Clinical Images
Immune Therapy: A Cure and a Cause
Authors: Gustave Weiland MD, Gabrielle Rocque MD
A 56-year-old man with a history of diffuse large B cell lymphoma in remission presented with a 1 month history of facial palsies, balance issues, hoarseness, difficulty swallowing, and weight loss. His initial diagnosis of diffuse large B cell lymphoma was treated with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) therapy 30 years prior. Seven months prior to presentation, he was diagnosed with a recurrence. He was treated with bendamustine, rituximab, and polatuzumab and had a complete response.
On presentation, he denied nausea, vomiting, headache, and changes in vision or hearing. He was febrile to 101.2 °F with tachycardia. Neurological exam was unremarkable. CT and MRI imaging of the brain noted numerous hyperintense lesions throughout the cerebrum, cerebellum, basal ganglia, and brainstem. He was HIV negative. Cerebrospinal fluid was negative for infection. Flow cytometry studies were negative for lymphoma. Toxoplasma antibodies from the CSF were equivocal. Brain biopsy was consistent with T. gondii.
MCQ: A patient presents to your hospital with headache, fever, and confusion. She has multiple medical problems and sees multiple specialists. Which of the following would increase her risk of having reactivation of a latent infection or an opportunistic infection?
A) She had a liver transplant five years ago and takes tacrolimus and mycophenolate mofetil.
B) She is currently receiving fludarabine for her diagnosis of follicular lymphoma.
C) She has inflammatory bowel disease and has started treatment with rituximab.
D) All of the above
Figure Legend:
T1 weighted magnetic resonance imaging of the brain showing multiple enhancing lesions.
References:
(1) Savsek L, Opaskar TR. Cerebral toxoplasmosis in a diffuse large B cell lymphoma patient. Radiol Oncol. 2016;50(1):87-93.
(2) Chintakuntlawar A, Kidd M, Al-kali A, Wilson W, Thompson CA. Toxoplasmosis in patients with hematologic malignancies. Leuk Lymphoma. 2015;56(2):536-8.
(3) Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 18e. New York, NY: McGraw-Hill; 2012.
(4) Touahri T, Pulik M, Fezoui H, Genet P, Lionnet F, Louvel D. Toxoplasmic encephalitis in a non-HIV patient with follicular lymphoma. Int J Hematol. 2002;75(1):111-2.
(5) Safa G, Darrieux L. Cerebral toxoplasmosis after rituximab therapy. JAMA Intern Med. 2013;173(10):924-6.
Author Information:
Gustave Weiland is an internal medicine resident at the University of Alabama at Birmingham.
Gabrille Rocque is an assistant professor of oncology at the University of Alabama at Birmingham.