A 40-year-old male is brought to the emergency room with confusion, lethargy, and decreased strength in his left arm. He is HIV-positive. He was diagnosed several months ago, but he refused any kind of therapy. His most recent CD4 cell count was 40/μL. A lumbar puncture is performed, but cerebral spinal fluid findings and cytology are inconclusive. A CT scan reveals a well-defined small focal lesion in the right cerebral hemisphere. Biopsy findings are consistent with primary CNS lymphoma. You decide to proceed with radiation therapy and corticosteroids, and to institute HAART. Which of the following is the best prognostic sign for this patient's condition?

Question

A 40-year-old male is brought to the emergency room with confusion, lethargy, and decreased strength in his left arm.  He is HIV-positive.  He was diagnosed several months ago, but he refused any kind of therapy.  His most recent CD4 cell count was 40/μL.  A lumbar puncture is performed, but cerebral spinal fluid findings and cytology are inconclusive.  A CT scan reveals a well-defined small focal lesion in the right cerebral hemisphere.  Biopsy findings are consistent with primary CNS lymphoma.  You decide to proceed with radiation therapy and corticosteroids, and to institute HAART.  Which of the following is the best prognostic sign for this patient's condition?

Quizplus · Accepted Answer

Explanation: Primary CNS lymphoma (PCNSL) is a common malignancy in patients with advanced HIV infections, and is strongly related to the Epstein-Barr virus (EBV). It is usually associated with a significant degree of immunosuppression. Most patients with PCNSL have a persistently depressed CD4 count (< 50/μL). Institution of HAART therapy is associated with an improved prognosis, especially in patients who demonstrate an improvement in the immune status (e.g. increase in CD4 count and decrease in viral load), because the degree of immunosuppression seems to be the major determinant of these patients' survival. (Choice E)Radiation therapy, combined with corticosteroids, induces a rapid response in 20-50% of patients; however, this does not seem to significantly prolong the overall survival. (Choice B) The measurement of EBV DNA levels in the CSF can be used to monitor the therapy; however, its prognostic role is not clear. (Choice C) An increase in the level of soluble B-cell marker in the CSF has been suggested as a diagnostic tool for PCNSL. (Choice A) PCNSL is almost always confined to the CNS. Staging is of value only in a minority of patients. Educational objective: The degree of immunosuppression seems to be the major determinant of the survival in patients with PCNSL.

A 40-Year-Old Male Is Brought to the Emergency Room with Confusion, Lethargy, and Decreased