| 제목 |
Diffuse Large B-Cell Lymphoma Presenting as Neurolymphomatosis of Sciatic Nerve |
| 소속 |
Soon Chun Hyang University Bucheon Hospital, Department of Rehabilitation Medicine1, Soon Chun Hyang University Seoul Hospital, Department of Rehabilitation Medicine2, Soon Chun Hyang University Cheonan Hospital, Department of Rehabilitation Medicine3 |
| 저자 |
Yeon Hee Cho 1*, Seung Yeol Lee 1†, Hyun Seok 1, Sang Hyun Kim 1, Hyun Jung Kim 1, Jin Young Kim 1, Jun Young Ahn 1, Jeong Se Noh 2, Siha Park 3 |
Introduction
Diffuse large B cell lymphoma is the most common type of non-Hodgkin lymphoma. A rapidly growing tumor mass often present in single or multiple, nodal or extranodal sites. Neurolymphomatosis is an uncommon presentation of lymphoma when malignant lymphoid cells invade the peripheral and/or cranial nerves. The main characteristics associated with NL include painful peripheral neuropathy, radiculopathy with weakness of the involved lower extremity and cranial neuropathy. As symptoms of NL are non-specific, early diagnosis and treatment are essential for good prognosis and preventing of nerve damage. Here, we report a case of slowly progressed DLBCL involved with brain and peripheral nerve which initially misdiagnosed as lumbosacral polyradiculopathy.
Case presentation
A 63-year-old man who has a history of hypertension and diabetes mellitus first visited our outpatient clinic on April, 4, 2018. he complained motor weakness (grade 3~4 on the Medical Resource Council scale), diffuse muscle atrophy and severe pain on his left lower extremity (grade 10 on the Visual Analogue Scale). He had a in-car accident 5 months ago and since then, has been suffering from pain. On electrodiagnostic study, nerve conduction study showed normal conduction. Needle electromyography showed abnormal spontaneous activities in the left L3-S1 paraspinalis, adductor longus, tibialis anterior, peroneus longus, vastus medialis, rectus femoris and gluteus maximus muscles. These result was compatible with left lumbosacral polyradiculopathy. PET-Computed Tomography and laboratory test were performed to rule out malignancy, but there was no abnormal findings on 2018. Two months later, his pain worsened again to grade 10 on VAS. Motor weakness of left lower extremity was further progressed, the strength of hip flexor and knee extensor became grade 2, and ankle dorsiflexor and plantarflexor was grade zero. Whole spine and pelvic MRI showed herniated intervertebral disc on L5-S1 level and compressive neuropathy of left sciatic nerve. One year later, he experienced VAS 8 pain on left lower extremity. In follow-up PET-CT, there is focal hypermetabolic lesion in the left proximal thigh muscle(Fig. 1) and pelvic MRI showed oval cystic mass on left sciatic nerve(Fig. 2). Moreover, he began to complain about short term memory disturbance. Brain MRI(Fig. 3) was then performed, and showed multiple homogeneous enhancing lesions. For differential diagnosis, endoscopic biopsy of brain was done. Finally, he was diagnosed with diffuse large B-cell lymphoma which is positive to auto-immunohistochemical stain(CD20, CD79). He immediately began chemotherapy with the R-CHOP protocol and Whole brain radiotherapy.
Conclusion
We report a case of slowly progressed DLBCL presenting as neurolymphomatosis which was involved with peripheral nerve first and central nervous system later, continuous follow-up should be needed for differential diagnosis of malignancy. |
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Figure 1. PET-CT showed hypermetabolic mass in the left pelvic side wall and hypermetabolic muscle lesion in the anterior aspect of left proximal thigh.
Figure 2. (A) Pelvic MRI-T2 image showed oval cystic mass in left sciatic nerve, suggesting nerve sheath tumor such as schwannoma. (B) Pelvic MRI-T2 image showed enhancing soft tissue lesion along left sciatic nerve
Figure 3. Brain MRI-T2 FLAIR image showed homogeneous enhancing lesions with diffusion restriction along the walls of the bilateral lateral, 3rd, 4th ventricles, choroid plexus, suprasellar area, and pineal gland.
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