Mystery Case: CNS posttransplant lymphoproliferative disorder

A 74-year-old right-handed Hispanic woman with history of renal transplant 19 years prior presented at an away institution with episodic confusion and gait ataxia progressing over 2 weeks. She was alert and oriented on initial presentation but with fluctuation in mental status and without obvious cranial nerve, motor, or sensory deficits. The patient received transplant immunosuppression therapy with mycophenolate mofetil (Cellcept; Roche, Basel, Switzerland) and had a history of hypertension and chronic kidney disease. CT of the head showed a hypodense lesion in the right temporal lobe. MRI of the brain demonstrated multifocal, infiltrative T2-hyperintense white matter lesions involving the right temporo-parietal region, right frontal lobe, left parietal lobe, and left thalamus (figure, A–C). Gadolinium was not administered due to renal dysfunction. Lumbar puncture (LP) showed 63 leukocytes with lymphocytic pleocytosis (88%), elevated protein (80 mg/dL), and normal glucose (71 mg/dL). CSF Gram stain and culture were negative. She was treated with corticosteroids and acyclovir for presumed autoimmune/demyelinating vs infectious etiologies. She developed multiple witnessed periods of behavioral arrest with eye blinking and confusion concerning for seizures. She was transferred to our institution.
Source: Neurology - Category: Neurology Authors: Tags: All Immunology RESIDENT AND FELLOW SECTION Source Type: research