CASE OF THE WEEK
                   PROFESSOR YASSER METWALLY
CLINICAL PICTURE

CLINICAL PICTURE:

A 48-year-old female pa...
Figure 1. Precontrast (A) and postcontrast (B) MRI T1 images showing scattered cerebellar, temporal lobes and
brain stem h...
Figure 3. MRI FLAIR images showing bilateral hyperintense zones scattered in the cerebral white matter and the
immediate p...
The lesions were not associated with a mass effect and showed no definite enhancement. Whole-body 18F-
fluorodeoxyglucose ...
We report a 45-year-old man with systemic lymphoma whose initial manifestation was sudden-onset
leukoencephalopathy, mimic...
SUMMARY

The presented case indicates that diffuse large B-cell lymphoma may initially appear as a treatable
leukoencephal...
know more details.
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Case record...Paraneoplastic leukoencephalopathy

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Case record...Paraneoplastic leukoencephalopathy
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Case record...Paraneoplastic leukoencephalopathy

  1. 1. CASE OF THE WEEK PROFESSOR YASSER METWALLY CLINICAL PICTURE CLINICAL PICTURE: A 48-year-old female patient was admitted to our hospital due to sudden gait disturbance. One month prior to the admission, She suddenly began to experience difficulty performing simple calculations and dressing himself. This patient visited a local hospital, where She was diagnosed with cerebral infarction and treated with anticoagulation therapy; no relevant disease, medication, smoking, or alcohol history was noted. She had lost 8 kg in the 6 months prior to this event, and She was easily fatigued and experienced night sweating and general weakness. Her cognitive impairment worsened over the next several weeks. She visited our hospital in order to obtain a second opinion. On admission, the patient was alert and Her orientation was intact. She was a right-handed. She was apathetic, showed right/left disorientation, and had difficulty performing simple calculations and writing. Her reading and comprehension were normal. Cognitive functioning was assessed using the Mini-Mental State Examination (MMSE), on which She scored 18 points out of a possible 30; She lost 5 points on the calculation item, 3 points on memory recall, 2 points on time orientation, 1 point on writing, and 1 point on the interlocking pentagons item. The only abnormal finding on cranial nerve examination was mild dysarthria. Her motor power was symmetric and preserved in all four extremities, but all muscles were moderately hypertonic. Her deep-tendon reflexes were increased on both sides. She showed symmetric and intact responses to all sensory stimuli and Her cortical senses were intact. Her neck was supple, and carotid bruit was not audible. She exhibited small, shuffling, and hesitant steps on gait examination. The patient's blood pressure was 107/75 mmHg, and Her heart rate was 90 beats/min. We performed brain magnetic resonance imaging (MRI) and routine blood tests. Brain MRI showed multiple lesions with high signal intensity in the white matter of the bilateral hemisphere on fluid-attenuated inversion recovery and diffusion- weighted imaging (DWI), and magnetic resonance angiography showed normal intracerebral and carotid arteries (Fig. 4A). Apparent diffusion coefficient (ADC) mapping and enhanced T1-weighted imaging were not included in the MRI analyses. Blood test results showed increased liver enzymes, but serology findings were negative for hepatitis B and C viruses, the Venereal Disease Research Laboratory Test, and human immunodeficiency virus. A coagulation panel disclosed normal prothrombin and activated partial thrombin times, but the levels of C and S proteins were markedly decreased, ranging from only 30% of the normal value. She was negative for serum autoantibodies, including antinuclear antibody, lupus anticoagulant, and antineutrophil cytoplasmic antibody. RADIOLOGICAL FINDINGS RADIOLOGICAL FINDINGS:
  2. 2. Figure 1. Precontrast (A) and postcontrast (B) MRI T1 images showing scattered cerebellar, temporal lobes and brain stem hypointense zones, with mild enlargement of the temporal horns bilaterally. Also noticed meningeal enhancement completely ensheathing the pons. Figure 2. MRI FLAIR (A,B) and MRI T2 images showing scattered hyperintese zones around the 4th ventricle and withen the pons. The hyperinetse zones has no mass effect.
