Seeing Double: A Rare Presentation of Non-Hodgkin Lymphoma

Case Report

Ann Hematol Oncol. 2017; 4(6): 1155.

Seeing Double: A Rare Presentation of Non-Hodgkin Lymphoma

Fitzgerald LA¹* and Stephens DM²

¹Department of Internal Medicine, University of Utah, USA

²Division of Hematology and Hematologic Malignancies, Huntsman Cancer Institute, USA

*Corresponding author: Fitzgerald LA, Department of Internal Medicine, University of Utah, 30 North 1900 East, Room 4C104, Salt Lake City, USA

Received: May 13, 2017; Accepted: June 12, 2017; Published: June 22, 2017


Background: This is the case of a new diagnosis of aggressive non- Hodgkin lymphoma presenting as acute neurologic deficits. Upon evaluation, the patient is found to be suffering from Neurolymphomatosis, a rare manifestation of lymphoma characterized by direct invasion of the nerve roots by lymphoma cells. This case is unique in that it is even rarer to have neurolymphomatosis as the presentation of new lymphoma diagnosis.

Case Presentation: A 65 year-old female presents with acute-onset diplopia and slurred speech. Upon evaluation for stroke, an incidental chest mass is found. Biopsy of the mass is consistent with Burkitt Lymphoma and her neurologic deficits are diagnosed as Neurolymphomatosis. Unfortunately, without rapid and aggressive therapy, the patient succumbed to her disease.

Conclusion: Neurolymphomatosis is a rare manifestation of non-Hodgkin lymphomas and an even rarer presentation of a new lymphoma diagnosis. It should remain on the differential diagnosis of secondary central nervous system involvement of lymphoma as the rapid recognition of this disease process is critical for mitigating morbidity and mortality.

Keywords: Neurolymphomatosis; Non-Hodgkin lymphoma; Burkitt lymphoma; CNS involvement by lymphoma


CN: Cranial Nerve; CT: Computed Tomography; NHL: Non- Hodgkin’s Lymphoma; CNS: Central Nervous System; R-CHOP: Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone; CODOX-M: Cyclophosphamide, Vincristine, Doxorubicin, High-dose Methotrexate; IVAC: Ifosfamide, Cytarabine, Etoposide, and Intrathecal Methotrexate

Case Presentation

A 65 year-old female with a history of liver cirrhosis presented with acute-onset double vision and slurred speech. The stroke response team was activated in the Emergency Department. Despite initial concerns, however, her clinical picture would become less consistent with acute stroke. The patient’s past medical history is notable for cirrhosis complicated by ascites, esophageal varices, and chronic thrombocytopenia. Her cirrhosis was secondary to Hepatitis C infection, which had been treated prior to presentation. She had a 40 pack-year smoking history and reported quitting one month prior to presentation. In addition to the above, the patient also endorsed headache, abdominal pain, and nausea upon presentation. Review of systems was negative for fever, confusion, shortness of breath, cough, hemoptysis, or chest pain.

Upon presentation, the patient was afebrile with vital signs notable only for mild hypertension. She was alert and oriented to person, place, and time and was noted to be in mild distress. Remarkable findings on examination included inward gaze of the right eye [cranial nerve (CN) VI palsy], mild right-sided facial droop (CN VII palsy), and mild slurring of speech (CN IX/X). Strength was full and symmetric. Sensation was intact. She was given a NIH Stroke Scale score of 5. Laboratory analysis was significant for a normal WBC and a platelet count of 99,000 cells/mm3, which was at baseline. Radiographic studies included unremarkable CT scan of the head, CT angiogram of the head/neck with no findings suggestive of acute ischemia, and chest X-Ray with right-sided opacity and pleural effusion. Incidentally, the CT angiogram revealed apartially visualized large mediastinal mass (Figure 1).