Diffuse Large B cell Lymphoma Presenting As Cranial Polyneuropathy (Case Report)

An interesting case of diffuse Large B cell lymphoma presenting as cranial polyneuropathy (polyneuritis craialis)

Ismail A. Khatri, MD, Fahd Sultan, MBBS, Maimoona Siddiqui, FCPS, Tayyab S. Akhter, MBBS,

Arsalan Ahmed, MD (Neurology), Umair Afzal, MD

Division of Neurology, Shifa International Hospital, Sector H-8/4, Islamabad, Pakistan

Introduction:

Polyneuritis cranialis in the absence of peripheral polyneuropathy is an uncommon neurological problem with a variety of likely etiologies. The diagnostic evaluation may be challenging.

Case Report:

We report the case of a 57 year old previously healthy gentleman, who presented with double vision for 3 weeks; drooping of right eyelid for 2 weeks; difficulty in swallowing liquids; and hoarseness of voice for 5 days. His examination showed right complete III^rd nerve, left VI, subtle left LMN VII^th , and right IX, X, XII^th nerve palsy with hoarse voice and absent gag. Right hip flexors were weak (4/5) and plantars were down going. Rest of the neurological examination was normal. The differential diagnoses included brain stem meningoencephalitis, variant of GBS, para-infectious or paraneoplastic syndrome. MRI brain was unremarkable, Lumbosacral MRI showed mild disc disease. NCS and EMG showed mild L5-S1 radiculopathy on right. Hematological studies, electrolytes, autoimmune, and toxicology screen were non contributory. CSF examination showed 250 cells, predominantly lymphocytes, with low glucose and raised proteins. He was started on IV steroids along with anti-tuberculous therapy (ATT), considered brainstem encephalitis or CNS TB. Lumbar puncture was repeated after 1 week that showed decrease in cell count and proteins. He was discharged on ATT and tapering steroids. At 2 week follow-up, he had worsening of left VII^th nerve palsy and increased weakness of right thigh with quadriceps atrophy. He also had nausea and vomiting. CT scan of chest, abdomen and pelvis showed no significant abnormality. Upper GI endoscopy with biopsy of gastric fundus showed large B-cell lymphoma. Patient was started on chemotherapy and ATT was stopped.

Conclusion:

Cranial polyneuropathy is an uncommon disorder, and can be presenting feature of large B-cell lymphoma.