Central Nervous system Lesion shortly post renal transplantation- Difficult case

This was a -14 years old girl ,ESRD due to renal hypoplasia /dysplasia, received renal transplant from Unrelated donor (30 yrs old)/ no HLA study/D+/R+ for CMV-IgG,EBV IgG) since 2.8.2012.The 1st wk post TX because of rising of creatinin from 1.5 mg/dl to 2.6 mg/dl she treated with MP and ATG with diagnosis of Acute rejection. Two weeks later she she presented with fever (T-38.5 C), vomiting, suicidal thought, aggressive behavior, depression and mood changes .CMV –Ag was positive (viral load 470x10^3 copy)-Treated with: GCSF+ Meropenem + Vancomycin + IVIG+ gancyclovir+ valcyte + Floxetine but after two weeks of treatment gancyclovir stopped for bone marrow suppression and severe leucopenia. Afterward she admitted for another five times for abdominal pain, anorexia, mood changes. Medication was Cell cept (750+500)+ sandimun (75+100)+ Prednisolon (7.5)+COTMX. Four months post transplant she admitted again for Cough + rhinorhea , weight loss (3 kg), nausea, vomiting, anorexia, fever (38 C),staring and seizure (3 episodes) . CSF was nl, cultures were negative , brain MRI and brain CT scan – NL, CNS PCR was positive for EBV and CMV and blood CMV PCR load was 1920. Blood study showed EBV-Ab-VCA-IgG was positive ,IgM negative, and JC-BK virus positive She received IVIG + antibiotics + gancyclovir. Subsequently , she felt miserable , had mood disorder and depressed and sometimes lethargic.The control Brain MRI one month later while she was still hospitalized showed progressive patchy area in hemisphere and basal ganaglia and cerebellum. The 2nd CSF PCR was negative for CMV, EBV, HSV, and Blood PCR was negative for toxoplasmosis DNA and Cryptococcus. AZT stopped and IVIG was given. But The neurologic symptoms and signs were progressive, she had high fever, needed mechanical ventilation, had GI hemorrhage, and had pleural effusion. Lung Ct scan showed nodules,Third MRI of Brain showed the progression of the previous patchy lesions. Consult with hematologist recommended Rituxiamb IV and IT. The patients passed away five days later despite those treatment.Conclusion- The possibility of Brain Lymphoma due to EBV was high. Unfortunately there were no tissue samples and the interpretation according serology and PCRs were problematic. Judies use of immunosuppressive is important to keep the EBV under control