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Letter to the Editor
Progressive multifocal leukoencephalopathy: Report of a case preceding the diagnosis of systemic lymphoma
Leucoencefalopatía multifocal progresiva: a propósito de un caso que precede al diagnóstico de un linfoma sistémico
A. Ostolazaa,
Corresponding author
, I. Gastóna, J. Martaa, I. Ormazabalb, M.E. Erroa,c
a Servicio de Neurología, Complejo Hospitalario de Navarra, Pamplona, Spain
b Servicio de Hematología, Complejo Hospitalario de Navarra, Pamplona, Spain
c Laboratorio de Neuroepigenética-Navarrabiomed, Universidad Pública de Navarra (UPNA), IdiSNA (Navarra Institute for Health Research), Pamplona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Progressive multifocal leukoencephalopathy &#40;PML&#41; is a demyelinating disease of the central nervous system caused by reactivation of John Cunningham &#40;JC&#41; virus in immunosuppressed individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Immunosuppressive treatment in patients with haematologic neoplasms predisposes to the development of the disease<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#59; it is extremely rare for PML to be diagnosed before the neoplasm&#46; We present the case of a patient with PML as the initial manifestation of systemic lymphoma&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In March 2020&#44; a 74-year-old woman was admitted to our hospital due to a 2-month history of progressive muscle weakness of the left upper limb&#46; Physical examination revealed left hemiparesis and ipsilateral central facial palsy&#46; Blood analysis revealed mild anaemia &#40;haemoglobin&#58; 11&#46;9&#8239;g&#47;dL&#41; and elevated erythrocyte sedimentation rate &#40;62&#8239;mm&#47;h&#41; and beta-2-microglobulin level &#40;6789&#8239;&#181;g&#47;L&#41;&#46; Brain MRI showed altered signal intensity in the right frontal lobe&#44; which displayed diffusion restriction&#44; but no contrast enhancement on T1-weighted sequences &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#8211;C&#41;&#46; The patient was discharged with a diagnosis of ischaemic stroke and began rehabilitation treatment&#46; Two months later&#44; she was readmitted due to worsening of hemiparesis&#46; A brain MRI study revealed progression of the lesion &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D and E&#41;&#46; PCR testing for JC virus in the CSF yielded positive results&#46; Treatment was started with mirtazapine at 15&#8239;mg&#47;24&#8239;hours and citalopram at 20&#8239;mg&#47;24&#8239;hours&#44; but symptoms did not improve&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Suspecting an underlying neoplastic disease&#44; we performed a chest and abdomen CT scan&#44; which revealed splenomegaly and adenopathic conglomerates in the abdomen and pelvis&#59; these findings are suggestive of a lymphoproliferative process&#46; Finally&#44; after an inguinal biopsy&#44; the patient was diagnosed with high-grade B-cell non-Hodgkin lymphoma&#46; In the light of the progressive worsening&#44; chemotherapy was ruled out&#46; However&#44; we did start infusions of cidofovir dosed at 5&#8239;mg&#47;kg&#44; administered twice weekly&#46; During treatment&#44; the patient presented a partial motor improvement&#46; A further brain MRI study showed a slight reduction in the size of the lesions&#46; On account of the patient&#8217;s significant clinical improvement after 8 months&#8217; treatment with cidofovir&#44; we decided to start a cycle of chemotherapy with cyclophosphamide&#44; doxorubicin&#44; vincristine&#44; and prednisolone&#46; A follow-up CSF analysis performed before onset of chemotherapy revealed a considerable reduction in the number of copies of JC virus &#40;710 IU&#47;mL&#44; vs 15 960 IU&#47;mL in the previous study&#41;&#46; However&#44; 14 months after symptom onset&#44; the patient died due to massive intracranial haemorrhage&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">We present the case of a patient whose diagnosis of a haematologic neoplasm resulted from the detection of PML&#46; We believe that the systemic lymphoma caused a state of immunosuppression that predisposed the patient to PML&#44; as she was not receiving any immunosuppressive treatment&#46; Differential diagnosis considered the possibility of lymphoma dissemination to the brain due to the diffusion restriction in the lesions&#59; however&#44; treatment with cidofovir led to a clear clinical and radiological improvement&#44; and significantly decreased JC viral load in the CSF&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Primary asymptomatic infection with JC virus occurs during childhood in most patients&#44; with the virus subsequently remaining latent&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In immunosuppressed individuals&#44; the virus infects and destroys oligodendrocytes&#44; causing progressive demyelination of white matter in the brain&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> After HIV-positive individuals&#44; patients with haematologic neoplasms are the largest group at risk of developing PML&#46; In addition to the immunosuppression caused by the haematologic-oncological disease itself&#44; chemotherapy and immunosuppressive treatments cause a further deterioration of these