  3. 3. Figure 3. MRI FLAIR images showing bilateral hyperintense zones scattered in the cerebral white matter and the immediate periventricular area, especially involving the genu of the corpus callosum. The hyperintense lesions apparently have no mass effect. Notice the moderate hydrocephalic changes. Figure 4. Brain MRI data. Brain MRI showing multifocal white-matter lesions with high signal intensity on fluid- attenuated inversion recovery (FLAIR), MRI, and DWI, with an increased apparent diffusion coefficient value. Compared to the initial image (A), the lesions An abdominal computed tomography was performed to exclude a hepatic malignancy. This revealed multiple ill- defined, low-attenuation lesions, and multifocal, patchy, arterial, high-attenuation lesions in both lobes of the liver, with splenomegaly and bilateral adrenal gland enlargement, suggesting lymphoma. Brain MRI performed 4 weeks after the initial MRI showed enlargement of multifocal confluent subcortical lesions, with increased signal on ADC maps, suggesting an inflammatory lesion such as demyelinating disease, rather than an acute infarction (Fig. 4B).
  4. 4. The lesions were not associated with a mass effect and showed no definite enhancement. Whole-body 18F- fluorodeoxyglucose (FDG) and positron-emission tomography (PET) revealed multiple hypermetabolic lesions in the bilateral adrenal glands, liver, and lymph nodes, as shown in Fig. 5. However, there was no alteration of brain metabolism. Figure 5. Whole-body FDG PET. Fusion PET with abdominal computed tomography (CT) revealed multiple hypermetabolic lesions involving the liver, lymph nodes, and both adrenal glands (A, B: white arrows). Brain PET did not show any significant alteration of metabolism. A lumbar puncture study was performed to exclude CNS infection or leptomeningeal involvement of lymphoma. This showed normal opening pressure with a clear color, and two white blood cells were found, with markedly increased levels of protein (191.2 mg/dL) and glucose (92 mg/dL; serum glucose, 136 mg/dL). Polymerase chain reaction studies against viral genes, including human herpes virus types 1-6 and JC virus were all negative. There was no evidence of tuberculosis, Lyme disease, or fungal infection in staining and culture studies of a lumbar puncture specimen. Malignant cells were not found on repeated cytologic evaluation of lumbar puncture specimens. No oligoclonal band or myelin basic protein was found. The presence of paraneoplastic autoantibodies was not evaluated and a biopsy of the brain lesion was not undertaken. A liver mass biopsy disclosed diffuse large B-cell lymphoma. The patient was diagnosed with paraneoplastic leukoencephalopathy due to diffuse large B-cell lymphoma and was treated with systemic chemotherapy, including cyclophosphamide, doxorubicin, vincristine, and prednisone. Her cognitive impairment and gait disturbance gradually improved over the next 2 months, She regained the ability to calculate and write letters, Her MMSE score improved to 28, and She regained the ability to walk and to articulate when speaking. The final brain MRI showed that the extent of the lesion had markedly decreased (Fig. 4C). A large proportion of patients with paraneoplastic disorders can be grouped into the clinicopathologic entity of paraneoplastic encephalomyelitis (PEM). Small cell lung carcinoma is the tumor most commonly associated with PEM, and some patients with a variety of other neoplasms. PEM is characterized clinically and pathologically by patchy, multifocal involvement of any or all areas of the cerebral hemispheres, limbic system, cerebellum, brain stem, spinal cord, dorsal root ganglia, and autonomic ganglia. Neuronal loss is accompanied by a variable degree of perivascular and leptomeningeal infiltration of mononuclear cells, including T and B lymphocytes and plasma cells. [13,14] Leptomeningeal infiltration might be responsible for the Leptomeningeal enhancement observed in this case. DIAGNOSIS: DIAGNOSIS: STROKE MIMICKING PARANEOPLASTIC LEUKOENCEPHALOPATHY AS AN INITIAL MANIFESTATIONS OF DIFFUSE LARGE B-CELL LYMPHOMA DISCUSSION DISCUSSION: Systemic lymphoma can be difficult to recognize due to its diverse manifestations. Paraneoplastic leukoencephalopathy has rarely been reported in the context of lymphoma.
