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Washington University Experience | NEOPLASMS (HEMATOLYMPHOID) | Lymphoma, primary | 14A0 Case 14 History
Case 14 History ---- The patient was a 70 year old man with a past medical history of type II diabetes, chronic obstructive pulmonary disease, and hypertension. In late November of 2005 he had left eye blurring followed one month later by unsteady gait, mild left hemiparesis and mental status changes including emotional lability and inappropriate giddiness. MRI showed increased T2 signal in the brainstem, basal ganglia, thalami and deep white matter with minimal enhancement in the right frontal white matter and no leptomeningeal enhancement. CSF from 2 lumbar punctures showed mild lymphocytosis, no malignancy, and was negative for HSV, VZV, CMV, ACE, VDRL, and oligoclonal bands. Multiple serologic tests included HIV, an arbovirus panel, West Nile Virus PCR and protein electrophoresis. He had a positive Lyme antibody and was treated with a six week course of ceftriaxone although confirmatory tests were negative. He was discharged in early January and subsequently was readmitted in an OSH later that month and underwent a lung biopsy and gallium scan due to the suspicion of neurosarcoid, both of which were negative. He was transferred to BJH in early February 2006 and his initial exam was significant for emotional lability, mild left hemiparesis, left sided dysmetria and truncal instability. Workup included a repeat MRI was somewhat worse than the previous scans. Cerebrospinal fluid flow cytometry demonstrated reactive lymphocytes. A cerebral angiogram was negative for vasculitis. He had a positive EBV PCR in the CSF and a negative Toxoplasmosis PCR. Chest, abdomen, and pelvis CT only demonstrated pulmonary edema. Rheumatoid factor, ANA, ENA were negative. Throughout the hospitalization, his examination worsened, and he became less responsive. EEG demonstrated right greater than left slowing. Within a few days his exam worsened he was found to be hypotensive with candida albicans growing in his urine. He was intubated and started on vasopressors but his family chose to withdraw care. He died immediately after extubation.
