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Washington University Experience | NEOPLASMS (HEMATOLYMPHOID) | Lymphoma, secondary | 7A0 Case 7 History
Case 7 History ---- The patient was a 35 year old man who was diagnosed with HIV in 1986. At the onset of his current presentation he had a CD4 count <30 and non-Hodgkin’s lymphoma of the pachymeninges which left him without the use of his lower extremities secondary to cord compression that did not improve with CHOP chemotherapy. The patient was found to have gastric involvement of the lymphoma in June of 1994. His other infections have included clostridium difficile colitis in April of 1994 which was complicated by colonic perforation requiring exploratory laparotomy and ileostomy. There was also a questionable episode of pneumocystis pneumonia in 1994. He has had condyloma acuminata in 1980 and serologic hepatitis B in 1986. ---- The patient was admitted on 8/1994 with a complaint of a worsening morning headache over the last 3-4 days, low grade dysarthria and forgetfulness. The patient has had headaches on and off for months but noted a recent worsening leading to severe pain on the day of admission. Additionally, he had facial droop on the right side and had difficulty forming words. Head CT obtained on the night of the admission revealed a 5 X 8 mm lesion in the right temporal lobe in the region of the uncus with low attenuation involvement of the white matter of the upper left parietal lobe and mass effect in the left frontal horn. This lesion was initially thought to be due to either an extension of the patient's lymphoma or toxoplasmosis. Treatment was started for Toxoplasmosis with Dapsone and Clindamycin. Since there existed a possibility also for CMV or HSV, Acyclovir was also empirically started. ---- Despite being maintained on phenobarbital for seizure prophylaxis, on August 27 the patient experienced right facial seizure type activity that was controlled with Valium. Given his use of phenobarbital with breakthrough seizures, Dilantin was begun IV. On August 29 patient had flaccid paralysis of the right arm, right facial weakness and no leg function. Later in that day he became unresponsive except for sternal rubs. He also had a 10 minute focal facial seizure and a 1 minute grand mal seizure that resolved spontaneously. The patient was declared dead on at the end of August 1994.
