A case of primary intraocular B-cell lymphoma masquerading alongside varicella-zoster virus retinitis

We describe an unusual case of a 73-year-old gentleman with primary intraocular large B-cell lymphoma masquerading alongside varicella-zoster virus retinitis.

Retrospective case report and review of the literature.

A 73-year-old Hispanic gentleman was referred for evaluation of a granulomatous panuveitis and acute retinal necrosis in the right eye (OD). He complained of blurred vision and constant dull pain OD for a one-week duration. After minimal response to initial antiviral therapy, a diagnostic pars plana vitrectomy (PPV) with vitreous biopsy was performed with aspiration of subretinal fluid. Quantitative PCR (qPCR) detected 3,400,000 copies/mL of varicella-zoster virus (VZV), prompting treatment with high-dose intravenous acyclovir for one week with transition to oral valacyclovir for six weeks. Despite aggressive antiviral treatment, the retinitis worsened, prompting a repeat PPV with vitreous biopsy in addition to a chorioretinal biopsy. VZV was not detected in the repeat vitreous sample sent for qPCR, indicating adequate antiviral therapy. Chorioretinal biopsy with flow cytometric analysis revealed a diffuse large B-cell lymphoma (DLBCL). Findings were suggestive of a primary intraocular DLBCL with concomitant VZV retinitis.

Primary intraocular lymphoma is particularly challenging to diagnose as it may masquerade as uveitis and retinitis. Infectious causes superimposed on underlying neoplastic processes can delay diagnosis and treatment, as seen with our patient.