Nonspecific viral-like ocular symptoms as the initial presentation of aggressive primary CNS diffuse large B-cell lymphoma
Keywords:
Primary Central Nervous System Lymphoma, Diffuse Large B-Cell Lymphoma, Vitreoretinal LymphomaAbstract
Primary central nervous system lymphoma (PCNSL) is a rare and aggressive extranodal diffuse large B-cell lymphoma (DLBCL) that may involve the spinal cord, brain, leptomeninges, or eyes. Ocular manifestations, particularly primary vitreoretinal lymphoma (PVRL), can precede central nervous system involvement, making early diagnosis challenging. At first glance, the ocular symptoms may resemble those of a nonspecific viral illness and may temporarily improve with corticosteroids; however, the same underlying disease can later manifest as a diffusely infiltrative malignancy involving multiple regions of the brain.
We report the case of a 52-year-old male who presented in 2020 with progressive visual decline in the left eye. Despite extensive ophthalmologic evaluation, including vitreous sampling and cytology, no definitive evidence of lymphoma was identified, and the condition was initially managed as a viral infection treated with corticosteroids. Over time, the patient developed progressive neurological involvement, and two years later, in 2022, neuroimaging revealed multifocal intracranial lesions involving the cerebral peduncle, corpus callosum, and supratentorial structures. Due to this, a stereotactic brain biopsy was done, which confirmed diffuse large B-cell lymphoma consistent with PCNSL. The patient was treated with high-dose chemotherapy and autologous stem cell transplantation (ASCT), achieving complete remission on imaging. In late 2025, he developed visual deterioration due to an occipital relapse and began salvage R-ICE chemotherapy in February 2026.
This case highlights how ocular-onset PCNSL may masquerade as an inflammatory or viral eye disease, delaying diagnosis. Persistent, treatment-refractory uveitis-like presentations should raise suspicion for vitreoretinal lymphoma, and long-term surveillance is essential due to the risk of late relapse.
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