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 Table of Contents     
CASE REPORT
Year : 2014  |  Volume : 29  |  Issue : 2  |  Page : 92-93  

Primary central nervous system lymphoma in an human immunodeficiency virus-infected patient mimicking bilateral eye sign in brain seen in fluorine-18 fluorodeoxyglucose-positron emission tomography/computed tomography


1 Department of Nuclear Medicine and Positron Emission Tomography-Computed Tomography, Comprehensive Cancer Care Centre, Kovai Medical Centre and Hospital Limited, Coimbatore, Tamil Nadu, India
2 Department of Hematology, Comprehensive Cancer Care Centre, Kovai Medical Centre and Hospital Limited, Coimbatore, Tamil Nadu, India

Date of Web Publication9-Apr-2014

Correspondence Address:
Koramadai Karuppusamy Kamaleshwaran
Department of Nuclear Medicine, Positron Emission Tomography-Computed Tomography and Radionuclide Therapy, Comprehensive Cancer Care Centre, Kovai Medical Centre and Hospital Limited, Coimbatore, Tamil Nadu - 641 014
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.130290

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   Abstract 

Fluorodeoxyglucose-positron emission tomography/computed tomography (FDG PET/CT) has proven useful in the diagnosis, staging, and detection of metastasis and posttreatment monitoring of several malignancies in human immunodeficiency virus (HIV)-infected patients. It also has the ability to make the important distinction between malignancy and infection in the evaluation of central nervous system (CNS) lesions, leading to the initiation of the appropriate treatment and precluding the need for invasive biopsy. We report an interesting case of HIV positive 35-year-old woman presented with headache, disorientation, and decreased level of consciousness. She underwent whole body PET/CT which showed multiple lesions in the cerebrum which mimics bilateral eye in brain. A diagnosis of a primary CNS lymphoma was made and patient was started on chemotherapy.

Keywords: 18-F fluorodeoxyglucose-positron emission tomography/computed tomography, bilateral eye sign in brain, HIV positive, primary central nervous system lymphomaw


How to cite this article:
Kamaleshwaran KK, Thirugnanam R, Shibu D, Kalarikal RE, Shinto AS. Primary central nervous system lymphoma in an human immunodeficiency virus-infected patient mimicking bilateral eye sign in brain seen in fluorine-18 fluorodeoxyglucose-positron emission tomography/computed tomography. Indian J Nucl Med 2014;29:92-3

How to cite this URL:
Kamaleshwaran KK, Thirugnanam R, Shibu D, Kalarikal RE, Shinto AS. Primary central nervous system lymphoma in an human immunodeficiency virus-infected patient mimicking bilateral eye sign in brain seen in fluorine-18 fluorodeoxyglucose-positron emission tomography/computed tomography. Indian J Nucl Med [serial online] 2014 [cited 2019 Jul 23];29:92-3. Available from: http://www.ijnm.in/text.asp?2014/29/2/92/130290


   Introduction Top


Three cancers are especially prevalent in human immunodeficiency virus (HIV)-positive individuals and are considered acquired immunodeficiency syndrome (AIDS) defining illnesses: Kaposi sarcoma, high-grade B-cell non-Hodgkin lymphoma, and invasive cervical carcinoma. [1] Several studies have evaluated the role of fluorodeoxyglucose positron emission tomography (FDG PET) in the diagnosis of central nervous system (CNS) complications in patients with AIDS, with particular attention paid to the differentiation between toxoplasmosis and lymphoma. [2],[3] There are previous reports of F-18 FDG PET/computed tomography (CT) in HIV patients with cerebral lymphoma but the interesting mimicking bilateral eye sign in brain was not reported.


   Case Report Top


A 35-year-old female HIV patient presented with headache and altered mental status. She was referred for whole body PET/CT for detection of involvement of CNS and other sites. PET/CT showed an intense uptake in the multiple lesions noted in both the cerebrum [Figure 1], with a standardized uptake value (SUV max) of 30-35. A diagnosis of primary CNS lymphoma was made and she was started on chemotherapy.
Figure 1: Whole body fluorodeoxyglucose-positron emission tomography (PET)/ computed tomography (CT) Axial CT (a), PET (b), Fused PET/CT (c), maximum intensity projection image (d) showing intense uptake in the multiple lesions in cerebrum with an standardized uptake value max of 30-35

