Central nervous system lymphoma associated with mycophenolate mofetil in lupus nephritis

Cancer and multiple sclerosis: 2023 recommendations from the French Multiple Sclerosis Society

BACKGROUND

Epidemiological data reveal that 45% of persons with multiple sclerosis (PwMS) in France are more than 50 years. This population more than 50 is more susceptible to cancer, and this risk may be increased by frequent use of immunosuppressive drugs. Consequently, concerns have arisen about the potential increased risk of cancer in PwMS and how patients should be screened and managed in terms of cancer risk.

OBJECTIVE

To develop evidence-based recommendations to manage the coexistence of cancer and multiple sclerosis (MS).

METHODS

The French Group for Recommendations in MS collected articles from PubMed and university databases covering the period January 1975 through June 2022. The RAND/UCLA method was employed to achieve formal consensus. MS experts comprehensively reviewed the full-text articles and developed the initial recommendations. A group of multidisciplinary health care specialists then validated the final proposal.

RESULTS

Five key questions were addressed, encompassing various topics such as cancer screening before or after initiating a disease-modifying therapy (DMT), appropriate management of MS in the context of cancer, recommended follow-up for cancer in patients receiving a DMT, and the potential reintroduction of a DMT after initial cancer treatment. A strong consensus was reached for all 31 recommendations.

CONCLUSION

These recommendations propose a strategic approach to managing cancer risk in PwMS.

Primary central nervous system lymphoma in a patient with neuropsychiatric systemic lupus erythematosus receiving mycophenolate mofetil: A case report and literature review

A 41-year-old woman with a 14-month history of systemic lupus erythematosus (SLE) presented with headache, aphasia, and agraphia. A laboratory examination revealed mild proteinuria, hypocomplementemia, and elevated anti-double-stranded DNA antibody levels. A cerebrospinal fluid analysis demonstrated elevated protein and interleukin-6 levels. Magnetic resonance imaging (MRI) of the brain identified multiple lesions suggestive of brain edemas and small haemorrhages. She was diagnosed as having neuropsychiatric lupus and lupus nephritis and received remission induction therapy with high-dose corticosteroid and intravenous cyclophosphamide. She achieved a complete remission, and treatment with mycophenolate mofetil (MMF) was initiated 3 months thereafter for remission maintenance. At 13 months after the exacerbation of SLE, she complained of headache and nausea. A gadolinium-enhanced MRI of the brain revealed a low-signal-intensity tumour with marginal ring enhancement of 50 mm in the left frontal lobe. The tumour was excised, and the histological diagnosis was diffuse large B-cell lymphoma with positive Epstein-Barr virus (EBV). MMF was discontinued. Remission induction therapy with rituximab, high-dose methotrexate, procarbazine, and vincristine was administered, and she achieved remission. Previous reports suggest that use of MMF is associated with primary central nervous system (CNS) lymphoma (PCNSL) in patients with lupus nephritis or other autoimmune diseases or in post-transplant patients. Our observation that PCNSL occurred after CNS involvement of SLE suggests that EBV and CNS inflammation arising from SLE might have contributed to the development of PCNSL.

A 64-year-old woman with rapid neurologic decline diagnosed with Toxoplasma encephalitis after presumed metastatic cancer

In an era of fragmented medical care, concurrent clinical features that ultimately lead to a unified diagnosis may not be prioritized appropriately. We present a case of a 64-year-old woman referred to hematology clinic for anemia, with recent memory loss and gait disturbance. Two months later, she developed pneumonia; imaging workup showed a left renal mass. Neurologic function continued to decline precluding definitive nephrectomy. She then presented with new-onset seizure and initial neuro-imaging was reported as unremarkable. One month later, outpatient neurologic workup demonstrated new left-sided weakness which prompted hospitalization and repeat neuro-imaging, which showed a 1.7-cm right frontal lobe mass lesion with surrounding vasogenic edema. The patient ultimately underwent craniotomy with resection of the mass lesion; pathology did not show metastatic renal cell cancer, the provisional clinical diagnosis. Rather, immunostaining revealed a parasite and ultimately led to a diagnosis of Toxoplasma encephalitis, an infection whose clinical presentation had been interpreted by healthcare providers for months to be a result of metastatic cancer.

