case_images: PMC9868130_01
case_images: T2 FLAIR MR images show hyperintense right corticospinal tract (A), corona radiata, frontal and parietal lobes signal (B), corpus callosum dorsal parts (C), cerebral peduncular, and hemisphere white matter (D,F). Contrast-enhanced T1-weighted axial MR image shows no visible contrast enhancement or intraaxial changes (E). Diffusion-weighted axial MR images show slightly restricted diffusion (G). Contrast-enhanced T1-weighted axial MR images show enlargement of cranial nerves bilaterally (n.oculomotorius, and n. trigeminus) (H). The differential of these MR findings included viral encephalitis, demyelinating disease, lymphoma, and leptomeningeal metastases.
case_images: pore-28-1610866-g001.jpg
case_images: PMC9868130_01_pore-28-1610866-g001.jpg
case_images: F1
case_images: Head MRI showed diffuse changes bilaterally (Figure 1).
case_images: Treatment regimens given to the patient and treatment effect on: (A) CNS disease. Evaluated as:EBV copy number in CSF (cerebrospinal fluid), percent of ENKL cells in CNS flow cytometry, percent of recipient chimerism in CSF (after alloSCT). Every measurement point of CSF analysis was also intrathecal prophylaxis with chemotherapeutic agents. (B) Systemic disease. Evaluated as:EBV copy number in blood, percent of recipient chimerism in the blood (after alloSCT). SMILE, Etoposide, Ifosfamide, Methotrexate, Dexamethasone, and Peg-asparaginase; Radiotherapy, nasal and craniospinal irradiation; DHAP, dexamethasone, cytarabine and cisplatin; alloSCT, allogeneic stem cell transplantation; DLI, donor lymphocyte infusion; VST, virus-specific T cells; MRI, head magnetic resonance imaging.
case_images: pore-28-1610866-g002.jpg
case_images: PMC9868130_01_pore-28-1610866-g002.jpg
case_images: F2
case_images: During the treatment period of 1.5 years, the patient received nine treatment lines, including SMILE chemotherapy with following nasal and craniospinal irradiation, alloSCT, and novel agents (Nivolumab, Daratumumab, Thalidomide, Lenalidomide, virus-specific T cells) combined with intrathecal chemotherapy as shown in Figure 2.
case_images: Follow-up MRI scans during different periods of treatment. (A) T2 FLAIR, DWI, contrast-enhanced T1 axial MR images at the level of basal ganglia. (B) T2 FLAIR, DWI, contrast-enhanced T1 axial MR images at the level of frontal horns of the lateral ventricles. 05 April 2019 Primary MRI scan. 12 June 2019 MRI follow-up examination after completion of first-line chemotherapy shows revisal of the hyperintensity lesions in the right parietal lobe, corpus callosum, and corona radiata. 01 August 2019 MRI follow-up examination demonstrates the progression of the lesion in the right parietal lobe. No additional lesions were found. 28 January 2020 MRI follow-up examination demonstrates enlarged enhancing lesion of the dorsal part of the corpus callosum with restricted diffusion. 10 August 2020 MRI follow-up examination demonstrates T2 hyperintense contrast-enhancing masses of the dorsal part of corpus callosum extending to basal ganglia with significantly restricted diffusion, perifocal edema, and compression of the ventricle system.
case_images: pore-28-1610866-g003.jpg
case_images: PMC9868130_01_pore-28-1610866-g003.jpg
case_images: F3
case_images: Changes in MRI images during various treatment lines can be seen in Figure 3.