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Neurology Resident and Fellow Section

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1 Neurology Resident and Fellow Section
Presentation of Diffuse Large B-cell Lymphoma with bilateral sequential oculomotor neuropathy Teaching NeuroImages Neurology Resident and Fellow Section © 2018 American Academy of Neurology

2 Vignette A 56-year-old male with HIV on combination antiretroviral therapy (CD4 count 368 cells/µL; HIV-RNA<20 copies/mL) suffered sequential, bilateral oculomotor nerve palsy after recent travel to Africa. Non-expansile enhancement of the oculomotor nerves was noted on MRI imaging. Multiple CSF studies showed lymphocytic pleocytosis without neoplastic cells. Molecular testing on the serum was positive for Plasmodium falciparum by PCR early in the course of presentation but symptoms progressed despite treatment for P. falciparum. Infectious etiologies including Cryptococcus neoformans, histoplasmosis, varicella zoster virus, herpes simplex virus, and JC virus were ruled out. He developed multiple cranial neuropathies (bilateral 3rd, 5th, 9th and 10th), encephalopathy and expired from cytomegalovirus related cardiopulmonary complications. Lymphadenopathy was not observed during the course of his illness. Galla et al. © 2018 American Academy of Neurology

3 Imaging Figure 1: T1 fat saturation post gadolinium MRI brain Axial (A, C) and Coronal (B, D) sections show non-expansile enhancement of left (red arrows) and right (green arrows) oculomotor nerve. Galla et al. © 2018 American Academy of Neurology

4 Imaging Galla et al. Figure 2: Pathology of left basal ganglia
Hematoxylin and eosin stained sections show perivascular (A) and infiltrative (B) patterns of involvement by DLBCL. Immunohistochemistry demonstrates expression of CD79a B-cell marker (C, D). Original magnification 10x Galla et al. © 2018 American Academy of Neurology

5 Presentation of Diffuse Large B-cell Lymphoma with bilateral sequential oculomotor neuropathy
Autopsy revealed intracranial and pericardial diffuse large B-cell lymphoma (DLBCL). Isolated oculomotor palsy is a rare presentation of DLBCL with less than 20 reported cases1, 2. The risk for DLBCL, an AIDS-defining illness, increases with decreasing CD4 counts; however, it can occur in HIV despite normal CD4 counts3. References 1. Sato H, Hashimoto T, Yoneda S, Hirabayashi K, Oguchi K, Higuchi K. Lymphoma as a cause of isolated oculomotor nerve palsy. J Clin Neurosci 2011;18: 2. Lee WW. Lymphoma presenting as cranial nerve neuropathies in HIV-infected patients. AIDS Read 2008;18:606-10, 621. 3. Biggar RJ, Chaturvedi AK, Goedert JJ, Engels EA, HIV/AIDS Cancer Match Study. AIDS-related cancer and severity of immunosuppression in persons with AIDS. J Natl Cancer Inst 2007;99: Galla et al. © 2018 American Academy of Neurology

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