Multiple brain biopsies for EBV-positive diffuse large B-cell lymphoma with extensive necrosis in a post-transplant patient: A case report.

A 62-year-old woman presented to the emergency department with left hemiparesis grade III and dysarthria lasting for three weeks. She had undergone kidney transplantation in 2007 and had hypothyroidism, treated with immunosuppressants. Brain magnetic resonance imaging revealed a 3.8-cm peripheral enhancing lesion with extensive central necrosis in association with marked perilesional edema. The irregular ring-like enhancing lesion showed diffusion restriction and mildly increased regional cerebral blood volume in the rim portion of the mass. ¹¹C-methionine positron emission tomography (PET) revealed slightly increased uptake in the peripheral lesion. The provisional diagnosis was a high-grade glioma. Stereotactic multiple biopsies were performed for the central necrotic area and peripheral enhancing lesion. The non-enhancing areas showed only necrotic material, without viable cells, and the enhancing portion showed viable cells for an accurate diagnosis in frozen biopsy. The pathologic diagnosis was Epstein-Barr virus (EBV)-positive diffuse large B-cell lymphoma (DLBCL) with extensive necrosis. PET of the chest, abdomen, pelvis, and neck soft tissues ruled out systemic diseases. She underwent whole brain radiotherapy at a dose of 30.6 Gy. Eight months later, her neurological symptoms had improved, with a stable brain lesion and improved perilesional edema. We report a case of an immunocompromised patient diagnosed with EBV-positive DLBCL, which showed atypical radiologic findings including extensive necrosis, and multiple biopsies were required for the final diagnosis.