A Review of Clinical and Imaging Findings in Tumefactive Demyelination

OBJECTIVE. Tumefactive demyelination mimics primary brain neoplasms on imaging, often necessitating brain biopsy. This article reviews the literature for the clinical and radiologic findings of tumefactive demyelination in various disease processes to facilitate identification of tumefactive demyelination on imaging. CONCLUSION. Both clinical and radiologic findings must be integrated to distinguish tumefactive demyelinating lesions from similarly appearing lesions on imaging. Further research on the immunopathogenesis of tumefactive demyelination and associated conditions will elucidate their interrelationship.

Mycophenolate Mofetil-induced Diffuse Large B-cell Lymphoma in Which a Solitary Lung Nodule Remitted Spontaneously

A 76-year-old woman with dermatomyositis was being treated with prednisolone, tacrolimus, and mycophenolate mofetil. There was a solitary lung nodule in the right middle lobe on chest computed tomography at a routine follow-up examination. A transbronchial lung biopsy was performed, and the histopathologic findings indicated diffuse large B-cell lymphoma. An immunodeficiency-associated lymphoproliferative disorder was suspected, and mycophenolate mofetil was stopped without adding any other therapy. Nine months later, the pulmonary nodule had disappeared on chest computed tomography.

Eosinophilic granulomatosis with polyangiitis (EGPA) on remission with a new neuropathy: a rare case of mycophenolate induced primary CNS lymphoproliferative disease

Introduction

Mycophenolate Mofetil (MMF), although a widely used immunosuppressant; an increasing concern of MMF induced Primary Central Nervous System Lymphoma (PCNSL) are being reported. Timely diagnosis and management of MMF induced PCNSL can play a vital role in improved outcomes.

Case Presentation

Eighty-one-year-old female with history of Eosinophilic Granulomatosis with Polyangiitis (EGPA) presented with word finding difficulty, right-hand weakness and right foot clumsiness. EGPA had been stable with MMF for 6 years. Physical examination revealed weakened right-hand grip, positive right-sided dysdiadokokinesia and right foot drop. MRI-brain identified three enhancing solid lesions – in right parietal, left insular and left mid brain extending into the left thalamus. Brain biopsy revealed a focally dense lymphoid infiltrate with CD20 positive B cells, with large atypical cells resembling Hodgkin Reed-Sternberg cells. With concern for immunosuppression related PCNSL, MMF was stopped. Patient was treated with 8 weeks of rituximab therapy for its least toxic profile and concomitant benefit in EGPA. On a 2 month follow up MRI-brain, near total resolution of the intracranial lesion was observed. Patient still had some residual right lower extremity incoordination, however, strength and speech normalized with resolution of dysdiadokokinesia. Patient was advised to discontinue MMF indefinitely and remains on low dose prednisone daily.

Conclusion

MMF is an inhibitor of Inosine Monophosphate Dehydrogenase which prevents T- and B-cell proliferation. PCNSL is a potential complication of chronic immunosuppression with this medication. Discontinuation of the drug along with immunosuppressive therapies have been the effective therapeutic options till date.

Primary central nervous system lymphoma in neuropsychiatric systemic lupus erythematosus: case-based review

Primary central nervous system lymphoma (PCNSL) sometimes occurs in immune-compromised hosts or patients with autoimmune diseases. Some cohort studies have previously reported an increased risk of non-Hodgkin's lymphoma in systemic lupus erythematosus (SLE), while some cases of PCNSL in patients with SLE were reported. We present the case of PCNSL which developed in a patient with the active phase of neuropsychiatric SLE (NPSLE). Furthermore, we reviewed published English articles to confirm the characteristics of PCNSL related to SLE. To our knowledge, this is the first report of PCNSL occurring in NPSLE. Histology demonstrated B-cell lymphoma with a positive Epstein-Barr virus-encoded RNA. This patient recovered following surgical resection of the lymphoma, whole brain radiation therapy, intravenous infusion of rituximab (RTX), and administration of belimumab after RTX. Given the series of reviews, our report suggests that the persistence of damage in the central nervous system (CNS) and long-term exposure to immunosuppressants may impact oncogenic immune responses within the CNS, leading to PCNSL development.

Epstein-Barr virus-associated primary central nervous system lymphoma in a patient with diffuse cutaneous systemic sclerosis on long-term mycophenolate mofetil

BACKGROUND

Epstein Barr virus (EBV)-associated primary central nervous system lymphoma (ePCNSL) is increasingly recognized in immunocompromised subjects, including patients receiving systemic immunosuppressive therapy. Here, we report the first case of primary CNS lymphoma associated with EBV in a patient with diffuse cutaneous systemic sclerosis (dcSSc) receiving long-term mycophenolate mofetil (MMF).

