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Progressive multifocal leukencephalopathy and cerebral toxoplasmosis in a patient with CLL

A 63-year-old man with a 10 year history of Chronic Lymphocytic Leukemia (CLL) presented with apraxia, forgetfulness, and cognitive impairment. He had been treated with single agent fludarabine at diagnosis and combination therapy with fludarabine, cyclophosphamide, and rituximab 8 months previously. MRI showed high signal in the white matter of right frontal, left frontal, and parietal areas. (see Image 1) Cerebrospinal fluid (CSF) analysis was normal with no organisms seen. Brain biopsy showed white matter replacement with oligodendroglial intranuclear inclusions and adjacent ruptured toxoplasmosis cysts. (see Image 2) Immunohistochemistry was positive for JC virus and PCR of CSF confirmed the presence of the virus as well as toxoplasma. He developed progressive ataxia, dysphagia, and dementia and died 4 weeks after diagnosis. Progressive multifocal leukoencephalopathy is associated with the use of purine analogues and rituximab in CLL [1,2]. The incidental finding of toxoplasma illustrates how markedly immunosuppressive these regimens are.