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   Discussion Top


Neurologic complications occur frequently in HIV-positive patients because of opportunistic infection, malignancy, or the HIV itself. [3] As many as 10% of all AIDS patients will initially present with neurologic symptoms and between 40% and 60% of patients with AIDS will eventually develop CNS complications during the course of their disease. [4] The evaluation and management of HIV-positive patients presenting with neurologic findings is challenging because the symptoms at initial presentation, such as fever, headache, altered mental status, and focal neurologic signs or seizures, are not specific. In addition, conventional imaging techniques, such as CT or magnetic resonance imaging (MRI), are often not useful in determining the causes of mass lesions. For example, both primary CNS lymphoma and toxoplasmosis produce similar focal or multifocal ring-enhancing lesions on CT and MRI. [5]

Several studies have evaluated the role of FDG PET in the diagnosis of CNS complications in patients with AIDS, with particular attention paid to the differentiation between toxoplasmosis and lymphoma. [6] Hoffman et al., [7] performed both a visual and semiquantitative evaluation of CNS lesions using FDG PET. In every case of lymphoma, FDG uptake was significantly higher than that of nonmalignant lesions. In a similar study, Villringer et al.,[8] assessed the ability of FDG PET to differentiate between toxoplasmosis and lymphoma. Eleven AIDS patients with CNS lesions were examined and the SUVs of the lesions were compared with that of a contralateral brain area to control for differential FDG uptake between lesions in white matter and those in gray matter. O'Doherty et al., [9] measured SUVs ranging between 0.14 and 3.7 over cerebral lesions due to toxoplasmosis, significantly lower than the SUVs in lymphomas which had values between 3.9 and 8.7. FDG PET thus has promise as a reliable, noninvasive method of differentiating between primary CNS lymphoma infections. A low SUV of the lesion adds confidence to a working diagnosis of toxoplasmosis when treated empirically and may avoid a brain biopsy. However, definitive diagnosis can only be made by tissue diagnosis. Our case describes a classical finding in CNS lymphoma which mimics a bilateral eye sign in brain which has SUV max of 30-35.

 
   References Top

1.Frisch M, Biggar RJ, Engels EA, Goedert JJ. AIDS-Cancer Match Registry Study Group. Association of cancer with AIDS-related immunosuppression in adults. JAMA 2001;285:1736-45.  Back to cited text no. 1
    
2.Heald AE, Hoffman JM, Bartlett JA, Waskin HA. Differentiation of central nervous system lesions in AIDS patients using positron emission tomography (PET). Int J STD AIDS 1996;7:337-46.  Back to cited text no. 2
    
3.Manzardo C, Del Mar Ortega M, Sued O, Garcia F, Moreno A, Miro JM. Central nervous system opportunistic infections in developed countries in the highly active antiretroviral therapy era. J Neurovirol 2005;11:72-82.  Back to cited text no. 3
    
4.Elder GA, Sever JL. Neurologic disorders associated with AIDS retroviral infection. Rev Infect Dis 1988;10:286-302.  Back to cited text no. 4
    
5.Levy RM, Bredesen DE, Rosenblum ML, Davis RL. Central nervous system disorders in AIDS. Immunol Ser 1989;44:371-401.  Back to cited text no. 5
    
6.Goshen E, Davidson T, Avigdor A, Zwas TS, Levy I. PET/CT in the evaluation of lymphoma in patients with HIV-1 with suppressed viral loads. Clin Nucl Med 2008;33:610-4.  Back to cited text no. 6
    
7.Hoffman JM, Waskin HA, Schifter T, Hanson MW, Gray L, Rosenfeld S, et al. FDG PET in differentiating lymphoma from nonmalignant central nervous system lesions in patients with AIDS. J Nucl Med 1993;34:567-75.  Back to cited text no. 7
    
8.Villringer K, Jager H, Dichgans M, Ziegler S, Poppinger J, Herz M, et al. Differential diagnosis of CNS lesions in AIDS patients by FDG-PET. J Comput Assist Tomogr 1995;19:532-6.  Back to cited text no. 8
    
9.O'Doherty MJ, Barrington SF, Campbell M, Lowe J, Bradbeer CS. PET scanning and the human immunodeficiency virus-positive patient. J Nucl Med 1997;38:1575-83.  Back to cited text no. 9
    


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