CASE REPORT

A 51-year-old female with dcSSc had been on MMF 2 grams daily, which was initiated for a rapidly rising modified Rodnan skin score (mRSS), severe pruritus, and progressive joint contractures. She had an impressive response to this therapy with a significant decrease in her mRSS. Her condition remained stable for the next five years, after which she developed worsening headaches for 2-3 weeks, associated with dizziness, gait instability, and left homonymous hemianopia. MRI scan of the brain revealed a solitary 2.4cm peripherally enhancing right parietal lobe mass. Excised tissue from the right parietal lobe mass showed EBV-associated diffuse large B cell lymphoma. She received four cycles of chemotherapy (high dose methotrexate and rituximab). Currently, her condition is being monitored. Her left homonymous hemianopia persists.

CONCLUSION

Because of a favorable toxicity profile, MMF is increasingly being used as long-term immunomodulatory therapy for a wide variety of autoimmune disorders. Nevertheless, patients on long-term MMF should still undergo regular CNS surveillance, not only for opportunistic infections but also for opportunistic malignancies such as PCNSL. Progressive focal or non-focal neurological deficits should always raise the alarm. Prompt evaluation and management can prevent irreversible neurological sequelae.

Mimickers of neuropsychiatric manifestations in systemic lupus erythematosus

Systemic lupus erythematosus (SLE), presenting with new onset or worsening neuropsychiatric (NP) symptoms, is a challenge in clinical practice. Mimickers such as infections, drug-induced side effects, metabolic abnormalities, malignancies, and alcohol-related disorders have to be excluded, before attributing the manifestations to disease activity. Proper diagnosis is essential to guide adequate management and reduce morbidity and mortality. In this review article, we will highlight clinical, laboratorial, and neuroradiological features that are helpful to assist in the differential diagnosis.

Management of primary central nervous system lymphoma

A rare tumor, primary central nervous system lymphoma can affect immunocompetent and immunocompromised patients. While sensitive to radiotherapy or chemotherapy crossing the blood-brain barrier, it often recurs. Modern treatment consists of high-dose methotrexate-based induction chemotherapy, often followed by consolidation with either radiotherapy or further chemotherapy. Neurotoxicity is however a concern with radiotherapy, especially for patients older than 60 years. The benefit of the addition of rituximab to chemotherapy is unclear. Targeted therapies and immunotherapy have been effective in some patients and are tested on a larger scale. Survival has improved in the last decade, but remains poor in older patients.

SLE and Non-Hodgkin's Lymphoma: A Case Series and Review of the Literature

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disorder punctuated by varied multiorgan complications all along the course of its natural history. Lymphoma represents a relatively well-recognized malignant phenomenon associated with lupus. The cause and effect relationships of lymphoma in SLE have been subject to extensive scrutiny with several studies reporting on clinic-pathologic characteristics and risk factors predicting lymphoma development in SLE. However, the pathogenic role of immunosuppressives in SLE-related lymphoma still remains unclear, and indices to help guide diagnosis, prognostication, therapy, and posttreatment monitoring are yet to be established. In this review, we describe 3 SLE patients who developed non-Hodgkin's lymphoma at different time points of their disease. Through a careful dissection of the aforementioned cases, we intend to apprise readers of the currently available literature surrounding risk factors, management, and prognosis in SLE-related lymphoma. We will also review and discuss the implications of immunosuppressives in SLE-related lymphoma and the role of mycophenolate mofetil in SLE-related primary CNS lymphoma development.

Development of primary central nervous system lymphoma in a systemic lupus erythematosus patient after treatment with mycophenolate mofetil and review of the literature

Primary central nervous system lymphoma (PCNSL) is a rare form of extranodal non-Hodgkin lymphoma and four cases of PCNSL have previously been described in association with mycophenolate mofetil. We report the fifth case of PCNSL in a patient with lupus nephropathy while on mycophenolate mofetil treatment.

Mycophenolate mofetil and systemic lupus erythematosus

Mycophenolate mofetil (MMF) is an immunosuppressive agent which provides protection against acute transplant rejection, in patients who undergo kidney, heart and liver transplantation. Recently MMF has been used in various autoimmune conditions, including systemic lupus erythematosus (SLE). In SLE, MMF has been more extensively used in the treatment of proliferative lupus glomerulonephritis (GLN) and following the success in this field, it has also been used to control extra-renal manifestations. However, in the majority of cases MMF was administered to patients with refractory SLE manifestations and, therefore, no definite conclusion could be drawn from these experiences.

