case_images: PMC11310032_01
case_images: (A) MRI (T2 sequence) of the spinal cord in the sagittal plane at the onset of neurological symptoms (B) and the progressive spinal cord atrophy after 2 years, directly after the initiation of obinutuzumab. The initial CSF cytology including (C) Pappenheim staining, magnification 1:200 and (D) CD3 staining of the lymphocytes (magnification 1:200) showed a lymphocytic pleocytosis without evidence of neoplastic infiltration. (E) Longitudinal changes in HEV RNA levels following the administration of ibrutinib, acalabrutinib and obinutuzumab (the black arrows represent the start and the black bars the duration of application). The black dots represent HEV PCR measurement timepoints in serum, the blue dots show HEV RNA levels in CSF. The period of application of ribavirin is illustrated with an orange bar. cd, cluster of differentiation; CSF, cerebrospinal fluid; HEV, hepatitis E virus; MRI, magnetic resonance imaging; PCR, polymerase chain reaction; RNA, ribonucleic acid.
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case_images: Examination of cerebrospinal fluid (CSF) showed elevated protein (960 mg/L), cell count (23 cells/microL) and lactate (2.8 mmol/L) without evidence of cancer cells ( Figures 1C, D ). Magnetic resonance imaging (MRI) of the brain and spine showed slight cervical myelopathy of the posterior funiculus of the cervical region (C2-C5;  Figure 1A ). Ribavirin therapy was initiated (800 mg/d;  Figure 1E ). HEV infection, the patient received obinutuzumab for CLL treatment ( Figure 1E ), a humanized anti-CD20 antibody, at a dose of 1000 mg/d. He subsequently developed bowel and urinary retention. MRI of the spine revealed increasing atrophy of the thoracic spinal cord ( Figure 1B ).
case_images: The figure displays the suggested treatment algorithm for the interdisciplinary management of immunocompromised cancer patients with neurological symptoms and an atypical constellation considering the critical aspects of HEV infection. MRI, magnetic resonance imaging; CSF, cerebrospinal fluid; IgG, Immunoglobulin G; CNS, central nervous system; PNS, peripheral nervous system; CIPN, chemotherapy-induced polyneuropathy; HEV, hepatitis E virus; PNS, peripheral nervous system; RNA, ribonucleic acid.
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case_images: PMC11310032_01_fimmu-15-1445944-g002.jpg
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case_images: To facilitate decision making in immunocompromised cancer patients, we developed a comprehensive cross-sectional diagnostic pathway that incorporates HEV screening ( Figure 2 ).