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CD5-Positive Primary Intraocular B-Cell Lymphoma Arising during Methotrexate and Tumor Necrosis Factor Inhibitor Treatment.

Nagata K, Inaba T, Kinoshita S - Case Rep Ophthalmol (2015)

Bottom Line: Optic nerve invasion was observed on magnetic resonance imaging.Primary intraocular lymphoma (PIOL) may develop in patients receiving MTX and TNF inhibitor treatment.EBV infection may play an important role in the pathogenesis of PIOL arising during immunosuppressive therapy.

View Article: PubMed Central - PubMed

Affiliation: Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan.

ABSTRACT

Purpose: To report a case of CD5+ primary intraocular B-cell lymphoma arising during methotrexate (MTX) and tumor necrosis factor (TNF) inhibitor treatment in a young patient with rheumatoid arthritis and uveitis.

Case presentation: A 39-year-old woman treated with MTX and a TNF inhibitor for rheumatoid arthritis and uveitis had steroid-resistant vitreous opacity. A vitreous sample was obtained by using diagnostic vitrectomy and was categorized as class V based on cytologic examination. Flow cytometric analysis of the vitreous sample revealed that abnormal cells were CD5+, CD10-, CD19+, CD20+ and immunoglobulin light-chain kappa+, suggesting the diagnosis of CD5+ primary intraocular B-cell lymphoma. Polymerase chain reaction (PCR) detected immunoglobulin heavy-chain gene rearrangement. Epstein-Barr virus (EBV) DNA was detected in the vitreous sample by using PCR, and immunohistochemistry revealed EBV latent membrane protein-1 expression in the abnormal cells infiltrating the vitreous. Optic nerve invasion was observed on magnetic resonance imaging.

Conclusion: Primary intraocular lymphoma (PIOL) may develop in patients receiving MTX and TNF inhibitor treatment. EBV infection may play an important role in the pathogenesis of PIOL arising during immunosuppressive therapy.

No MeSH data available.


Related in: MedlinePlus

Fundus findings before and during vitrectomy. a A color fundus photograph of the right eye showing severe vitreous opacity. b Axial gadolinium-enhanced T1-weighted magnetic resonance imaging of the brain shows enhancement of the right optic nerve.
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Figure 1: Fundus findings before and during vitrectomy. a A color fundus photograph of the right eye showing severe vitreous opacity. b Axial gadolinium-enhanced T1-weighted magnetic resonance imaging of the brain shows enhancement of the right optic nerve.

Mentions: A 39-year-old female patient with RA had been undergoing treatment with MTX and a TNF inhibitor (etanercept, infliximab, or golimumab) for 10 years. She had uveitis in the right eye since 2010, for which she was treated by her own ophthalmologist. Uveitis episodes with hypopyon, posterior synechia, and severe vitreous opacity were observed occasionally, and were responsive to topical corticosteroid and subtenon triamcinolone acetonide injection. Genital ulcer and skin eruptions had appeared once. She had HLA-B51 and HLA-B27. Therefore, the etiology of uveitis was thought to be Behcet's disease, HLA-B27-associated uveitis, or RA-associated uveitis. In August 2013, she presented to a former ophthalmologist with decreased vision. Ocular examination revealed a visual acuity of 0.7 in the right eye. Slit-lamp examination revealed keratic precipitate and anterior chamber cells, and fundus examination revealed vitreous opacity in the right eye. She received subtenon triamcinolone acetonide injection. However, vitreous opacity worsened, and her visual acuity decreased. Because of steroid-resistant vitreous opacity, she was referred to the Kyoto Prefectural University of Medicine Hospital in January 2014. Ocular examination revealed a visual acuity of 0.01 in the right eye. Intraocular pressure in the right eye was 14 mm Hg. Slit-lamp examination revealed neither keratic precipitate nor cells in the anterior chamber. Fundus examination revealed severe vitreous opacity in her right eye (fig. 1a). Because of severe vitreous opacity, the retinal vessels and retina could not be observed in detail. There was no abnormal finding in her left eye. She received pars plana vitrectomy, and a vitreous sample was collected during surgery. Cytologic examination of the vitreous specimen showed that more than half of the cellular component consisted of abnormal lymphoid cells (fig. 2a). They were slightly to moderately large in size with irregular-shaped nuclei, occasionally showing prominent nucleoli, but neither vacuoles nor granules were definitely found in their cytoplasm. Flow cytometric analysis revealed these abnormal cells to be positive for CD5, CD19, CD20, and immunoglobulin light-chain kappa but negative for CD10 (fig. 2b). Polymerase chain reaction (PCR) detected immunoglobulin heavy-chain gene rearrangement. Interleukin (IL)-10 and IL-6 levels in the vitreous sample were 32 and 288 pg/ml, respectively. Quantitative PCR for Epstein-Barr virus (EBV) revealed 1.09 × 107 copies/ml in the vitreous samples and abnormal cells infiltrating the vitreous expressed EBV latent membrane protein (LMP)-1 in the vitreous cell block (fig. 2c). These findings were consistent with a diagnosis of immunosuppression-related intraocular large B-cell lymphoma. Magnetic resonance imaging revealed optic nerve invasion (fig. 1b). No other lymphoma lesion was detected using positron emission tomography. The patient received intravitreal MTX injection and systemic chemotherapy.


