PMC5237726_01
MRI at admission (day 34). Top two images are T2-weighted, middle two are T1-weighted, and bottom two are T2/FLAIR-weighted. Multifocal enhancing lesions in both cerebral hemispheres and in the left cerebellum concerning metastasis, infection, or inflammatory etiology. Redemonstration of areas of hemorrhage in the left frontal lobe is seen on CT scan. 4 mm left to right midline shift is present. Centrally necrotic lesion in the left thalamus measures 14 x 11 mm. Lesion in the right caudate head measures 11 x 10 mm. Enhancing lesion in the posterior left cerebellum measures 9 x 6 mm.
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Repeat head imaging demonstrated multifocal parenchymal hemorrhage with surrounding cerebral edema and mass effect with a 5 mm left to right shift (Figure 2).
Brain biopsy pathology (day 50). Brain tissue fragments with hematoxylin and eosin stain showing blood vessels surrounded by predominantly mononuclear cells. Occasional thrombi are present as well as fibrinoid and liquefactive necrosis. No granulomas or multinucleated cells are seen.
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Intraoperative tissue biopsy showed atypical perivascular lymphoid infiltrate, more consistent with a vasculitis (Figures 3 and 4).
Immunohistochemistry/CD20 stain of brain biopsy (day 50). CD20+ perivascular B-cell infiltrates. Many also are staining positive for EBV-encoded RNA (EBER), which is not depicted but indicates presence of Epstein-Barr Virus. Additional stains of the sample suggested increased presence of polymorphic plasmacytes and T-cells.
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Intraoperative tissue biopsy showed atypical perivascular lymphoid infiltrate, more consistent with a vasculitis (Figures 3 and 4).
MRI after completion of rituximab and whole brain radiation (day 97). Rituximab started on day 63; cranial XRT started on day 70. Abnormal parenchymal enhancement in both cerebral hemispheres that have decreased in size. Increased hemorrhage in bilateral frontal and parietal lobe lesions. In the right frontal lobe there is a 15 mm rim-enhancing fluid collection. The edema surrounding most of the lesions has decreased in size. The left cerebellar lesion has decreased from 5 mm to 2 mm.
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His MRI showed remarkable response with regression of most of the central nervous system lesions (Figure 5).
MRI at six-month posttherapy follow-up (day 270). Many of the areas previously demonstrating diffusion hyperintensity have improved and/or resolved. Several areas of diffusion hyperintensity remain. FLAIR hyperintensities are grossly similar except for some improvement in the left thalamic region and some worsening in the right parietal region.
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His MRI six-month posttreatment (Figure 6) showed no increase in lesion size and moderate improvement with resolution of several areas.