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Scleroză multiplă sau limfom primar al sistemului nervos central?

1
Dr. Ștefănescu Vlad-Claudiu1 ; Dr. Ştefănescu Daniela2 ; Dr. Elena-Adriana Solomon1 ; Dr. Adriana
Octaviana Dulămea1,3.
1
- Institutul Clinic Fundeni
2
- Spitalul Clinic Colentina
3
– Universitatea de Medicină şi Farmacie „Dr. Carol Davila”

Introducere: Scleroza multiplă şi limfomul cerebral primar sunt două afecțiuni diferite, care au ca
punct comun afectarea sistemului imun. În timp ce în scleroza multiplă se regăsesc modificări de tip
inflamator şi neurodegenerativ, în limfomul cerebral primar este descrisă proliferarea aberantă a
limfocitelor.

Prezentarea cazului: Un tânăr de 26 de ani, a fost inițial suspectat de o boala de tip vasculită sau
boala demielinizantă a sistemului nervos central. Examinările IRM cerebral inițiale au evidentiat
hiperintensitati de substanta alba, benzile oligoclonale in LCR au fost negative şi potențialele evocate
vizuale normale. Pe criterii clinice si imagistice pacientul a fost diagnosticat cu scleroza multipla
recurent remisiva si a inceput tratament imunomodulator timp de o luna, dar starea sa clinica s-a
degradat abrupt şi a prezentat crize epileptice. La repetarea examinării IRM s-au decelat leziuni izo ±
hiper T2,FLAIR, cu priza neomogena de contrast. S-a efectuat o puncție-biopsie cerebrala dintr-o
leziune superficiala dar care nu a precizat cu exactitate diagnosticul si pacientul este in final
îndrumat în clinica noastră, unde după repetarea testelor de laborator şi repetarea examinării IRM
se ridică suspiciunea de limfom cerebral. În urma efectuării unei noi biopsii cerebrale pacientului i se
confirmă diagnosticul de limfom primar al SNC (LPSNC) cu celule mari B, CD20+. Efectuează prima
cură de Metotrexat şi radioterapie cu ameliorarea stării generale.

Discuții: Leziunile cerebrale evidentiate de examinările IRM inițiale ar putea fi expresia unui limfom
intravascular care a fost agravat de tratamentul imunomodulator. Concomitenta bolii demielinizante
cu LPSNC constituie o alta posibilitate care trebuie luata in considerare.

Multiple sclerosis or primary central nervous system lymphoma?


1
Dr. Ștefănescu Vlad-Claudiu1 ; Dr. Ştefănescu Daniela2 ; Dr. Elena-Adriana Solomon1 ; Dr. Adriana
Octaviana Dulămea1,3
1
– Fundeni Clinical Institute
2
– Colentina Clinical Hospital.
3
- „Dr. Carol Davila” University of Medicine and Pharmacy

Introduction: Multiple sclerosis and primary cerebral lymphoma are two separate diseases who
share a common target: the immune system. While in multiple sclerosis there may be inflammatory
or neurodegenerative processes, in primary cerebral lymphoma, aberrant proliferation of the B
lymphocytes is the main characteristic described.

Case presentation: A 26-year-old male patient was initially suspected of cerebral vasculitis or a form
of demyelinating disease of the nervous system. Initial brain MRI revealed unspecific white matter
hyperintensities, oligoclonal band in CSF were negative and evoked potentials were negative. Based
on clinical signs and brain MRI findings he was first diagnosed with relapsing remitting multiple
sclerosis and administered immunomodulatory treatment for one month but the symptoms
progressed and he had several seizures. He had another MRI exam which showed several lesions iso
± hyper T2 w, with inhomogenous contrast enhancement. A brain biopsy was performed but the
lesion was superficial and the result was inconclusive. The patient was referred into our clinic.
Further laboratory tests, and another cerebral MRI raised the suspicion of primary cerebral
lymphoma so another brain biopsy was performed, this time from the center of three different
lesions. The result of the biopsy was primary cerebral lymphoma with large CD20+ B-lmphocytes.
The patient received the first dose of Metothrexate and started radiotherapy and the symptoms
slowly regressed.

Discussion: Brain MRI lesions revealed by the initial examinations could be an expression of an
intravascular lymphoma that was aggravated by the immunomodulatory treatment. Concurrent
demyelinating disease with LPSNC is another possibility that should be considered.