  5. 5. We report a 45-year-old man with systemic lymphoma whose initial manifestation was sudden-onset leukoencephalopathy, mimicking stroke. This patient, who was eventually diagnosed with diffuse large B-cell lymphoma, initially presented with sudden cognitive impairment and gait disturbance. Radiological studies suggested a paraneoplastic leukoencephalopathy. Chemotherapy for lymphoma resulted in clinical and radiological improvement. This case signifies the diversity of CNS manifestations, which include cerebral infarction, lymphoma invasion, atypical infectious encephalitis, and paraneoplastic encephalopathy, [1,2,5,6] in a patient with systemic lymphoma. The presenting sudden-onset focal neurologic deficit and high-signal-intensity lesion on DWI suggested an initial diagnosis of cerebral infarction. The combined systemic symptoms, including progressive weight loss, night sweating, and general weakness, were suggestive of systemic disease, but they were neglected. It is unlikely that a patient with cerebral infarction would have a progressive clinical course after symptom onset and slow-growing lesions on brain MRI. The newly expanded lesion had high signal values on both DWI and ADC mapping. It is therefore highly unlikely that this lesion was the result of acute infarction given that the latter exhibits a high signal value on DWI and a low ADC value during the acute stage as a result of isotropically restricted water diffusion by cytotoxic edema. [7] Brain lymphoma usually presents as a single or multiple enhancing lesions in immunocompetent patients. [8] However, intravascular infiltration of large B-cell lymphoma shows different MRI findings, typically involving the white matter, with minimal enhancement after contrast administration and little mass effect, and is typically referred to as intravascular lymphomatosis. [5] It has been reported that the ADC values of CNS lymphomas are lower than those of other intracerebral tumors and are close to those seen in acute infarction.9 Intravascular infiltration of large B-cell lymphoma shows low ADC values due to combined ischemic brain injuries. [10] However, this patient had a lesion with high signal values on ADC mapping. Additional studies were performed to exclude CNS malignancy. FDG PET allows the evaluation of metabolic activity and provides additional information that aids in the differentiation between lymphoma and nonneoplastic conditions, including CNS lymphoma.[11] The brain lesion in our patient did not show increased metabolism, suggesting that it was not neoplastic. Cytologic evaluation of repeated lumbar puncture specimens did not show malignant cells, and the protein level was markedly increased, suggesting an active inflammatory or demyelinating process. Lumbar puncture specimens were checked repeatedly for the presence of viral genes, and the results were consistently negative against JC virus and other infectious pathogens. The findings of brain MRI, FDG PET, and lumbar puncture studies strongly suggested that the brain lesion in our patient did not involve direct lymphoma invasion or infectious disease, but rather resulted from an active inflammatory disease such as demyelinating encephalopathy. Our patient showed a good response to systemic chemotherapy, suggesting paraneoplastic leukoencephalopathy as the most probable diagnosis. There have been a few reported cases of combined demyelinating CNS lesions in patients with systemic malignancy. [3,4] There has been one report of diffuse encephaloradiculopathy involving the cerebrum, brainstem, cerebellum, and peripheral nerves in a patient with silent hepatocellular carcinoma. [3] Tumor-associated immunological interruption was suggested as a possible mechanism underlying diffuse demyelination of the nervous system. [3] Another case report describes acute multifocal CNS demyelination as the initial presentation of lung adenocarcinoma without CNS metastasis. [4] The pathomechanism may involve paraneoplastic autoantibodies or immunomodulation by the malignancy itself and/or by treatment. Brainstem or temporal lobar involvement in systemic malignancy is more commonly reported than cerebral white-matter involvement, a condition known as limbic encephalitis, which is often associated with several autoantibodies, including