Ddx of CSF lymphocytic pleocytosis with normal glucose:

1
Ddx of CSF lymphocytic pleocytosis with normal
glucose

• Viruses enteroviruses, mumps, HSV 1 and 2, HIV,
  Influenza, measles, VZV, CMV
• Spirochetes treponema, borrelia
• Tick-borne rickettsia, ehrlichia
• Vasculitis Bechets, migraine
• Drugs NSAIDs, TMP/SMX, azathioprine, OKT3, INH,
  IVIG

2
CSF lymphocytosis with decreased glucose

• Partially treated bacterial meningitis
• Listeria
• M. TB
• Crypto, cocci, histo, candida, blasto
• HSV-1, mumps, LCV
• Sarcoidosis
• Leptomeningeal carcinomatosis

3
Encephalitis

• HSV diagnosed via MRI, EEG, CSF PCR, CSF HSV
  antibody titer
• HHV-6 CSF viral culture, sera
• VZV CSF viral culture, CSF PCR, CSF VZV
  antibody titer
• Enteroviruses CSF culture
• LaCrosse sera, CSF virus-specific IgM
• Measles clinical, brain Bx
• Neurosyphilis VDRL and either the FTA-ABS or the
  MHA-TP on the CSF.
• --positive CSF VDRL establishes the diagnosis
  but a negative test does not exclude the
  diagnosis
• --negative CSF FTA or MHA excludes the
  diagnosis but a positive one does not confirm Dx

4
CNS mass lesions in the immunosuppressed

• Cerebral toxoplasmosis
• Primary CNS lymphoma
• Progressive multifocal leukoencephalopathy
• TB, fungal brain abscess
• Focal viral encephalitis (CMV, HSV, VZV)
• Metastatic systemic lymphoma or Kaposis
• Acute CVA
• Toxo vs. tumor send EBV PCR on the CSF,
  anti-toxoplasma antibody on CSF and serum brain
  biopsy definitive Dx

5
Primary CNS lymphoma

• CT single or multiple iso/hypodense lesions
  with intense contrast enhancement
• MRI enhancing TI weighted images, hyperintense
  tumor and surrounding edema in T2 weighted image
• Periventricular growth pattern
• Stereotactic brain bx do not give steroids
  prior to bx as these tumors are exquisitely
  sensitive

6
Primary CNS lymphoma

• B cell lineage most often large cell,
  immunoblastic, or burkitt-like
• EBV associated
• --most cells express Epstein-Barr nuclear
  antigen and latent membrane protein
• --these proteins may mimic receptor engagement
  that activates B cells
• --these proteins also inactivate p53 and RB
  tumor suppressor genes

7
Treament and Prognosis

• Symptomatic therapy alone median survival of
  2-3 months
• Steroids 4-5 months
• Radiation 12.2 months
• RT plus CHOD 16.1 months
• RT plus MTX 33 months
• Surgery not indicated diffuse tumor

8
PTLD

• Small bowel, heart, lung more so than liver,
  kidney, bone marrow
• EBV seronegative pts who develop primary EBV in
  the post transplant period are at higher risk
• Spectrum Mono-like syndrome to diffuse
  aggressive lymphoma (can include 1º CNS)
• Treatment chemo/RT, IFN-a, anti-B cell
  monoclonal antibody, EBV specific CTL