Concurrent EBV positive CNS diffuse large B-cell lymphoma and peripheral T-cell lymphoma, NOS

Introduction: A 19-year-old woman with EBV mononucleosis presented for acute respiratory failure and sepsis. She represented three months later with headaches, blurred vision, and nausea with imaging showing leptomeningeal and multiple cranial nerve enhancement and multifocal hypermetabolic pulmonary nodules. Several months of clinical improvement were followed by exacerbation of pulmonary symptoms. A kidney biopsy showed an abnormal EBVnegative T-cell population without diagnostic immunophenotypic abnormalities, consistent with a peripheral T-cell lymphoma, NOS. Two cycles of CHOEP and several cycles of GDP were given for progression with interruption by a SARS-CoV-2 infection and a left parietal infarct. An Ommaya reservoir was placed and rituximab given. On follow-up, interval increased enhancement was noted along the genu of the corpus callosum and anterior to the right lateral ventricle with stable disease present in the anterior frontal lobes. Material and methods: A left frontal lobe biopsy was routinely fixed in 10% formalin and embedded in paraffin blocks. H&E staining, immunohistochemistry (CD3, CD20, MIB1) and EBV ISH were performed. Results: Histological sections showed a discohesive population of medium to large atypical lymphoid cells with areas of necrosis. These cells stained positive for CD20 and EBV by ISH with a MIB1 proliferation index of > 90%, consistent with diffuse large B-cell lymphoma. Unfortunately, the patient developed a significant postoperative hematoma with midline shift and passed away. Conclusion: Concurrent lymphomas are rare and represent less than 5% of all lymphomas. A state of immunosuppression associated with some T-cell lymphomas leads to a prominent EBV associated B-cell proliferation.