1302 - The Fog Within: Encephalopathy as a Prelude to Central Nervous System (CNS) Lymphoma, Epstein Barr Virus (EBV), and Fungal Meningitis

Thursday, February 19, 2026

5:00 PM - 6:30 PM AST

Presenting Author(s)

LE

Lauren K. Etzkorn, BS

Medical Student
Western Michigan University Homer Stryker MD School of Medicine - Kalamazoo, MI
Lisle, Illinois, United States

Co-Author(s)

ER

Emily Rothermel, MD

Resident Physician
Carolinas Rehabilitation
Mount Holly, North Carolina, United States
SD

Sima A. Desai, MD

Brain Injury Medicine Fellowship Program Director
Carolinas Rehabilitation
Charlotte, North Carolina, United States

Submitter(s)

LE

Lauren Etzkorn, BS

Western Michigan University Homer Stryker MD School of Medicine - Kalamazoo, MI
Kalamazoo, Michigan, United States

Case Diagnosis: Acute encephalopathy with primary CNS lymphoma and concomitant EBV and fungal meningitis

Case Description: 62-year-old male with a history of kidney transplant on chronic immunosuppression, candidal esophagitis, varicella zoster virus, and cytomegalovirus presented to the hospital with acute, generalized weakness and confusion. Brain MRI revealed multiple basal ganglia lesions concerning for high-grade lymphoma versus atypical infection. PET scan showed hypermetabolic brain lesions suspicious for malignancy. CSF studies showed lymphocytic pleocytosis, low glucose, high protein, markedly elevated EBV DNA, and positive Fungitell. He was treated empirically for bacterial and fungal meningitis. His hospital course was complicated by obstructive hydrocephalus. During acute rehabilitation, he demonstrated downward gaze palsy, diplopia, and impaired oculomotor control. Symptoms were addressed with occlusion glasses, compensatory visual strategies, and oculomotor exercises. Amantadine initiation improved cognitive deficits and fatigue. Although he required moderate-assistance for vision strategies at discharge, he progressed from maximum-assistance to supervision for activities of daily living. Post-rehabilitation brain biopsy confirmed primary CNS lymphoma and MRI showed improvement in midbrain lesions.

Discussions: Primary CNS lymphoma is a rare, aggressive extranodal non-Hodgkin lymphoma. EBV-positive variants are more common in immunosuppressed patients. Diagnostic challenges arise when clinical and radiographic features overlap with infectious etiologies, particularly in transplant recipients on immunosuppressants. Concurrent CNS infections further complicate management. This case highlights the unique neurorehabilitation needs of patients with combined oncologic-related, infectious-related, and neurological impairments, including vision and cognitive deficits. Early integration of neuro-ophthalmologic strategies and pharmacologic neurostimulation can enhance functional recovery.

Conclusions: This case illustrates the diagnostic complexity of CNS lesions in immunosuppressed patients, especially in the setting of concurrent malignant and infectious processes. It also emphasizes the importance of early, multidisciplinary rehabilitation to optimize outcomes.