Lymphoma

Case #355: MRI Brain, 6/6/95: CNS Lymphoma

CC: Transient blindness, OU.

HX: This 48y/o RHM was referred by ophthalmology for evaluation of an episode of transient blindness, OU, that occurred one morning during 6/94 while driving his car. The episode lasted 3-5 seconds, during which he was unable to see anything out of either eye. However, he was able to stop his car, but ended up in the opposite lane facing traffic. During the episode he felt a sense of deja vu. The symptoms did not recur.

In addition, he had developed RUE weakness and clumsiness over the past 2 years which manifests in occasional dropping of objects with his right hand. He had also been experiencing right-sided pain(RUE, RLE) which was more noticeable when lying down. He felt the pain was "deep, like bone pain." Changing body position and moving about relieved the pain. The pain was never "severe enough" to take medication. He felt "burned out" by his job as the coordinator of the Forensic(debate) Program at the University of Iowa. He stated he would almost like to be fired so he could do something different and relax.

He occasionally had mild headaches occurring approximately once a month; these are relieved by Ibuprofen. He had had a 10# weight gain over a 6 month period prior to presentation.

MEDS: NONE

PMH: 1)appendectomy and tonsillectomy.

FHx: Mother has Rheumatoid arthritis. Father has PUD. Sister has an unknown mental illness. Maternal grandfather died of Crohn's disease and his Maternal Aunt and Grandmother have diabetes.

SHx: Smokes 10 clove cigarettes per day. Denies ETOH use, but smokes Marijuana once per week. He denies any other illicit drug use. He is married and has no children.

EXAM:BP119/67 HR84 RR12 36.0C

MS: A&O to person, place and time. Speech normal. Appeared anxious.

CN: unremarkable.

Motor: 5/5 throughout all four extremities. Normal muscle tone and bulk.

Sensory: unremarkable.

Coord: unremarkable.

Station/Gait: unremarkable.

Reflexes: 2+/2+ throughout. Plantar responses were flexor, bilaterally.

Gen EXAM: unremarkable.

COURSE: CBC, GS, PT/PTT, HIV titers done on 8/14/94 were unremarkable. He was reassured that his non-specific symptoms in the face of a normal neurologic exam were probably stress related. A Transthoracic Echocardiogram done 9/20/94 was unremarkable.

He returned to the Neurology clinic on 6/8/95 complaining of one week of right hand clumsiness. He was having difficulty writing. Furthermore he had been experiencing right knee "buckling" while walking. His wife noted that his right foot had been dragging for the past 1-2 days prior to 6/8/95. He denied symptoms of Lhermitte's and Uhthoff's phenomena. He underwent an MRI Brain scan on 9/6/95. This revealed multiple white matter lesions on T2 weighted images. The largest was approximately 3cm in diameter in the left parietal lobe. There was cortical atrophy involving the bifrontal regions. The cerebellum and brainstem appeared normal.

He underwent lumbar puncture on 6/9/95: Opening pressure 17cm H20. CSF: Protein 46mg/dl(normal 15-45), glucose 64, 0 WBC, 0 RBC, Albumin25.8mg/dl(normal14-20). CSF Cultures(bacterial, fungal, AFB) were negative. CSF cytology was not obtained.

Visual Evoked Potentials were abnormal showing poorly defined waveform without appreciable P100 on 6/20/95.

Case #355

He returned to Neurology Clinic on 6/14/95 with increased clumsiness and weakness in the RUE and RLE. He was then given a 3 day course of Solu-Medrol 1.0gram IV qd and placed on a Prednisone taper for presumed demyelinating disease. He claimed subjective improvement of his right sided weakness on 6/15/95, but clinical exam revealed no improvement even by 6/16/95.

His symptoms subjectively improved and remained stable until one week prior to 7/2/95 when he experienced a single episode of urinary incontinence and progressive worsening of his right hemiparesis, and new progressive dysarthria. On 7/2/95, he experienced a generalized tonic-clonic seizure in the UIHC ER. He was given IV Dilantin and intubated. A HCT revealed a left parietal enhancing mass of 3 x 3 cm with minimal edema. MRI brain scans done on 6/3/95 and 6/6/95 revealed white matter lesions felt consistent with multiple sclerosis. A PET scan on 7/6/95 revealed a large hypermetabolic focus in the left parietal white matter. This finding was felt consistent with either tumor or acute MS plaque. He was placed on Decadron.

On 7/26/95, he underwent stereotactic biopsy of the left parieto-occipital lesion. Pathological analysis revealed diffusely infiltrating neoplasm demonstrating angiocentricity. The neoplastic cells had irregular, hyperchromatic nuclei and scant amounts of cytoplasm. Occasional small nucleoli and rare mitotic figures were present. No vascular proliferation or necrosis was seen. The findings were felt consistent with malignant lymphoma of the B-cell immunophenotype.

He underwent 12 cycles of intrathecal Methotrexate, Vincristine, Procarbazine and Leucovorin chemotherapy, and 4200cGy cranial radiation, and IV ARA-C chemotherapy. He was last seen 9/96 and was ambulatory and conversant with lucid thought. He had 5-/5 strength and mild dysarthria.