BACKGROUND Although rare, primary central nervous system lymphoma (PCNSL) affects 0.5 per 100,000 individuals. It is estimated that 5% of cases will develop into secondary central nervous system lymphoma (SCNSL) and 2-5% will evolve into recurrent CNS lymphoma (RPCNSL) with the diffuse large B-cell lymphoma (DLBCL) variant of RPCNSL. METHODS This is a retrospective study; data obtained via chart review. RESULTS We compared 3 patients with RPCNSL to 3 patients with SCNSL. All patients were EBV and HIV negative, DLBCL variant. The average age of diagnosis with the first malignancy with RCNSL was 62.7 years old and age at recurrence was 66.7. With SCNSL, the initial age of diagnosis averaged to 72.7 years old and with secondary presentation at an average age of 76. Initial PCNSL treatments for RPCSNL were steroids, RCHOP with radiation, and DeAngelis Protocol. Initial malignancies for patients with SCNSL were renal cell carcinoma in 2 patients and atypical chronic lymphocytic leukemia variant with 17p deletion. All patients with RPCNSL presented with altered mental status and 2/3 SCNSL patients were altered upon presentation; 1 SCNSL patient was asymptomatic. The lesions within the RPCNSL cohort were all single lesions, localized to the frontal and temporal lobes. Within the SCNSL cohort, 2/3 patients had multiple lesions, whereas 1 patient had single lesions. All of the RPCNSL patients were ultimately on palliative care. SCNSL 2/3 were lost to follow-up and 1/3 elected to proceed with further treatment. CONCLUSION Although differing in etiology, there are shared features among SCNSL and RPCNSL. Most relapses are in the central nervous system, a small number of relapses are isolated systemic relapses, and clinical symptoms occur early and vary. Treatment is similar for both, although the prognosis for RPCNSL is very poor.
Background. Powassan is a positive-sense, single-stranded, enveloped RNA virus that is a tick-borne Flavivirus, transmitted by Ixodes species, with groundhogs being the usual mammalian host. The virus is endemic to North America, with peak transmission during the summer and fall. The incubation period is 7–34 days, followed by a prodrome of flu-like symptoms. Although most infected individuals are asymptomatic, the virus can penetrate the CNS to produce a viral encephalitis. The key to the diagnosis is a positive serology. Results. The patient is a 62-year-old male with a past history of a right putamen infarct, hepatitis C, hypertension, and substance abuse who presented due to acute onset altered mental status, dysarthria, and left-sided facial droop. He had several tick bites around the time of presentation in December. He was empirically treated for possible meningitis, as CSF revealed WBC 370 (80% mononuclear cells); RBC 10, protein 152 mg/dL, and glucose 59 mg/dL. An MRI scan of the brain showed a subacute left putamen stroke. MRAs of the head and neck were unremarkable. A Mayo Clinic Encephalopathy Panel was unremarkable; however, a New York State Arbovirus panel revealed Powassan IgM ELISA as well as Powassan Polyvalent microsphere immunofluorescence assay reactivity. His hospital course was complicated by critical illness myopathy and respiratory failure requiring tracheostomy. Conclusion. The Powassan virus is a known etiology for encephalitis in North America. Although the peak incidence of transmission is in the summer and fall, this does not exclude transmission during other seasons. Due to the increasing prevalence of Powassan virus in Lyme-endemic areas particularly in the Midwest and Northeast, United States, patients with an unexplained altered mental status in these regions should be screened for Powassan virus, regardless of the time of year.
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