Intraocular Lymphoma after Cardiac Transplantation: Magnetic Resonance Imaging Findings
A 64-year-old diabetic man underwent cardiac transplantation for ischemic cardiomyopathy in September 2006. He was maintained on immunosuppressive therapy with tacrolimus, mycophenolate, and prednisolone. In April 2007, he visited a local clinic with a complaint of decreased vision in the right eye that had persisted for 3 months and was diagnosed with diabetic retinopathy complicated by cataract and vitreous hemorrhage. He underwent phacoemulsification with posterior chamber lens implantation, pars plana vitrectomy, membrane peeling, endolaser, and intravitreal injection of Avastin (Bevacizumab, Genentech/Roche, San Francisco, CA, USA). Despite the operation, the visual acuity continued to rapidly decline and with a diagnosis of endophthalmitis, the patient was referred to our ophthalmologic department in June 2007. On initial examination, the patient was afebrile and denied weight loss, gastrointestinal trouble, headache, or sore throat. The visual acuity was 20/400 oculus dexter and 20/30 oculus sinister. Slit lamp examination showed 4+ cells in the right anterior chamber. A thick, turbid material was drawn by vitreous tapping, but not specific microorganisms were isolated on culturing this material. Intravitreal injection and topical application of antibiotics did not improve the patient's clinical symptoms. In August 2007, the patient underwent vitrectomy, endolaser, and removal of the intraocular lens and he received intravitreal injection of antibiotics but showed no clinical improvement. In November 2007, the visual acuity of the right eye declined to hand movement, and ophthalmologic examination revealed an intraocular mass at the iridocorneal angle and anterior chamber of the right eye. Cytologic preparations of the anterior chamber aspirate revealed a few atypical lymphoid cells and many apoptotic cells, suggestive of PTLD.\nMagnetic resonance (MR) imaging was performed to further characterize the lesion and demonstrated a smooth, undulating soft-tissue lesion in the iris and the anterior chamber in the right eye. Compared with the vitreous humor, the lesion was hyperintense on T1- () and hypointense on T2-weighted images (), and it was well enhanced after the administration of contrast material (). The transplantation team and the ophthalmologist made a joint decision to perform enucleation, because the ocular infection was intractable to conventional therapy and the recovery of visual acuity was deemed unlikely. Routine histopathological analysis and immunohistochemical staining of the ocular mass showed an extensive mononuclear cell infiltrate with large cells and a vesicular chromatic pattern, consistent with diffuse large B-cell lymphoma (). In situ tissue hybridization demonstrated a substantial fraction of latent Epstein-Barr virus (EBV). In October 2010, the patient died of heart and renal failure complicated by sepsis from pneumonia and cholecystitis.