2000 Associates' Presentations
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Lady with Weakness, Atacia and Fever
Savita M. Chander, MD, University of Wisconsin Medical School, Madison, WI
A 59 yr. Lady was admitted to the hospital with chief complaints of diplopia, frontal headaches, gait problems and intermittent fevers. Four months prior to admission, she was diagnosed with a left Bell's palsy that had subsequently resolved. During the next few months, she started developing problems with walking as well as progressive right leg pain and weakness. She sought medical help, when she started having a constant left frontal and peri orbital headache and double vision. An MRI scan of her head revealed a left tentorial meningioma. Her past medical history was significant for hypertension and anxiety. Surgeries in the past included tubal ligation and breast augmentation. Her medications on admission included propranolol, spironolactone, HCTZ, triazolam, zoloft, tegretol, and hydrocodone. She was a current smoker with a a 20-pk year history and took occasional alcohol. On admission, she was alert, with stable vitals and the only pertinent findings were positive binovular diplopia and she kept her left eye closed most of the time. Power in her right lower extremity was 4-/5 in both proximal and distal groups with mild diminution of her reflexes. She also had a abnormal tandem walk. Labs at the time of admission including a CBC, chem 7, Ca, Mg, PO4 were normal.
CSF studies showed an elevated protein at 136 (CSF IgG Index was high). An EMG of her face and right lower extremity showed an axonal motor radiculoneuropathy thought to be consistent with either CIDP or a variant of Guillain Barre syndrome. The patient was then treated with IVIG.
There was no improvement in her condition, and she continued to have fever. The white count and her platelet count started decreasing. An infectious disease consult was obtained, during which she was noted to have a massive hepatosplenomegaly. She also complained of a cough with mucopurulent sputum. A CT scan of her abdomen revealed a massive hepatosplenomegaly. The chest CT showed ground glass opacities and thickening of her upper airways, but a lung diopsy showed only an atypical lymphoid infiltrate. A bone marrow biopsy was positive for a total of 5 AFB. The biopsy also showed that 10-15% of her marrow was infiltrated with large cells with prominent nucleoli compatible with lymphoma and flow cytogenetics confirmed this as a large cell lymphoma. The AFB in the marrow was then thought to be a false positive result. The rest of her ID work up including cultures (bacterial and fungal) and viral titres were negative. The patient's neurological symptoms and the diplopia in particular responded to the CHOP chemotherapy and intrathecal MTX, and hence the pt was classified as a stage IV B Large Cell Lymphoma with CNS involvement.
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