the anti-Hu antibody. [4] However, self-limiting, acute, disseminated encephalomyelitis cannot be excluded as a possible diagnosis in this case. [12] The findings of this case suggest that systemic lymphoma involves the CNS in the form of paraneoplastic encephalopathy. It must be differentiated from cerebral infarction, direct lymphoma invasion, and atypical infection in order to determine the therapeutic plan and accurately forecast the prognosis. This case also suggests that systemic malignancy must be considered in the differential diagnosis of young patients with sudden-onset neurological deficits due to brain lesions involving multifocal white matter. SUMMARY
  6. 6. SUMMARY The presented case indicates that diffuse large B-cell lymphoma may initially appear as a treatable leukoencephalopathy. Lymphoma and leukemia are systemic diseases that affect many organs, including the central nervous system (CNS). [1] These cancers may affect the CNS directly via the production of intraparenchymal or extra-axial mass lesions, or meningeal infiltration, or indirectly by coagulopathy, metabolic disturbance, or paraneoplastic antibody production. [1] Atypical infections, such as John Cunningham (JC) virus or toxoplasmosis, can lead to the development of brain lesions in lymphoma patients. [2] Paraneoplastic leukoencephalopathy as an initial manifestation of systemic malignancy is rare, but several reports have described its intriguing clinical course and possible pathomechanism. [3,4] Although biopsy sampling is mandatory for a definitive diagnosis, it is often impossible to perform due to the location or size of the lesion, or patient refusal. The recent considerable progress in imaging technologies has provided a noninvasive modality for assessing intracranial lesions in lymphoma patients.We present herein a case of a man with sudden gait disturbance and cognitive impairment who was initially diagnosed with cerebral infarction, but was subsequently diagnosed with paraneoplastic encephalopathy associated with systemic lymphoma. Paraneoplastic encephalomyelitis (PEM) is a multifocal inflammatory disorder of the central nervous system (CNS) associated with remote neoplasia. Frequently, the disorder is accompanied by subacute sensory neuronopathy (SSN) due to involvement of the dorsal root ganglia. Anti-Hu antibodies may be detected in both of these conditions. Although various malignancies have been reported in PEM, 80% of cases are associated with bronchial cancer, typically small-cell lung carcinoma. Neurologic manifestations commonly precede the diagnosis of cancer, although variable presentations have been reported. Symptoms usually progress over the course of weeks to months, reaching a plateau of neurologic disability. Neurologic impairment may be more debilitating than the associated cancer. No effective therapeutic approaches have been established, although immunosuppressive therapies are employed commonly. Neurologic dysfunction probably results from an autoimmune reaction directed against onconeural antigens in the human nervous system. Polyclonal immunoglobulin G (IgG) anti-Hu antibodies or type 1 antineuronal nuclear antibodies are most prevalent (~50%), although several other circulating autoantibodies have been identified. Some patients have no identifiable paraneoplastic antibodies. These markers of paraneoplasia have an undetermined pathogenic role. Cytotoxic T cell–mediated neuronal damage is suspected, although no animal models have been developed to confirm this. Almost all cases of PEM with anti-Hu antibodies are related to small-cell lung carcinoma. These antibodies react with a group of 35- to 40-kilodalton neuronal RNA-binding proteins, including HuD, PLE21/HuC, and Hel-N1. Nuclear and cytoplasmic staining of CNS neurons demonstrates the presence of these antibodies. A ubiquitous protein, HuR, is also an antigenic target. The neuronal proteins are homologous to the embryonic lethal abnormal visual (Elav) protein in Drosophila species. Anti-Hu antibodies may alter the production of these proteins, which are essential for the development, maturation, and maintenance of the vertebrate nervous system. Intrathecal synthesis of anti-Hu antibodies may represent an autoimmune cross-reaction with neurologic tissue, triggered by a remote carcinoma. Other PEM antibodies include anti-CV2, anti-Yo, anti-Ma1, anti-Ta or anti-Ma2, and several other atypical antibodies. Recent reports have noted detection of the prion-related 14-3-3 protein and of herpes simplex virus by polymerase chain reaction (PCR) in the cerebrospinal fluid (CSF) of patients with PEM. The significance of these findings is unclear.  