Primary CNS lymphoma, HIV + AMS

Thanks to Jack Shuler for presenting a great case! And thanks to Joe Shatzel and Sven Olson for coming and sharing some pearls. This is a case of a young MSM male who has a history of HIV presenting with altered mental status and gait instability found to have a new diagnosis of primary CNS lymphoma (DLBCL).

 N Engl J Med 2014; 371:447-456

N Engl J Med 2014; 371:447-456

Main Points

  1. ) The gait exam can be extremely useful in the neurological exam. There are several classic gaits to be aware of. See the Stanford 25 page for a great video of Abraham Verghese demonstrating them.

  2. ) The CD4 nadir is useful for prognostication but also a guess at what the CD4 becomes when a patient stops ART.

  3. ) The treatment for CNS DLBCL includes a methotrexate based-regimen since R-CHOP has difficulty penetrating the BBB. It is important to monitor for drug-drug interactions with ART.

Want to learn more?-

HIV associated neurocognitive disorder

This consists of a wide spectrum of conditions from asymptomatic changes to dementia. HIV neurocognitive disorder should be considered as the diagnosis when infections (opportunistic + atypical presentation of common), mass effect, vasculidities, IRIS, and malignancies have been ruled out. Here is a great JAMA article about this.

HIV defining malignancies

Here is a great JCO review article on AIDS defining malignancies which classically includes Kaposi’s, NHL, HL and cervical cancer. However HIV also increases the risk of many cancers (eg synergy with HCV leading to HCC). The thought is HIV invades the immune system and establishes latency in multiple organs which predisposes individuals to developing cancers.