Lumbosacral nerve root lesion with malignant lymphoma

摘要

A 66-year old man presented with a one-year history of progressive pain and weakness in his left leg. Neurological examination showed severeparesis, muscle atrophy, areflexia of the left leg, and dysesthesia and hypoesthesia in L5, S1, S2 dermatome, all of which suggested a lumbosacralpolyradiculopathy. Routine hematological examinations were within normal limits. Cerebrospinal fluid examination showed an elevated protein level(83 mg/dl) with slight pleocytosis (13 cells/mm 3). Cytological analysis of the cerebrospinal fluid showed no malignancy. Needle electromyographyshowed diffuse signs of denervation of the nerves related to L5 and S1 nerve roots. Enhanced computed tomography presented an intrapelvictumor-like lesion [Figure 1]a and [Figure 1]b. The lesion seemed to protrude to the pelvis through the anterior sacral foramina. Lumbosacralmagnetic resonance imaging (MRI) revealed a left-side dominant swelling in L5, S1, and S2 nerve roots [Figure 1]c. Sagittal [Figure 1]d andcoronal [Figure 1]e T1-weighted MRI image showed a distinct gadolinium-enhancement of the left lumbosacral nerve roots. Initial whole-bodyexamination revealed no other lesions. He received intravenous immunoglobulin and steroid therapy after a tentative diagnosis of chronicinflammatory demyelinating polyradiculoneuropathy had been made. Leg pain was temporarily relieved, although leg weakness and muscle atrophynever recovered. Soluble interleukin-2 receptor was elevated to 2070 U/ml. Finally, a repeated cytological examination of the cerebrospinal fluidand random skin biopsy revealed large atypical cells positive for CD 20 and he was diagnosed as having a diffuse large B-cell lymphoma.Malignant lymphoma is a common disease and an occasional cranial nerve infiltration has been described.[1] However, infiltration of the peripheralnervous system by the lymphoma cells, termed as “neurolymphomatosis,” is a rare presentation of the disease.