In this paper, after a brief description of the mechanisms of action, the pharmacokinetics and metabolism of MMF which are relevant in SLE, and after a short discussion on the utility of performing therapeutic dose monitoring of mycphenolic acid, the experiences with the use of this drug in the different SLE manifestations were summarized and some personal data in patients with GLN were reported. Finally, the hypothetical use of MMF as a preventive strategy against the occurrence of severe manifestations in patients with mild SLE has been put forward and discussed.

Primary lymphoma of CNS, mycophenolate mofetil and lupus

Lymphoproliferative disorders are known to complicate immunosuppressive therapy and two cases of primary lymphoma of CNS (PCNSL) have previously been described in association with mycophenolate mofetil (MMF) treatment. We report the third case of PCNSL in a patient with lupus nephropathy while on MMF treatment. PCNSL may be seen more frequently considering the increased use of MMF in immunosuppressant responsive conditions.

[Central nervous system lymphoma revealed by lymphocytic meningitis in a patient with systemic lupus erythematosus: An unusual association]

INTRODUCTION

We report an unusual observation of central nervous system (CNS) lymphoma in a 60-year-old woman with systemic lupus erythematosus and fatal outcome.

OBSERVATION

The patient had systemic erythematosus lupus for 7 years, treated with mycophenolate mofetil and developed lymphocytic meningitis in 2015 associated to the presence of EBV in the cerebrospinal fluid and a necrotic vermis' lesion. Diagnosis of large B-cell lymphoma was histologically confirmed from stereotaxic biopsy, shortly before she died from neurological complications.

CONCLUSION

Even though the current association is unusual, lymphocytic meningitis with hypoglycorrachia in patients with systemic lupus erythematosus may reveal CNS lymphoma and diagnosis confirmation requires stereotaxic biopsy in order not to delay specific therapeutic management.

A Review of the Potential Utility of Mycophenolate Mofetil as a Cancer Therapeutic

Tumor cells adapt to their high metabolic state by increasing energy production. To this end, current efforts in molecular cancer therapeutics have been focused on signaling pathways that modulate cellular metabolism. However, targeting such signaling pathways is challenging due to heterogeneity of tumors and recurrent oncogenic mutations. A critical need remains to develop antitumor drugs that target tumor specific pathways. Here, we discuss an energy metabolic pathway that is preferentially activated in several cancers as a potential target for molecular cancer therapy. In vitro studies have revealed that many cancer cells synthesize guanosine triphosphate (GTP), via the de novo purine nucleotide synthesis pathway by upregulating the rate limiting enzyme of this pathway, inosine monophosphate dehydrogenase (IMPDH). Non-proliferating cells use an alternative purine nucleotide synthesis pathway, the salvage pathway, to synthesize GTP. These observations pose IMPDH as a potential target to suppress tumor cell growth. The IMPDH inhibitor, mycophenolate mofetil (MMF), is an FDA-approved immunosuppressive drug. Accumulating evidence shows that, in addition to its immunosuppressive effects, MMF also has antitumor effects via IMPDH inhibition in vitro and in vivo. Here, we review the literature on IMPDH as related to tumorigenesis and the use of MMF as a potential antitumor drug.

Longterm Followup After Tapering Mycophenolate Mofetil During Maintenance Treatment for Proliferative Lupus Nephritis

Objective.

To determine the timing for safe reduction of mycophenolate mofetil (MMF) dose during remission-maintenance therapy of proliferative lupus nephritis.

Methods.

The study population consisted of 44 patients evaluated retrospectively; MMF dose was empirically tapered in 18/44 patients until the latest observation.

Results.

Patients reducing MMF ≤ 18 months after remission/complete remission had a 6.8-fold/6.3-fold higher risk of relapse compared to those taking a stable dose (p = 0.001, p = 0.011, respectively). Reducing MMF later than 18 months was not associated with increased relapse rates.

Conclusion.

Reducing MMF > 1.5 years after remission/complete remission seems to warrant drug tapering without increased risk of disease flare in proliferative lupus nephritis.

Primary hypothalamic lymphoma in a patient with systemic lupus erythematosus: case report and review of the literature

A 67-year-old female was admitted to our department with difficulty in speech, disorientation, memory loss and seizures. Blood laboratory tests revealed diabetes insipidus. This patient had been treated with steroids for systemic lupus erythematosus (SLE) for 30 years. Due to this treatment neurological symptoms had been understated causing a long delay in performing ulterior researches. A brain MRI revealed a mass lesion in the hypothalamic area. A biopsy was performed and histopathological diagnosis was malignant large B cell lymphoma. Subsequently, she received methotrexate therapy but died of pneumonia during the second cycle. Primary central nervous system lymphoma in association with SLE is a rare occurrence but it should be considered in the diagnostic process when neurological symptoms occur. A brain MRI must be performed and corticosteroids should be interrupted. A biopsy of the cerebral mass lesion permits diagnosis and appropriate therapy may be administered.

