Case of HIV-positive man with vision loss, altered mental status

The authors review the case and differential diagnosis of a 55-year-old HIV-positive man who presented with acute unilateral vision loss and altered mental status. He was found to have biopsy-proven diffuse large B-cell lymphoma.

Ophthalmic evaluation revealed light perception vision OD with a right relative afferent pupillary defect, conjunctival chemosis, large mutton-fat keratitic precipitates and diffuse cream-colored vitreous cells. Brain and orbit MRI showed choroidal thickening OD, multifocal deep periventricular and deep ganglionic enhancing lesions, and a suprasellar mass. Brain biopsy showed diffuse large B-cell lymphoma.

Intrathecal chemotherapy with methotrexate and cytarabine and whole brain radiation therapy failed. The patient’s mental status deteriorated. He developed pancytopenia, neutropenic fever and septic shock and subsequently died while under palliative care.

The authors note that the incidence of primary central nervous system (CNS) lymphoma in HIV patients is 2 to 6%, up to 10% in autopsy series, and has increased since the introduction of highly active antiretroviral therapy. Although primary CNS lymphoma represents only 1% of non-Hodgkin lymphoma in the general population, it is as high as 15% in HIV-infected patients.

They say that although MRI is helpful in the diagnosis of primary CNS lymphoma, these lesions can mimic intracranial infections in AIDS, especially toxoplasmosis. Therefore, serologic studies and cerebrospinal fluid analysis are needed to rule out toxoplasmosis.