Introduction
The involvement of the secondary central nervous system (CNS) is a rare but almost always fatal outcome in diffuse large B cell lymphoma (DLBCL). We report a rare case of a DLBCL patient with complete remission who was transferred to rehabilitation department and diagnosed as lymphoma relapse after presentation of multiple cranial nerve palsies.
Case report
A 73-year-old male presented with 4 weeks of progressive left upper limb weakness, right ptosis, and hoarseness. He was diagnosed as stage IV diffuse large B-cell lymphoma 6 months ago after abrupt dyspnea and right costovertebral angle tenderness. He defied 6 cycles of R-CHOP chemotherapy. A computed tomography (CT) abdomen scan and Positron emission tomography (PET)/CT after chemotherapy revealed complete resolution of primary disease.
At the time of his deficits, the brain and cervical magnetic resonance imaging (MRI) showed no evidence of CNS involvement. 3 times of spinal tapping showed no evidence of cerebrospinal fluid (CSF) inflammation and paraneoplasic antibody (Ab) test for possibility of peripheral neuropathy associated with his symptoms were all negative. He subsequently developed incomplete ptosis, internal and external ophthalmoplegia in the right eye, suggestive of right 3rd and 6th cranial nerve palsy (Fig. 1).
Even so, as there was no evidence of lymphoma involvement, he was transferred to rehabilitation department for further evaluation. The electrophysiologic study showed sensory dominant polyneuropathy. Video fluoroscopic swallowing test and fiberoptic endoscopic evaluation of swallowing (FEES) showed tracheal aspiration with severe retention. Immobile bilateral vocal cord movement with incomplete closure during FEES were suggestive of laryngeal nerve involvement (Fig. 2).
During our admission, aspiration pneumonia occurred and we went ventilator care in ICU. As he was not able to perform self expectoration and consistent saliva pooling inside laryngeal vestibule was observed during FEES, tracheostomy was done. Diaphragm ultrasonography showed a half decreased excursion of right diaphragm movement (1.19/2.55cm) suspicious of right hemidiaphragm paralysis. He was complete ventilator weaning was unattainable thereafter.
As his neurologic deficits deteriorated with time, we performed additional brain MRI, posterior fossa to focus on cranial nerve involvement. Finally, thickening and enhancement of left temporal fossa, left cavernous sinus, foramen ovale, right levator palpebra superioris and superior rectus muscles, which suggesting lymphoma involvement. He was transferred to hemato-oncology for additional chemotherapy.
Conclusion
Invasion of the multiple cranial nerves for a Non-Hodgkin’s lymphoma patient without previous CNS involvement is rarely reported. For our patient, not overlooking of these progressing symptoms through continuous neurologic examination and appropriate assessment, he was able to proceed on his additional chemotherapy.
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