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Washington University Experience | NEOPLASMS (HEMATOLYMPHOID) | Lymphoma, secondary | 12A0 Case 13 History
Case 12 History ---- The patient was a 52 year old man with a history of end stage renal disease secondary to diabetes mellitus type II, status-post renal transplant in February 2001. He also had a history of coronary artery disease, hyper tension, chronic sinusitis, and parathyroidectomy in December 2001. He was admitted to BJH in February 2002 following two months of lethargy and about 1 week of confusion and disorientation. He developed diplopia, which was secondary to a left sixth nerve palsy with inattention and disorientation, and nystagmus in all directions of gaze. Head CT showed chronic bilateral subdural hematomas, and MRI of the brain revealed increased T2 signal in in the left frontal lobe; adjacent to the third ventricle, aqueduct of Sylvius, and fourth ventricle; in the bilateral caudate heads, right cerebellum, and corpus callosum. Gadolinium enhancement was seen in the cerebellar and callosal lesions. CD20 positive atypical lymphocytes were demonstrated in the CSF. IV methotrexate was begun for suspected CNS NHL on 2-24-02, and an Ommaya reservoir was placed. Two days later, CSF infusion of MTX was given. After MTX, the patient showed little change in his neurologic exam. A CSF infusion of MTX was repeated on 3-3-02. Despite continued effort, the patient had a rapid deterioration over the next 48 hours with hypotension and Cheyne-Stokes respirations. He expired in March 2002. At autopsy malignant lymphoma was diffusely present involving lungs, kidneys and hepatobiliary systems. The weight of the unfixed brain was 1400 gm. The leptomeninges were cloudy and discolored over the superior frontal cortices bilaterally (right > left) and there is an approximately 0.3 cm defect in the right frontal cortex (consistent with Ommaya reservoir tract).
