International Conference on Neuro Oncology and Brain Tumor
professor from Iran university
Title: Multiple ring enhancing lesions on MRI of the brain in transplant recipient: A diagnostic dilemma
Biography: md ali
Post-transplantation primary central nervous system lymphoma (PT-PCNSL) is a very rare tumor that can present from months to years after transplantation. Although it is frequently encountered in a renal transplant recipient, can certainly present in liver and other solid organ transplant recipients too. Its symptoms can be varied ranging from non-specific symptoms such as headache, gait disturbance, change in mental status to the focal neurological deficit. Inflammatory markers such as C-reactive protein, LDH, and ESR may be elevated whereas CSF analysis often is inconclusive. MRI is a better diagnostic modality than CT; however, it can still be difficult to diagnose accurately these ring-enhancing lesions given the wide-range of the differential. As a result, brain biopsy becomes mandatory to establish the diagnosis in most cases. Here we present a case of PT-PCNSL, who was initially misdiagnosed and treated as brain abscess until brain biopsy proved it otherwise Case: A 41-year-old Hispanic female with a past medical history of bacterial endocarditis, renal transplant (1994) secondary to glomerulonephritis treated with mycophenolate and tacrolimus presented with a transient change in mental status. She had stable vitals without neurological deficits and the spontaneous return of baseline mental status. Her MRI showed two ring-enhancing lesions in the right temporal and parietal lobe. Considering her previous history of endocarditis, current immunosuppression, MRI findings and non-specific neurological manifestation, she was treated as a brain abscess without any significant response. Her blood culture remained negative, and CSF analysis was unremarkable. Therefore, she underwent brain biopsy that characterized it to be diffuse large B-cell lymphoma that was assumed to be post-transplant. Her immunosuppression was withheld; subsequently she underwent tumor resection followed by Rituximab therapy with an effective response, and she is currently disease free Discussion: Although PT –PCNSL is a very rare entity, it is increasingly recognized in transplant recipient as the number of transplant recipients rises, and better survival outcomes are achieved. Early diagnosis is a harbinger of a better outcome. Therefore high index of clinical suspicion should always be exercised in this patient population. Chronic immunosuppression plays a critical role in the etiopathogenesis of these neoplasms and often, the treatment is withholding immunosuppression itself. PT-PCNSL is hard to diagnose, easy to miss and rather difficult to treat with variable prognosis Although the differential diagnosis of ring-enhancing lesions on MRI includes glioma, metastatic malignant lesions, bacterial and non-bacterial abscesses, toxoplasmosis, and multiple sclerosis plaques, clinicians must consider PT-PNCSL highly in transplant recipients.