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Primary central nervous system lymphoma masquerading as herpes encephalitis: clinical, magnetic resonance imaging,
Pierre Giglio1, Rohit Bakshi, Sandra Block
1Department of Neurology, and Kaleida Health, State University of New York at Buffalo School of Medicine and Biomedical Sciences, USA.
Abstract:
An 84-year-old man presented with acute confusion, global aphasia, and fever. Magnetic resonance imaging (MRI) showed hyperintense lesions on T2-weighted and fluid-attenuated inversion recovery (FLAIR) images predominantly affecting the cortical gray matter of the left mesial temporal and inferior frontal lobes, and insula. Acyclovir was prescribed for presumed viral encephalitis. Clinical and MRI worsening prompted a left temporal lobe biopsy that revealed primary central nervous system lymphoma (PCNSL). This case adds to the MRI spectrum of PCNSL and illustrates that it may mimic the clinical and MRI presentation of herpes simplex encephalitis.
Insights
Primary central nervous system lymphoma (PCNSL) can mimic herpes simplex encephalitis, presenting with similar symptoms and MRI findings. Early biopsy is crucial for accurate diagnosis and appropriate treatment of PCNSL.
Area of Science:
- Neurology
- Oncology
- Radiology
Background:
- Primary central nervous system lymphoma (PCNSL) is a rare malignancy.
- Herpes simplex encephalitis (HSE) is a common cause of viral encephalitis with distinct clinical and imaging features.
- Distinguishing PCNSL from HSE is critical for timely and appropriate management.
Observation:
- An 84-year-old male presented with acute confusion, aphasia, and fever.
- MRI revealed T2/FLAIR hyperintensities in the left temporal, frontal lobes, and insula, suggestive of viral encephalitis.
- Despite acyclovir treatment, the patient's condition worsened, necessitating further investigation.
Findings:
- A left temporal lobe biopsy confirmed the diagnosis of primary central nervous system lymphoma (PCNSL).
- The MRI findings, initially presumed to be HSE, were characteristic of PCNSL.
- This case highlights the overlapping imaging spectrum of PCNSL and HSE.
Implications:
- PCNSL can present with clinical and radiological features mimicking herpes simplex encephalitis.
- Neuroimaging findings alone may not be sufficient to differentiate PCNSL from HSE.
- Brain biopsy remains essential for definitive diagnosis in ambiguous cases of suspected CNS infections or malignancies.