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• W4387248638 abstract "SESSION TITLE: Critical Care Case Report Posters 23 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: JC virus is a human polyomavirus with transmission through direct contact and can cause Progressive Multifocal Leukoencephalopathy (PML) in immunocompromised patients such as those with AIDS. We present a case of AIDS-associated PML and left sided weakness with headache found to have CNS B-cell lymphoma after delayed MRI. CASE PRESENTATION: A 36 year-old-female patient with a history of AIDS, non-adherent with antiretroviral therapy (ART) was brought to the ED for altered mental status. Exam revealed a GCS of 9, aphasia, dysphagia, hyperreflexia, and dense left-sided weakness. She had previously been admitted to another hospital 3 weeks prior for forgetfulness and weakness where CT Head revealed a right frontal lobe hypodense focus and MRI showed a 3 mm enhancing lesion of the anterior temporal lobe and cerebral atrophy. She started on Biktarvy and Prezobix for HIV encephalopathy. At that time, a Lumbar Puncture (WBC 1, RBC 2, Glu 57, Prot 25) was negative for multiple infections, she was discharged with a pending JCV PCR which then resulting positive for 261,000 copies (EBV was not tested). She was readmitted for altered mental status and treated empirically for meningitis and possible IRIS without MRI imaging. One week into hospital course, MRI Brain revealed a 9 mm ring enhancing lesion in the anterior temporal lobe with edema and repeat LP was significant for EBV 289k UI/mL. CSF flow cytometry revealed CD5 & CD10 B lymphocytes, markers associated with Lymphoma. Stereotactic brain biopsy then confirmed CNS lymphoma. In spite of methotrexate infusion for AIDS-related Primary CNS Lymphoma (PCNSL), patient deteriorated with uncal herniation and was declared brain dead. DISCUSSION: This case demonstrates how delayed MRI led to delayed diagnosis of PCNSL and PML which may have led to poor patient outcome. CNS involvement in patients with HIV presenting with focal neurological deficits has a broad differential diagnosis including space-occupying lesions (eg. PCNSL) or PML for which MRI is needed to confirm diagnosis. In AIDS-associated PML, headache and motor weakness occur in 32% and 42% of patients, respectively[1]. Reports of concomitant PCNSL and PML are suggestive of a role for JCV in developing CNS lymphoma[2]. Prompt diagnosis therefore may improve survival in immunocompromised patients who are at high risk of developing CNS neoplasms[3]. The possibility of IRIS and the administration of systemic corticosteroids is a complex decision given their immunosuppressive properties. First line treatment options for PCNSL includes methotrexate and rituximab. Outcomes are typically poor, prognostic scoring systems for overall survival are driven largely by age and activity performance. CONCLUSIONS: Our case emphasizes need for prompt repeat MRI in HIV patients with CNS involvement, whereby PCNSL could have been treated emergently, possibly avoiding fatal uncal herniation. REFERENCE #1: Berger JR, Aksamit AJ, Clifford DB, et al. PML diagnostic criteria: consensus statement from the AAN Neuroinfectious Disease Section. Neurology. 2013;80(15):1430-1438. doi:10.1212/WNL.0b013e31828c2fa1 REFERENCE #2: Gallia GL, DelValle L, Laine C, Curtis M, Khalili K. Concomitant progressive multifocal leukoencephalopathy and primary central nervous system lymphoma expressing JC virus oncogenic protein, large T antigen. Mol Pathol. 2001;54(5):354-359. doi:10.1136/mp.54.5.354 REFERENCE #3: Miskin DP, Ngo LH, Koralnik IJ. Diagnostic delay in progressive multifocal leukoencephalopathy. Ann Clin Transl Neurol. 2016;3(5):386-391. Published 2016 Apr 6. doi:10.1002/acn3.301 DISCLOSURES: No relevant relationships by Miqdad Dafaallah No relevant relationships by Ahmed Gubran No relevant relationships by Daniel Howell" @default.
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• W4387248638 date "2023-10-01" @default.
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• W4387248638 title "DELAYED DIAGNOSIS OF CNS LYMPHOMA IN A PATIENT WITH HIV-ASSOCIATED PML" @default.
• W4387248638 doi "https://doi.org/10.1016/j.chest.2023.07.1865" @default.
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