Lymphoma

Case #385: MRI Brain, 5/4/94: Lymphoma of 4th Ventricle.

CC: Vertigo

Hx: This 69y/o RHF was well until 4-5 weeks prior to presentation(5/1/94), when she began to develop recurrent nausea and vomiting, associated with vertigo and blurred vision, OU. The symptoms progressively worsened over the ensuing weeks ,during which she was treated for presumed otitis media. The patient presented locally on 4/28/94 and was found to have right facial weakness. An MRI scan, 4/28/94, reportedly demonstrated a left cerebellopontine angle tumor, thought to be an acoustic neuroma. On 5/1/94, she developed diplopia on leftward gaze. She was given Decadron for suspected increased intracranial pressure and referred to the UIHC Otolaryngology service and subsequently to Neurology.

MEDS: Tenormin, Lopid, Pravachol, Buspar, Meclizine 25mg q4hr, Premarin, ASA.

PMH:1)Coronary artery disease, 4Vessel CABG(12/89). 2)asymptomatic right carotid stenosis, RCEA(12/92). 3) Fem-Pop bypass(12/92).

FHx: noncontributory.

SHx: 1ppd cigarettes for 46years, quitting in 1993. Rare ETOH consumption.

ROS: no weight loss, Night sweats, fevers, chills.

EXAM: BP110.60 HR60 RR16 35.8C

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

CN: VFFTC. Right pupil slightly larger than left, though both pupils were reactive to light(size of pupils not noted). EOM intact except decreased leftward gaze( bilateral or unilateral not specified). significant nystagmus occured on leftward gaze with associated diplopia. Right upper and lower facial weakness. Facial sensation intact. Tongue midline with normal gag response. Auditory acuity was intact.

MOTOR: 5/5 strength throughout. Normal muscle tone and bulk.

Sensory: Intact PP/VIB/LT/TEMP

Coord: slight dysmetria on left FNF and dystaxia on left HKS.

Station: fell leftward on Romberg test upon eye closure.

Gait: unsteady and unable to TW.

Reflexes: 1/1 throughout. Plantars were flexor, bilaterally.

Gen Exam: unremarkable. Rectal exam unremarkable with heme negative stool.

COURSE: The patients outside MRI, 4/28/94, brain scan was reviewed and felt to demonstrate and enhancing 4th ventricle mass on T1 gadolinium enhanced images.

GS, CBC, PT, PTT, ESR, RPR, TSH, FT4 and HIV titers were negative. ANA 1:40. CSF ACE and Serum ACE were negative. CSF analysis(5/2/94): RBC 20, WBC 15(12 lymphocytes, 2 histiocytes, 1other), Protein 66, Glucose 67, Myelin basic protein <1.0(normal), cultures(fungal, AFB, Bacterial), Crytococal Antigen were negative. Beta 2 microglobulin 2.3(elevated). Cytology revealed markedly enlarged WBC in the CSF with irregular nuclei and multiple small nuclei. These findings suggest lymphoma, carcinoma or other primary CNS tumor. MRI brain, 5/4/94, revealed: 3-4mm rim of enhancing soft tissue extending around the anterior and left lateral aspect of the fourth ventricel. This extends inferiorly towards the left foramen of Luschka. There is also a 4-5mm area of abnormal enhancement of soft tissue at the infundibulum A thir 6-8mm area of abnormal enhancement occurs in the area of the left MCA trifurcation. The MRI findings are suspicious for lymphoma.

CXR, Chest and Abdominal CT, and mammogram were negative. The patient was presumed to have primary CNS lymphoma and subsequently treated with steroids, intrathecal metotrexate, and XRT.