2001 Associates' Presentations

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Lady with Bilateral Blindness, Left Abducent Nerve Palsy and a Heart Murmur

M. Djelmami-Hani, M.D.
K. Hussein, M.D.
I. Nadeem, M.D.
Sinai Samaritan Medical Center, Milwaukee, Wisconsin

34 year-old African American female with history of HIV, presented with a chronic history of headaches, a two-week history of left abducent nerve palsy and a two-day history of bilateral blindness. She was on antiretroviral HIV medications. Examination revealed left abducent nerve palsy, remarkably decreased bilateral visual acuity and no papilledema. Rest of the examination was unremarkable except for notable axillary lymphadenopathy and an apical systolic murmur radiating to the axilla. Her labs showed a CD4 count of 160 and no significant hematological or metabolic abnormalities. Chest X-ray showed cardiomegaly. MRI of the head showed a 1.8 cm mass of pineal gland and enlargement of the pituitary infundibular stalk. Lumbar puncture showed a clear CSF with high protein and normal cytology. CT of the chest showed enlarged hilar and axillary lymph nodes and a mass in the left ventricle. Echocardiogram showed multiple masses in the left ventricle and right atrium. Biopsy of the mediastinal lymph nodes showed a high grade B-cell lymphoma. Biopsy of the pituitary mass was felt to be of high risk and was not done. Radiation to the pineal mass resulted in resolution of the blindness. Repeat MRI showed regression in the size of the mass. After a cycle of systemic and intrathecal chemotherapy, the patient also demonstrated a resolution of the intracardiac mass on a follow up echocardiogram done a few weeks later. LDH as a tumor marker decreased from 4,000 to normal range. The patient was discharged in a stable condition with follow-up.

Discussion: About 10 percent of malignancies in HIV patients is non-Hodgkin's lymphoma. Cases of both primary and metastatic intracerebral and cardiac lymphomas have been reported in the literature albeit usually as case reports. Only four other cases of pineal and pituitary lymphomas have been reported and no reports of a case of cardiac and cerebral lymphoma in the same patient. Both lesions responded well to systemic and intrathecal chemotherapy with acute resolution of the blindness with cranial radiation therapy.

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