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Arquivos de Neuro-Psiquiatria

Print version ISSN 0004-282XOn-line version ISSN 1678-4227

Arq. Neuro-Psiquiatr. vol.76 no.8 São Paulo Aug. 2018

https://doi.org/10.1590/0004-282x20180049 

Images in Neurology

Primary central nervous system post-transplant lymphoproliferative disorder mimicking toxoplasmosis

Doença linfoproliferativa pós-transplante mimetizando toxoplasmose

Fabiano Reis1 

Aya Fukuda1 

João Felipe Leite Bonfitto2 

Ricardo Schwingel3 

Luciano Souza Queiroz2 

Fabio Rogerio2 

Marcia Torresan Delamain4 

1Universidade Estadual de Campinas, Hospital das Clínicas, Campinas SP, Brasil;

2Universidade Estadual de Campinas, Departamento de Patologia, Campinas SP, Brasil;

3Universidade Estadual de Campinas, Departamento de Radiologia, Campinas SP, Brasil;

4Universidade Estadual de Campinas, Departamento de Medicina Interna, Campinas SP, Brasil;


A 37-year-old woman was admitted with right-sided hemiparesis and mental confusion. She had received a renal allograft transplant 10 years earlier and was on immunosuppressive therapy with mycophenolate, prednisone and tacrolimus. Magnetic resonance imaging (MRI) and microscopic examination are shown in Figure 1. Spectroscopy, perfusion and evolution are shown in Figure 2.

Figure 1 (A) T2-weighted magnetic resonance imaging revealed a left supratentorial hypointense lesion surrounded by vasogenic edema and a peripheral ring enhancement with an eccentric nodule along the internal wall (eccentric target sign, an imaging pattern considered suggestive of toxoplasmosis, arrow) in the cortico-subcortical region on T1 weighted imaging after contrast administration (C) and leptomeningeal enhancement. (B) Lymphoid infiltrate comprising angiotropic pleomorphic large cells, including some with Reed-Sternberg-like features, together with smaller T cells and areas of necrosis (hematoxylin eosin, original magnification x200). (D) CD20 antigen expression by large cells surrounding and invading vessel walls (CD20 immunoperoxidase stain, original magnification x200). 

Figure 2 A somewhat high relative cerebral blood volume (rCBV map) can be seen in the left parietal lesion (arrow) and is represented in red (top left). Perfusion color maps derived from dynamic susceptibility contrast-enhanced perfusion weighted imaging show that the visual increase is elevated 3.1 times relative to the contralateral parenchyma (top right). One month after treatment, the lesion is reduced and there is no enhancement (bottom left). Magnetic resonance spectroscopy shows a significant elevation of the choline peak in 3.2 ppm (arrow) and in the choline/creatine ratio. The choline signal results from several different choline-containing compounds, which are involved in membrane synthesis, and degradation and elevation of this peak is more often seen in neoplasms. There is also an elevation in lipid-lactate peaks, in 1.3 ppm (arrowhead), which indicate necrosis and tissue damage with liberation of membrane lipids (bottom right). 

A diagnosis of monomorphic post-transplant lymphoproliferative disorder was made1,2,3. Mycophenolate was discontinued and the patient recovered.

We illustrate a post-transplant lymphoproliferative disorder lesion with ring-enhancing pattern, hyperperfusion and high choline and lipid/lactate levels. Perfusion and spectroscopy are not yet discussed in the literature and may help distinguish this from inflammatory lesions.

References

1. Honda M, Koga M, Kanda T. [Primary central nervous system post-transplant lymphoproliferative disorders]. Brain Nerve. 2014;66(8):947-54. Japanese. [ Links ]

2. Pedroso JL, Dutra LA, Braga-Neto P, Abrahão A, Andrade JBC et al. Neurological complications of solid organ transplantation. Arq Neuro-Psiquiatr. 2017;75(10): 736-47. https://doi.org/10.1590/0004-282x20170132Links ]

3. Lake W, Chang JE, Kennedy T, Morgan A, Salamat S, Başkaya M. A case series of primary central nervous system post-transplant lymphoproliferative disorder: imaging and clinical characteristics. Neurosurgery. 2013;72(6):960-70. https://doi.org/10.1227/NEU.0b013e31828cf619Links ]

Received: January 07, 2018; Revised: February 10, 2018; Accepted: March 05, 2018

Correspondence: Fabiano Reis; Departamento de Radiologia da FCM/Unicamp; Rua Tessália Vieira de Camargo, 126, Cidade Universitária Zeferino Vaz; Caixa Postal: 6111; 13083-887 Campinas SP, Brasil; E-mail: fabianoreis2@gmail.com

Conflict of interest: There is no conflict of interest to declare.

Creative Commons License This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.