Primary central nervous system (PCNS) PTLD is a very rare complication that occurs as a result of immunosuppression in the setting of solid organ transplantation. The median time from transplantation to diagnosis ranges from 1 to 4.4 years. We herein describe the case of a patient who developed EBV-positive PCNS PTLD approximately 12 years post renal transplant. A 50-year-old lady presented with a 12-week history of generalised throbbing headache, progressive vertigo, nausea and vomiting. Twelve years previously, she had a renal transplant for end stage renal failure secondary to atrophic pyelonephritis. Medications included ciclosporin 50 mg, azathioprine 100 mg and prednisolone 5 mg. The axial T2 and FLAIR MRI images demonstrated scattered areas of high signal involving bilateral cerebellar hemispheres, splenium of corpus callosum and right peritrigonal white matter (Abstract 089 figure 1A). Post contrast scans showed nodular enhancement involving both supratentorial and infratentorial compartments (Abstract 089 figure 1B). CSF examination revealed mild lymphocytic pleocytosis. CSF PCR for EBV was positive at 1000 copies/ml; BK virus and JC virus were negative. A biopsy of the posterior fossa lesion showed polymorphic population of lymphoid cells with nuclear atypia and mitotic figures in keeping with polymorphic type PTLD. The evaluation of an immunosuppressed patient presenting with intracranial lesions can be challenging. Indeed, several types of opportunistic infections or tumours can have similar presentations. A high index of suspicion for PTLD should be maintained whenever a transplant patient presents with an intracranial lesion.
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