Enchephalitis-like symptoms caused by central nervous system malignant lymphoma in a patient undergoing hemodialysis-A case report

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  • Ohta Mari
    Department of Internal Medicine, Shinjuku-Ishikawa Hospital
  • Ohnuki Takako
    Department of Internal Medicine, Shinjuku-Ishikawa Hospital
  • Shiohira Shunji
    Department of Internal Medicine, Shinjuku-Ishikawa Hospital
  • Yabuki Yasuko
    Department of Internal Medicine, Shinjuku-Ishikawa Hospital
  • Akao Masae
    Department of Internal Medicine, Shinjuku-Ishikawa Hospital

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  • 脳炎症状で発症し中枢神経原発悪性リンパ腫が疑われた透析患者の１例
  • 症例報告 脳炎症状で発症し中枢神経原発悪性リンパ腫が疑われた透析患者の1例
  • ショウレイ ホウコク ノウエン ショウジョウ デ ハッショウシ チュウスウ シンケイ ゲンパツ アクセイ リンパシュ ガ ウタガワレタ トウセキ カンジャ ノ 1レイ

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Abstract

We report a 78-year-old man on chronic hemodialysis who presented with encephalitic symptoms caused by central nervous system (CNS) malignant lymphoma. The patient presented with a two-week history of headache after every hemodialysis session. Computer tomography (CT) of the brain did not detect abnormal findings. Cerebrospinal fluid examination demonstrated 83/3mm3 of mononuclear cells and 295mg/dL of protein, suggesting viral meningoencephalitis. Despite treatment with acyclovir, the patient gradually became unconscious and was intubated because of respiratory failure. Steroid pulse therapy was transiently effective to improve conciousness. Repeated brain CT demonstrated enhanced tumor-like mass lesion involving right posterior limb of the internal capsule and left posterior cingulated sulcus. Serum and cerebrospinal fluid IL2-receptor levels were elevated to 919IU/mL and 259IU/mL, respectively. Cytological examination of the serial cerebrospinal fluid samples showed atypical lymphocytes with coarse patterns, strongly suggesting malignant lymphoma of the CNS. The patient died after a 6-month clinical course of disease. Autopsy was not performed. In the earlier stage of the clinical course, viral meningoencephalitis was suspected because of typical symptoms and increased mononuclear cells and protein in the spinal fluid. Brain CT and cerebrospinal fluid findings along with subacute unconsciousness and poor response to corticosteroid over time strongly suggested the presence of CNS malignant lymphoma. Therefore, CNS malignant lymphoma should be considered in the differential diagnosis of subacute unconsciousness in patients undergoing dialysis.

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