Diffuse large B-cell lymphoma of the central nervous system in mycophenolate mofetil-treated patients with systemic lupus erythematosus

Patients with systemic lupus erythematosus (SLE) are susceptible to the development of lymphoproliferative disorders and postulated causes include intrinsic defects in immune surveillance and iatrogenic administration of immunosuppressants. Since the introduction of mycophenolate mofetil (MMF) to the immunosuppressive regimen for the management of post-organ transplantation, there have been reports of primary lymphoma of the central nervous system (PCNSL). MMF has been widely used to treat active SLE patients with Class IV lupus nephritis. In addition to two previously reported cases of PCNSL among SLE patients on long-term MMF, we report a third patient who has been on treatment with MMF for 8 years. The histology showed features compatible with diffuse large B-cell lymphoma with strong immunohistochemical staining for CD20 and positive signal for Epstein-Barr virus (EBV)-encoded RNA by in-situ hybridization that is similar to other case reports, suggesting EBV driven B-cell lymphoproliferative disease. The patient responded to withdrawal of MMF, intravenous methotrexate, rituximab and whole brain radiotherapy. With the increasing use of MMF in active renal as well as non-renal exacerbations of SLE, PCNSL should be included in the differential diagnosis in patients who present with gradual onset of focal neurological deficit.

Mycophenolate mofetil for the treatment of juvenile onset SLE: a multicenter study

Mycophenolate mofetil (MMF) has proved to be an efficacious and safe therapy in adult lupus nephritis. Recently, this drug has been suggested as a possible new alternative treatment also for juvenile-onset SLE (juvenile-SLE). A multicenter study has been performed to evaluate the efficacy and safety of MMF in controlling the disease activity in children and adolescents with juvenile-SLE. Our results show that MMF was effective in reducing the disease activity or as a steroid-sparing agent in 14 of 26 patients (54%), stabilised the disease in 8 (31%) and was ineffective in 4 (15%). In particular, in patients without renal involvement, a good response was registered in 9 of 13 patients (69%). Among those patients with renal involvement, MMF was effective in 5 of 13 patients (38%), partially effective in 4 (31%) and ineffective in 4 (31%). No severe side effects have been observed; only two patients stopped the drug because of severe diarrhoea and abdominal pain. With the limits of a retrospective study, MMF seems to be effective and safe for the treatment of juvenile-SLE, especially in patients with no renal involvement.

Epstein Barr virus-associated primary CNS lymphomas in elderly patients on immunosuppressive medications

Unlike primary central nervous system lymphomas (PCNSLs) in patients with AIDS or organ transplants, PCNSLs in the elderly are usually not considered to be mediated by Epstein Barr virus (EBV); hence, diagnostic studies for EBV are not routinely performed. We encountered 4 patients, 65 years or older, who developed EBV-associated PCNSLs and who had been treated with a variety of immunosuppressive drugs for different autoimmune/collagen vascular disorders, including autoimmune polyneuropathy (mycophenolate mofetil for 5 years), polymyositis (prednisone for 16 years with intermittent methotrexate, azathioprine, and cyclophosphamide), myasthenia gravis (azathioprine >10 years), and rheumatoid arthritis (methotrexate >10 years). All patients had multifocal, necrotic brain lesions typical of EBV-positive PCNSLs on neuroimaging. Withdrawing immunosuppressives lead to PCNSL regression in some patients. The patient who had received mycophenolate mofetil was treated successfully for his EBV-associated PCNSL with rituximab and methotrexate, but later developed fatal systemic malignant melanoma, which was likely immunosuppression related. The striking feature of these cases is the variety of underlying diseases-and hence accompanying medications-that can be associated with EBV-associated PCNSLs. They serve as a diagnostic alert for neuropathologists and suggest that increased testing of PCNSLs for EBV by immunohistochemistry or in situ hybridization may be warranted in any patient on any immunosuppressive medication, but particularly the elderly.

