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Washington University Experience | NEOPLASMS (HEMATOLYMPHOID) | Lymphoma, immune-compromised | 8A0 Case 8 History
Case 8 History ---- The patient was a 33 year old man with a past medical history dating from December 1986 when he began having profuse watery diarrhea and a 100 lb. weight loss. He was diagnosed as having giardia gastroenteritis in 3/87. In addition he had positive serology for HIV and positive CMV titer at a level of 474. The patient was admitted to BJH in 6/87 with fever, aches and anxiety and was found to have pneumocystis pneumonia. The patient had a lumbar puncture performed as part of the fever workup which revealed an opening pressure of 182, glucose of 54, protein of 30, 11 RBCs, no WBCs, negative routine fungal and acid fast cultures and a cytocentrifuge that revealed 4 macrophages, 6 monocytes, 18 lymphocytes and 2 polys. While in the hospital the patient developed seizures which consisted of bilateral eyelid twitching and then generalized body twitching that lasted 2 minutes and was postictal for approximately 5 minutes. The VDRL was nonreactive, cryptococcal antigen was negative, cultures were negative, and cytology was negative. A repeat lumbar puncture performed 5 days later revealed 2 large unidentified cells, 12 macrophages, 25 lymphs and 55 segs. Cytology was labeled as being suspicious and cultures were negative. Eventually cultures from this LP grew CMV. CT and MRI scans were negative. The patient was discharged and readmitted approximately a week later because of increasing weakness in the right leg. On exam at that time he was noted to have impaired memory with decreased deep tendon reflexes with normal strength in the upper extremities and decreased strength in the lower extremities. The toes went down and there was no ataxia noted. He developed progressively worsening left lower extremity weakness and encephalopathy. This prompted the performance of a CT scan of the head which revealed a ring enhancing lesion that was irregular in shape and located in the right centrum semiovale just above the lateral ventricle. A stereotactic brain biopsy was performed. Which showed an atypical lymphoid infiltrate and necrosis most consistent with lymphoma. The patient was discharged in a near terminal condition and was readmitted several days later in a comatose state. He had another CT scan performed which revealed multiple ring enhancing lesions with surrounding edema and considerable mass effect. The lesions were found in the right temporal lobe, and in both frontal and parietal lobes. The patient continued in a comatose state and expired on July 1988.