Addendum  A new version of this PDF file (with a new case) is uploaded in my web site every week (every Saturday and remains available till Friday.)  To download the current version follow the link "http://pdf.yassermetwally.com/case.pdf".  You can also download the current version from my web site at "http://yassermetwally.com".  To download the software version of the publication (crow.exe) follow the link: http://neurology.yassermetwally.com/crow.zip  The case is also presented as a short case in PDF format, to download the short case follow the link: http://pdf.yassermetwally.com/short.pdf  At the end of each year, all the publications are compiled on a single CD-ROM, please contact the author to
  7. 7. know more details.  Screen resolution is better set at 1024*768 pixel screen area for optimum display.  For an archive of the previously reported cases go to www.yassermetwally.net, then under pages in the right panel, scroll down and click on the text entry "downloadable case records in PDF format"  Also to view a list of the previously published case records follow the following link (http://wordpress.com/tag/case-record/) or click on it if it appears as a link in your PDF reader REFERENCES References 1. Glass J. Neurologic complications of lymphoma and leukemia. Semin Oncol. 2006;33:342–347. 2. Yoon JH, Bang OY, Kim HS. Progressive multifocal leukoencephalopathy in AIDS: proton MR spectroscopy patterns of asynchronous lesions confirmed by serial diffusion weighted imaging and apparent diffusion coefficient mapping. J Clin Neurol. 2007;3:200–203. 3. Phanthumchinda K, Rungruxsirivorn S. Encephaloradiculopathy: a non-metastatic complication of hepatocellular carcinoma. J Med Assoc Thai. 1991;74:288–291. 4. Gonzales N, Jarboe E, Kleinschmidt-DeMasters BK, Bosque P. Acute multifocal CNS demyelination as first presentation of systemic malignancy. Neurology. 2005;65:166. 5. Song DK, Boulis NM, McKeever PE, Quint DJ. Angiotropic large cell lymphoma with imaging characteristics of CNS vasculitis. AJNR Am J Neuroradiol. 2002;23:239–242. 6. Brecher K, Hochberg FH, Louis DN, de la Monte S, Riskind P. Case report of unusual leukoencephalopathy preceding primary CNS lymphoma. J Neurol Neurosurg Psychiatry. 1998;65:917–920. 7. Lövblad KO, Laubach HJ, Baird AE, Curtin F, Schlaug G, Edelman RR, et al. Clinical experience with diffusion- weighted MR in patients with acute stroke. AJNR Am J Neuroradiol. 1998;19:1061–1066. 8. Fleming JO, Keegan BM, Parisi JE. A 52-year-old man with progressive left-sided weakness and white matter disease. Neurology. 2007;69:600–606. 9. Karaarslan E, Arslan A. Diffusion weighted MR imaging in non-infarct lesions of the brain. Eur J Radiol. 2008;65:402–416. 10. Baehring JM, Henchcliffe C, Ledezma CJ, Fulbright R, Hochberg FH. Intravascular lymphoma: magnetic resonance imaging correlates of disease dynamics within the central nervous system. J Neurol Neurosurg Psychiatry. 2005;76:540–544. 11. Palmedo H, Urbach H, Bender H, Schlegel U, Schmidt-Wolf IG, Matthies A, et al. FDG-PET in immunocompetent patients with primary central nervous system lymphoma: correlation with MRI and clinical follow-up. Eur J Nucl Med Mol Imaging. 2006;33:164–168. 12. Tenembaum S, Chitnis T, Ness J, Hahn JS. International Pediatric MS Study Group. Acute disseminated encephalomyelitis. Neurology. 2007;68(16) Suppl 2:S23–S36. 13. jean WC, Dalmau J, Ho A, Posner JB: Analysis of the IgG subclass distribution and inflammatory infiltrates in patients with anti-Hu-associated paraneoplastic encephalomyelitis. Neurology 44:140-147,1994 14. Bird Sj, Brown Mj, Shy ME, Scherer SS: Chronic inflammatory demyelinating polyneuropathy associated with malignant melanoma. Neurology 46:822-824,1996 15. Metwally, MYM: Textbook of neuroimaging, A CD-ROM publication, (Metwally, MYM editor) WEB-CD agency for electronic publication, version 10.4a October 2009

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