CD5-Positive Primary Intraocular B-Cell Lymphoma Arising during Methotrexate and Tumor Necrosis Factor Inhibitor Treatment.

Nagata K, Inaba T, Kinoshita S - Case Rep Ophthalmol (2015)

Fundus findings before and during vitrectomy. a A color fundus photograph of the right eye showing severe vitreous opacity. b Axial gadolinium-enhanced T1-weighted magnetic resonance imaging of the brain shows enhancement of the right optic nerve.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
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getmorefigures.php?uid=PMC4608665&req=5

Figure 1: Fundus findings before and during vitrectomy. a A color fundus photograph of the right eye showing severe vitreous opacity. b Axial gadolinium-enhanced T1-weighted magnetic resonance imaging of the brain shows enhancement of the right optic nerve.
Mentions: A 39-year-old female patient with RA had been undergoing treatment with MTX and a TNF inhibitor (etanercept, infliximab, or golimumab) for 10 years. She had uveitis in the right eye since 2010, for which she was treated by her own ophthalmologist. Uveitis episodes with hypopyon, posterior synechia, and severe vitreous opacity were observed occasionally, and were responsive to topical corticosteroid and subtenon triamcinolone acetonide injection. Genital ulcer and skin eruptions had appeared once. She had HLA-B51 and HLA-B27. Therefore, the etiology of uveitis was thought to be Behcet's disease, HLA-B27-associated uveitis, or RA-associated uveitis. In August 2013, she presented to a former ophthalmologist with decreased vision. Ocular examination revealed a visual acuity of 0.7 in the right eye. Slit-lamp examination revealed keratic precipitate and anterior chamber cells, and fundus examination revealed vitreous opacity in the right eye. She received subtenon triamcinolone acetonide injection. However, vitreous opacity worsened, and her visual acuity decreased. Because of steroid-resistant vitreous opacity, she was referred to the Kyoto Prefectural University of Medicine Hospital in January 2014. Ocular examination revealed a visual acuity of 0.01 in the right eye. Intraocular pressure in the right eye was 14 mm Hg. Slit-lamp examination revealed neither keratic precipitate nor cells in the anterior chamber. Fundus examination revealed severe vitreous opacity in her right eye (fig. 1a). Because of severe vitreous opacity, the retinal vessels and retina could not be observed in detail. There was no abnormal finding in her left eye. She received pars plana vitrectomy, and a vitreous sample was collected during surgery. Cytologic examination of the vitreous specimen showed that more than half of the cellular component consisted of abnormal lymphoid cells (fig. 2a). They were slightly to moderately large in size with irregular-shaped nuclei, occasionally showing prominent nucleoli, but neither vacuoles nor granules were definitely found in their cytoplasm. Flow cytometric analysis revealed these abnormal cells to be positive for CD5, CD19, CD20, and immunoglobulin light-chain kappa but negative for CD10 (fig. 2b). Polymerase chain reaction (PCR) detected immunoglobulin heavy-chain gene rearrangement. Interleukin (IL)-10 and IL-6 levels in the vitreous sample were 32 and 288 pg/ml, respectively. Quantitative PCR for Epstein-Barr virus (EBV) revealed 1.09 × 107 copies/ml in the vitreous samples and abnormal cells infiltrating the vitreous expressed EBV latent membrane protein (LMP)-1 in the vitreous cell block (fig. 2c). These findings were consistent with a diagnosis of immunosuppression-related intraocular large B-cell lymphoma. Magnetic resonance imaging revealed optic nerve invasion (fig. 1b). No other lymphoma lesion was detected using positron emission tomography. The patient received intravitreal MTX injection and systemic chemotherapy.

Bottom Line: Optic nerve invasion was observed on magnetic resonance imaging.Primary intraocular lymphoma (PIOL) may develop in patients receiving MTX and TNF inhibitor treatment.EBV infection may play an important role in the pathogenesis of PIOL arising during immunosuppressive therapy.

View Article: PubMed Central - PubMed

Affiliation: Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan.

ABSTRACT

Purpose: To report a case of CD5+ primary intraocular B-cell lymphoma arising during methotrexate (MTX) and tumor necrosis factor (TNF) inhibitor treatment in a young patient with rheumatoid arthritis and uveitis.

Case presentation: A 39-year-old woman treated with MTX and a TNF inhibitor for rheumatoid arthritis and uveitis had steroid-resistant vitreous opacity. A vitreous sample was obtained by using diagnostic vitrectomy and was categorized as class V based on cytologic examination. Flow cytometric analysis of the vitreous sample revealed that abnormal cells were CD5+, CD10-, CD19+, CD20+ and immunoglobulin light-chain kappa+, suggesting the diagnosis of CD5+ primary intraocular B-cell lymphoma. Polymerase chain reaction (PCR) detected immunoglobulin heavy-chain gene rearrangement. Epstein-Barr virus (EBV) DNA was detected in the vitreous sample by using PCR, and immunohistochemistry revealed EBV latent membrane protein-1 expression in the abnormal cells infiltrating the vitreous. Optic nerve invasion was observed on magnetic resonance imaging.

Conclusion: Primary intraocular lymphoma (PIOL) may develop in patients receiving MTX and TNF inhibitor treatment. EBV infection may play an important role in the pathogenesis of PIOL arising during immunosuppressive therapy.

No MeSH data available.


Related in: MedlinePlus