Table of Contents
Washington University Experience | NEOPLASMS (HEMATOLYMPHOID) | Lymphoma, primary | 10A0 Case 10 History
Case 10 History ---- The patient was a 60 year old man who was in his usual state of health until July 1977 when he had developed generalized headaches and right facial paresthesias. A decreased right eye blink was noted at that time. In September 1977 he had numbness of all limbs, right greater than left, horizontal diplopia and an unsteady gait. He had gradual recovery of all these symptoms except for slight unsteadiness. In early 1979 he had numbness of the right arm, itchy sensations of the trunk and limbs, dysphagia, hoarseness and incontinence. On exam in Feb. of 1979 he had slight gait unsteadiness, left heel-kneel-shin ataxia, slight right hand clumsiness and bilateral hyperreflexia. His right plantar response was extensor and he had mild decreased vibration in the right foot. Neuro-ophthalmologic exam showed rebound nystagmus and asymmetric intranuclear ophthalmoplegias suggesting a right brain stem lesion. He had vertical gaze nystagmus greater to the right and he had saccadic pursuits to the right. His workup at that time showed an LP with a glucose of 91, protein of 46, 17 cells, 4 PMN's and 6 mononuclear cells. The differential diagnosis at that time was multiple sclerosis, gliomatosis, central pontine myelinolysis and vascular disease. He was re-admitted in March 1979 with irritability, confusion and disorientation. Neurologic exam at that time was remarkable for recent memory deficits. LP was done, opening pressure was 140. Glucose was 85, protein 111. There were 630 cells, 170 white cells, 45% lymphocytes, 52% segs, and 3% monos. CT scan was repeated and dilatation of the lateral ventricles and a 3rd ventricular mass was noted. He was started on anti-tuberculous therapy. On 4/26 the patient had a respiratory arrest with ventricular arrhythmia and was transferred to neurosurgery at that time. The etiology of his arrest was thought to be secondary to increased intracranial pressure from his 3rd ventricular lesion. A right frontal ventriculostomy was attempted 4 times without returning of CSF. A right frontal craniotomy with a transcallosal approach to the right and left lateral ventricles and septum pellucidum region was also attempted. ---- A subtotal removal of necrotic tissue thought to be either granuloma or neoplasm was performed but a precise diagnosis was not possible at that time. No frankly lymphomatous areas were identified even upon reviewing the surgical material. Post-operatively he had a progressive downhill course with myoclonic jerks, inappropriate ADH and hypothyroidism. In June the patient had a cardiopulmonary arrest and could not be resuscitated.
