean ADC values and ratios were 0.892 × 10(-3) mm(2)/s (standard deviation: 0.082 × 10(-3) mm(2)/s) and 1.19 (standard deviation: 0.15), respectively. On the other hand, 75 % of the PCNS BCL displayed diffuse enhancement, two cases (16.7 %) contained ITSS, and the mean ADC values and ratios were 0.721 × 10(-3) mm(2)/s (standard deviation: 0.093 × 10(-3) mm(2)/s), and 0.99 (standard deviation: 0.17), respectively. Thus, the presence of heterogeneous lesions with ITSS that do not necessarily have as extensive restricted diffusion as PCNS BCL is suggestive of CNS PTLD in the appropriate clinical setting. The preliminary data in this series suggests that diffusion-weighted imaging may serve as a useful biomarker for monitoring treatment response, in which successful treatment of CNS PTLD may result in increased ADC values. In addition, foci of susceptibility effect in CNS PTLD tend to persist or increase over the course of treatment.

Neuro-oncological disorders of the cerebellum

This article provides an overview of the intra-axial tumors that affect the cerebellum, which can be categorized by location and age. For each tumor, we review conventional neuroimaging findings and discuss the value of more advanced neuroimaging techniques. Current management strategies are also briefly discussed. Finally, cerebellar paraneoplastic disorders and medication-induced cerebellar disorders are discussed.

Primary brain lymphomas after kidney transplantation: an under-recognized problem?

Primary central nervous system post-transplant lymphoproliferative disease (CNS PTLD) is a serious complication after solid organ transplantation that has not received much attention so far. However, it could become a more frequent problem with the introduction of new biological agents.

METHODS

We identified five cases with CNS PTLD in our center who were transplanted between 1986 and 2007, three men and two women, with a mean age of 55.9 years (range 42-74). Three patients had received only kidney transplant and two patients had received a kidney-pancreas transplant.

RESULTS

The mean time from first symptoms until diagnosis was 3.5 months (2-6). One patient was diagnosed post-mortem in autopsy. The mean time from transplantation to onset of neurological symptoms was 73.8 months (31-144). The initial clinical manifestation was heterogeneous: all five cases showed headache, four cases presented with gait disturbance, one with dysarthria and two with a confusional state. Epstein-Barr virus (EBV) immunoglobulin (Ig)G serology was positive in four out of five cases; in situ hybridization for EBV in brain biopsy samples was positive in three cases, negative in one and not available in one. In four patients, EBV polymerase chain reaction (PCR) was positive in cerebrospinal fluid (CSF). After diagnosis, overall immunosuppressive load was lowered in all patients (n = 4). Three patients died at 8-104 weeks (mean 40 weeks) after diagnosis and one patient is still alive 20 months after diagnosis.

CONCLUSIONS

CNS PTLD is a complication difficult to diagnose, frequently diagnosed too late and often refractory to treatment. A more aggressive screening might be necessary in patients even with mild CNS symptoms.