Lymphoma

Case #354: CT Brain, 7/10/95, & MRI Brain, 8/7/95: CNS Lymphoma.

CC: Confusion.

Hx: This 50y/o RHF presented with a 2 week h/o confusion and falling, more severe in the 2 days prior to this presentation. She was found the morning of 6/30/95, in the bathtub. She had been unable to get out of it for at least 24 hours. She had no prior h/o seizure. The reason for her remaining in the bathtub was unclear. She was confused upon evaluation at a local ER. HCT with contrast was performed, 6/30/95, and revealed a left frontal and right thalamic enhancing lesion with associated surrounding edema. She was then transferred to UIHC.

At UIHC she complained of lower backpain and her conversation raised the possibility of urinary urgency for the past 1-2 days.

MEDS: Prinavil, Estrogen.

PMH: HTN. Oophorectomy for "benign" lesion.

FHX/SHX: Widowed, Two sons. No h/o Tobacco/ETOH/Illicit drug use.

ROS: No recent fevers/chills/night sweats/ hematuria/cough/weight loss.

EXAM: BP148/52, HR67, RR18, 37.4C

MS: Somnolent but answers easily. Oriented to person, place, time. Knew the president.

Slowed thought process but appropriate. No dysarthria.

CN: unremarkable.

Motor: mild left hemiparesis: 5/4+ strength throughout. Weakness worse in LLE than LUE.

Sensory: unremarkable.

Coord: normal FNF and RAM

Station: not noted.

Gait: not noted.

Reflexes: Reflexes 2/2 and symmetric throughout. Plantar responses were not noted in chart.

Gen Exam: Two 1cm pigmented skin lesions on right breast with erythematous bases.

The remainder of the Gen Exam was unremarkable.

COURSE: GS, CBC, PT, PTT, CXR were within normal limits. The outside HCT, 6/30/95, was reviewed and showed a 2 x 2cm homogenously enhancing lesions in the left frontal and right thalamic regions, both with significant surrounding edema. No hydrocephalus.

She was placed on Decadron and Dilantin and clinically improved. Right breast skin biopsy findings were consistent with an angioma; there was no evidence of melanoma or metastasis. Mammogram, Abdominal and Chest CT were negative. She underwent left frontal stereotactic brain biopsy on 7/10/95. The findings were consistent with primary CNS B-cell lymphoma. She was subsequently treated with XRT and Intrathecal methotrexate and leukovorin/Vincristine/procarbazine chemotherapy. MRI Brain, 8/7/95, revealed an enhancing 3 x 3 x 3cm mass with surrounging edema in the right basal ganglia with mass effect on the thalamus, third ventricle and cerebral aqueduct. The ventricles are enlarged bilaterally. There is an ill-defined area of increased signal on Proton density, T2 and T1 with gadolinium images, in the left frontal lobe. There is increased signal involving the corpus callosum which may represent transependymal flow from the ventricle enlargement, or less likely tumor spread because there is no enhancement. She was last seen, 1/29/97; her neurologic exam in the neurooncology clinic was relatively unremarkable. She was conversant and ambulatory with little evidence of hemiparesis. Her MRI brain that day was stable.