11 Apr 2021

12/23/20: Primary CNS Lymphoma 2/2 HIV

PGY2 Ramon Lee presented a case of a 36 year old female with no past medical history who presents with 2 months of weight loss, fatigue and associated weight loss.  The patient reports a 40 pound weight loss over the last 2 months.  She also reports new posterior headache that started 1 day prior to presentation.  Denies any weakness, numbness, tingling, fevers, chills, lightheadedness, dizziness, vision changes, lymphadenopathy, oral lesions, sore throat, SOB, cough, n/v or abdominal pain.  Denies recent sick contacts or travel.  No home medications.  Patient born in Mexico and has been living in LA with her husband of 15 years and children.  Denies any alcohol/tobacco/drugs.

Vitals: T 37.3, HR 108, RR 18, BP 92/60, O2 sat 99% on RA

Physical Exam significant for A&Ox4, cachectic appearing female, normal cardiac and pulm exam, skin with multiple discrete dome shaped verrucous papules-nodules with surrounding hyperpigmentation on wrists, legs, dorsal feet, chest and knees; spares palms and soles.

CBC: WBC 1.6> Hb 11.6/Hct 33.2 <Plt 165 (MCV 90.7, RDW 14.8%)

CMP:

Na 130/K 4.0/Cl 94/HCO3 25/BUN 9/Cr 0.52<Glucose 114

ALP 103>T.protein 6.6/Albumin 4.0/AST 849/ALT 653/Tbili 0.5/Dbili 0.2

Ca 8.7, Mg 2.3, Phos 4.0

Coags: PT 13.1, INR 1

Infectious workup initiated, with the following findings:

  • BCx negative, UA negative
  • HIV Ag/Ab: Positive
  • CD4: 5/cumm
  • Fungal serologies: Crypto Ag negative, urine histo negative, cocci Ab negative
  • Toxo IgG negative
  • GC/CT negative
  • RPR negative
  • Hep A, B, C, E non-reactive
  • AFB smear neg x3, MTB PCR neg x2
  • Quant gold indeterminant
  • CMV PCR: 461
  • EBV DNA: 4511 copies/mL

CTH done with hypoattenuation of the white matter of the R frontotemporal lobe in the ACA/MCA territories with preservation of grey-white matter differentiation.  There is mass effect on the frontal horn of the R lateral ventricle and 3 mm leftward midline shift.

MRI brain showed 3.7cm ring enhancing intra-axial mass with signal changes crossing the corpus callosum.

Brain biopsy was done that showed diffuse large B cell lymphoma, nongerminal center phenotype; EBV positive.

Treatment: Patient was started on USC Deangelis protocol after CNS lymphoma diagnosis and was transferred to RLA for rehab. 2 months post presentation, the patient had developed superior sagittal and transverse sinus thrombosis with new ring enhancing lesions and plan was for whole brain radiation therapy.

Teaching points:

  1. AIDs defining malignancies: Non-Hodgkin’s lymphoma, Kaposi’s sarcoma and cervical cancer.
  2. When to get a brain bx in HIV patient with brain lesion
    1. Only 50% of brain abscess will be CNS toxo
    1. If toxo IgG is negative 50x more likely to be something else (50x more likely to be something else)
    1. If the CSF EBV PCR is positive, favors CNS lymphoma
    1. No radiologic response after 2 weeks of anti-toxo therapy
  3. Initiation of ART
    1. Improved mortality due to decrease frequency of opportunistic infections
    1. lowering the community transmission rate
    1. Resolution of KS, PML, diarrheal disease (microsporidia and cryptosporidia)
    1. Improved outcome of lymphoma
    1. Active pulmonary TB with AIDS, CD4 <50, start within 2 weeks; within 8 weeks if CD4 >50
    1. PCP can be as soon as patient is stable
  4. DO NOT start ART:
    1. Crypto meningitis induction due to IRIS
    1. Cocci meningitis due to IRIS
    1. TB meningitis due to IRIS
    1. Acute infections

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