PMC5633254_01
Magnetic resonance imaging (MRI) showing diffuse multi-focal hyperintense lesions on axial T2 fluid-attenuated inversion recovery (FLAIR) sequences on initial presentation (A-C), 3 weeks after presentation (D-F), 6 weeks after presentation (G-I), 5 (J-L) and 8 (M-O) months after presentation.
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Magnetic resonance imaging (MRI) with gadolinium contrast showed abnormal signal in the left insular region, left pons, and right cerebellum (Fig. 1A-C), but no enhancing lesions. MRI revealed worsening diffuse periventricular hyperintensities with more extensive pontine and cerebellar involvement (Figs. 1D-F, 2). CSF EBV VL had decreased to 5400 IU/mL, CSF pleiocytosis had resolved, MRI was improved (Figs. 1G-I & 2), and the patient had developed anti-EBV nuclear antigen IgG. MRI and LP findings were consistent with progressive infection (Figs. 1J-L & 2), and the patient was found to be viremic with EBV viral load of 900 IU/mL. Mycophenolate was discontinued, and oral valganciclovir 900 mg two times daily was resumed. The patient soon returned to her functional baseline, with resolution of viremia and MRI improvement (Fig. 1 M-O).
Clinical course, respective interventions, laboratory values and imaging.. Laboratory values and images have been linked to the closest timepoint of clinical assessment. Grey marks represent clinical or laboratory deterioration and black ones improvement. CSF, cerebrospinal fluid; EBV, Epstein-Barr Virus; FLAIR, fluid-attenuated inversion recovery; IV, intravenous; MRI, magnetic resonance imaging; TND, target not detected; <49 (plasma), EBV detected, below quantification cut-off.
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Re-admission was prompted 11 days later by mental status decline without changes in immunosuppression (Fig. 2). MRI revealed worsening diffuse periventricular hyperintensities with more extensive pontine and cerebellar involvement (Figs. 1D-F, 2). IU/mL. Intravenous ganciclovir was initiated with resultant improvement in mental status and decrease in CSF EBV VL (Fig. 2). CSF EBV VL had decreased to 5400 IU/mL, CSF pleiocytosis had resolved, MRI was improved (Figs. 1G-I & 2), and the patient had developed anti-EBV nuclear antigen IgG. MRI and LP findings were consistent with progressive infection (Figs. 1J-L & 2), and the patient was found to be viremic with EBV viral load of 900 IU/mL. Mycophenolate was discontinued, and oral valganciclovir 900 mg two times daily was resumed.