A 74-year-old woman was referred to our hospital due to steroid-resistant bilateral uveitis persisting for more than 3 years. The patient had no significant medical history and was seronegative for human immunodeficiency virus (HIV). She had undergone vitrectomy of the right eye that was negative for malignant cells. DNA extracted from the vitreous fluid was negative for immunoglobulin heavy locus (IgH) rearrangements, as determined by polymerase chain reaction (PCR). The levels of interleukin (IL)-10 and IL-6 in the vitreous fluid were 51 pg/mL and 712 pg/mL, respectively. The IL-10/IL-6 ratio was <1.0, which was atypical for a diagnosis of vitreoretinal lymphoma.
On admission to our hospital, the visual acuity of the right eye was almost lost. The fundoscopic image of the left eye obtained on admission is shown in Fig. 1A. An analysis after diagnostic pars plana vitrectomy of the left eye did not detect any malignant cells. DNA extracted from the vitreous fluid was negative for both IgH and T-cell receptor (TCR) rearrangements, as determined by PCR. These findings did not support that the uveitis occurred because of lymphoma. The concentrations of IL-10 and IL-6 were 53 pg/mL and 430 pg/mL, respectively. The ratio of IL10/IL6 of the left vitreous fluid was <1.0, similar to that in the right vitreous fluid, as indicated above. Screening for infectious diseases by quantitative multiplex PCR of the vitreous fluid DNA was performed for the detection of herpes simplex virus types 1 and 2, varicella-zoster virus, EBV, cytomegalovirus, human herpes viruses 6-8, Toxoplasma gondii, bacterial 16S, fungal 18S/28S, and mycobacterium tuberculosis, according to our previously described method. The PCR results were negative for all tested pathogens, except for EBV DNA, which was detected at 5.47x105 copies/mL. Her anti-EBV antibody titers were 1:80 for anti-viral capsid antigen (VCA)-IgG and 1:10 for anti-EB nuclear antigen (EBNA). Anti-VCA-IgM antibody was undetectable. An otolaryngological examination was negative for nasal lymphoma. EBV DNA was negative in the peripheral blood, and a systemic examination including the nasal cavity with 2-Deoxy-2-[18F] fluoro-D-glucose positron emission tomography (PET)/CT (FDG-PET/CT) did not detect any lesions. We could not determine the diagnosis of lymphoma and injected subtenon triamcinolone acetonide into the left ocular lesion. However, this failed to improve her symptoms. In order to preserve her visual acuity, 400 mug methotrexate (MTX) weekly for 6 weeks, based on the treatment protocol for vitreoretinal lymphoma, was administered into the left vitreous following the approval of the Institutional Review Board. The treatment resulted in a dramatic improvement, and the patient achieved complete response (CR; Fig. 1B).
However, two years after the MTX treatment and four years after the onset of symptoms, the uveitis of the right eye rapidly progressed. Because of severe ocular pain and loss of visual acuity that was considered irreversible, the patient underwent enucleation of the right eye. A pathological examination revealed massive necrosis and the absence of lymphoma cells (data not sown). While the symptoms were resolved, the patient subsequently underwent both an ophthalmological examination and magnetic resonance imaging (MRI) for the head and neck.
Two years and two months after enucleation, multiple hyperintense lesions were detected on T2-weighted fluid-attenuated inversion recovery (FLAIR) imaging MRI in the right occipital and parietal lobes and the precentral gyrus, and a left visual field defect was detected on an ophthalmological evaluation (Fig. 2). The tumor was suspected to be high-grade glioma and was removed by craniotomy; however, the pathological diagnosis was ENKL. As shown in Fig. 3, the infiltrating cells in the pathological specimen were positive for CD3, CD56, and TIA1. The tumor cells were positive for EBV. EBV DNA was negative in the peripheral blood. The DNA extracted from the right vitreous and brain lesions was amplified for the sequence analysis of LMP1, an EBV gene, to determine homology. The forward and reverse primers were 5'-GCT GTC GAC GCC ACC ATG GAA CAC GAC CTT GAG AGG-3' and 5'-GCT GGA TCC TTA GTC ATA GTA GCT TAG CTG AAC-3', respectively, and their nucleotide positions in EBV variant B95.8 (Genbank No. V01555) were 169474-169454 and 168160-168183, respectively. This lesion had sequence variations in each EBV. The conditions for the PCR reactions were as follows: 94 C for 2 minutes, 98 C for 10 seconds, 62 C for 30 seconds, and 68 C for 90 seconds for 40 cycles. The LMP1 sequence was confirmed after TA cloning with PCR products. As shown in Fig. 4, the repeat regions of LMP1 detected in the vitreous and brain lesion were identical. Based on the clinical, pathological, and genetic findings, the CNS lesion was confirmed to be closely associated with and most likely originated from the uveitis. The patient was treated with intravenous high-dose MTX at 3.5 g/m2, administered 3 times, and has since maintained CR for 24 months without recurrence.