SHM Converge Scientific Abstract ePoster Gallery-Not Acing It: Primary CNS Lymphoma in Setting of Neurosarcoidosis

Pdf Summary

This case describes a 58-year-old woman with known sarcoidosis and neurosarcoidosis who developed worsening neurologic deficits, fever, and multiple enlarging ring-enhancing brain lesions. Because neurosarcoidosis can mimic many other conditions, her lesions were initially treated as possible brain abscesses versus progression of neurosarcoidosis. She was discharged on broad-spectrum antibiotics, but returned weeks later with new left-sided weakness and persistent systemic illness.  <br /><br />Imaging showed increasing size and number of peripherally enhancing lesions with marked vasogenic edema and midline shift. Her CSF was inflammatory but nonspecific, and infectious studies were negative. Despite antibiotics and dexamethasone, her condition worsened. A delayed brain biopsy, performed after steroid exposure, showed an atypical extensively necrotic lesion with mixed B- and T-cell infiltrates adjacent to necrotic CD20-positive cells, raising strong concern for primary CNS lymphoma. Additional cultures remained negative, and PET imaging showed disease confined to the brain without systemic involvement.  <br /><br />She was treated with R-MPV chemotherapy and zanubrutinib, but there was no clinical or radiographic improvement after several months. She ultimately transitioned to comfort care.  <br /><br />The case highlights several important teaching points:  <br />- Ring-enhancing brain lesions have a broad differential, especially in immunocompromised patients.  <br />- Neurosarcoidosis can obscure the diagnosis of CNS lymphoma.  <br />- Peripheral diffusion restriction and lesion enlargement despite antibiotics should prompt concern for malignancy.  <br />- High-dose steroids and delayed biopsy can reduce diagnostic yield.  <br /><br />The authors emphasize that primary CNS lymphoma is rare but should remain on the differential in patients with sarcoidosis and progressive neurologic disease, and that early brain biopsy is crucial when the diagnosis is uncertain.

Asset Subtitle

Rose Nganga

Meta Tag

Author List Ann Marie Kumfer, Rose Nganga

Category Clinical Vignettes

Concept Neurosarcoidosis

Concept Primary Central Nervous System Lymphoma

Concept Brain biopsy

Concept Differential Diagnosis

Concept Cerebral Abscess

Distinguished Non-Finalist

Presenter Organization UNC Hospital

Presenting Author Rose Nganga

Track Adult

Keywords

sarcoidosis

neurosarcoidosis

primary CNS lymphoma

ring-enhancing brain lesions

brain biopsy

vasogenic edema

diffusion restriction

CD20-positive cells

R-MPV chemotherapy

zanubrutinib

Neurosarcoidosis

Primary Central Nervous System Lymphoma

Brain biopsy

Differential Diagnosis

Cerebral Abscess