patients&#8217; immune status&#46; A retrospective study conducted at an oncology centre gathered clinical data from 16 patients with haematologic cancer and diagnosed with PML in the period 2000-2015&#46; All but one of the patients had previously been treated with chemotherapy&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It is even rarer for diagnosis of PML to precede diagnosis of the neoplasm &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; As shown in the table&#44; our patient&#8217;s survival time was somewhat longer than those of other patients with similar characteristics&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">With respect to treatment&#44; the available options are limited and the clinical outcomes are rarely satisfactory&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> Prognosis is generally fatal&#44; with a mortality rate of approximately 90&#37; at 2 months after diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion&#44; our case demonstrates that PML can be the initial manifestation of a haematologic neoplasm&#44; and underscores the importance of tumour screening in patients presenting PML in the absence of any apparent cause of immunosuppression&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Informed consent</span><p id="par0040" class="elsevierStylePara elsevierViewall">The patient gave written informed consent to the publication of this study&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">This study has received no specific funding from any public&#44; commercial&#44; or non-profit organisation&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Brain MRI study&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Axial slices from FLAIR &#40;A&#41;&#44; gadolinium-enhanced T1-weighted &#40;B&#41;&#44; and diffusion-weighted sequences &#40;C&#41; at the time of the patient&#8217;s first admission&#44; showing altered signal in the right perirolandic area&#44; extending to the centrum semiovale&#46; The lesion presents no contrast enhancement&#44; and appears hyperintense on the diffusion-weighted sequence&#46; Two months later &#40;D&#41;&#44; the initial lesion had increased in size&#44; extending to the corpus callosum and internal capsule&#59; small satellite lesions were also visible in the adjacent white matter &#40;E&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">M&#58; man&#59; PML&#58; progressive multifocal leukoencephalopathy&#59; W&#58; woman&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sex&#47;age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Type of neoplasm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Interval from diagnosis of PML to diagnosis of haematologic neoplasm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Survival time after diagnosis of PML&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Viallard et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> 2005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&#47;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Angioimmunoblastic T-cell lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cidofovir&#44; cyclophosphamide&#44; vincristine&#44; and prednisone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bruce et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> 2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&#47;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Chronic lymphocytic leukaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Simultaneous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Present study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">W&#47;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High-grade B-cell non-Hodgkin lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cidofovir&#44; cyclophosphamide&#44; doxorubicin&#44; vincristine&#44; and prednisolone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "C&#46;S&#46; Tan"
                            1 => "I&#46;J&#46; Koralnik"
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                      ]
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                    0 => array:2 [
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                      "Revista" => array:6 [
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                      "autores" => array:1 [
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              "identificador" => "bib0020"
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                            0 => "J&#46;F&#46; Viallard"
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                          "etal" => false
                          "autores" => array:5 [
                            0 => "D&#46; Pavlovic"
                            1 => "A&#46;C&#46; Patera"
                            2 => "F&#46; Nyberg"
                            3 => "M&#46; Gerber"
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                    0 => array:2 [
                      "doi" => "10.1177/1756285615602832"
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                        "fecha" => "2015"
                        "volumen" => "8"
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Article information
ISSN: 21735808
Original language: English
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