Atopic dermatitis: systemic immunosuppressive therapy

Atopic dermatitis (AD) is a pruritic, relapsing skin disorder that negatively impacts the quality of life of those affected and that of their families. Treatment options for AD encompass a variety of emollients, topical corticosteroids, topical immunomodulators, phototherapy, and systemic agents. Such agents as systemic corticosteroids, cyclosporine, azathioprine, interferon-gamma, methotrexate, and mycophenolate mofetil have been shown to be efficacious in the treatment of moderate-to-severe AD but are not officially approved for this purpose. In this article, we review some of the data supporting efficacy of these medications and discuss some of the adverse events associated with their use.

Case 38: central nervous system lymphoma in a patient previously treated for Wegener's granulomatosis

A 72-year-old woman with a past history of Wegener's granulomatosis presented with a primary central nervous system lymphoma; this was found to be an Epstein-Barr virus-positive diffuse large B-cell lymphoma.

Effect of mycophenolate mofetil on pulmonary function in scleroderma-associated interstitial lung disease

OBJECTIVE

We sought to determine the effectiveness of mycophenolate mofetil (MMF) in scleroderma- associated interstitial lung disease (SSc-ILD).

METHODS

We retrospectively identified patients who met criteria for systemic sclerosis, had evidence of SSc-ILD on chest CT, received > 1 g/d of MMF for >or= 6 months, and had pulmonary function data available. Vital capacity (VC) and diffusion capacity of the lung for carbon monoxide (Dlco) at treatment onset were compared with VC and Dlco values 12 months before and 12 months after treatment onset. Twelve-month values were imputed from regression lines generated using all VC and Dlco measurements made in the 24-month period either prior to or following treatment onset.

RESULTS

Among 13 patients who met inclusion criteria, MMF was associated with a significant improvement in VC (mean, + 159 mL; confidence interval [CI], + 30 to + 289 mL; and + 4% of the predicted normal value; CI, + 2 to + 7%) after 12 months of treatment. In contrast, patients had a significant decrease in VC (mean, - 239 mL; CI, - 477 to - 0.5 mL; and - 5% of the predicted normal value; CI, - 11 to - 0.3%) in the 12 months prior to MMF treatment. Dlco did not change significantly during MMF treatment (mean, + 1% of the predicted normal value; CI, - 2 to + 5%) but decreased significantly in the 12 months prior to treatment (mean, - 5% of the predicted normal value; CI, - 10 to - 1%).

CONCLUSION

These retrospective data suggest MMF improves VC in patients with SSc-ILD.

Mycophenolate Mofetil in Lupus Glomerulonephritis: Effectiveness and Tolerability

Mycophenolate mofetil (MMF) is an immunosuppressive agent initially used in the treatment of transplant recipients. MMF has been used in renal, heart, and liver transplantation, where it seems more effective than other immunosuppressive regimens in reducing the incidence of acute rejection episodes. MMF has a variety of immunosuppressive effects, including selective suppression of T and B lymphocyte proliferation, and has been more recently used in many autoimmune inflammatory conditions. Systemic lupus erythematosus (SLE) is an autoimmune disease that can potentially involve any organ or system of the human body. Glomerulonephritis (GLN) has been recognized as the most frequent severe manifestation of SLE, leading to poor long-term prognosis. In the treatment of lupus GLN, several therapeutic approaches, all including immunosuppressive drugs, such as cyclophosphamide, azathioprine, or cyclosporine A, have been used. The short- and long-term toxicity of these drugs limits their use in a substantial number of patients. Over the last few years, MMF has emerged as an alternative therapeutic regimen in lupus GLN, mainly for patients refractory to other therapies. These studies have shown that it is highly effective and generally well tolerated.

EBV-associated lymphoproliferative disorder of CNS associated with the use of mycophenolate mofetil

Epstein-Barr virus (EBV)-associated lymphoid proliferations are a well-recognized complication of congenital or acquired systemic immunosuppression. The CNS is a frequent site for development of such lymphoid proliferations. We describe the clinical, imaging, and pathologic observations of a CNS disorder histologically similar to posttransplantation lymphoproliferative disorder that occurred in four patients with autoimmune disease treated with mycophenolate mofetil (MM). Two patients had polymorphous lymphoplasmacytic infiltration of brain parenchyma, and two had monomorphous infiltrations consistent with diffuse large B-cell lymphoma. In situ hybridization for EBV-encoded RNA was positive in all four patients. All patients improved after MM withdrawal and the use of rituximab. Because of a favorable toxicity profile, MM is now being used as steroid-sparing immunomodulatory therapy in autoimmune disorders. Based on our experience presented herein, we recommend caution in patient selection for MM and strict surveillance of those patients with autoimmune disorders who receive MM.