The Great Mimicker — Is it Lymphoma?

The ever lasting question, Is it lymphoma?

HPI:

40-year-old man was referred to ED for abnormal MRI. 2 weeks prior to admission patient developed acute onset dysarthria with marked slurred speech. Patient presented to a local ED, CT head was negative and was diagnosed with tonsillitis and discharged home.

When symptoms persisted patient presented to his PCP, MRI was ordered and when MRI did show corona radiate enhancing lesion shown above, he was referred to ED again for further workup.

Examination:

Neurology was consulted, patient has no other symptoms than dysarthria. Exam with only slurred speech and right extensor planter response. No prior episodes of loss of vision or other focal neurological deficits.

Workup:

MRI: 1.5 cm corona radiata lesion on FLAIR image that enhance with contrast, no diffusion restriction. Multiple subcorictal and juxtacortical FLAIR hyper intense lesions but non-enhancing.

MRI reported as either subcortical infarction versus demyelinating disease versus lymphoma.

Other routine labs including CBC and BMP were all unremarkable

The first question is: WHICH ONE?

Workup started with screening for demyelinating disease and ischemic disease.

• MRI cervical and thoracic spine were negative for any FLAIR lesions.
• CSF with normal cell count, protein and glucose. OCB and IgG synthesis are pending
• CTA and TTE were negative
• The only vascular risk factor is diabetes, no prior coronary artery disease, kidney disease or retinopathy.
• No history of prior focal neurological deficits.

The second question: HOW SHOULD WE TREAT?

• The presence of multiple juxtaxortical lesions on MRI, decision was to go with a trial of pulse steroids for possible multiple sclerosis. Also, if it is ischemia, steroids will not hurt.
• Patient had marked improvement in his symptoms and dysarthria markedly improved.

WE MISSED IT!

• Radiology called for an addendum to the CTA report. Patient has enlarged tonsils and cervical lymphadenopathy !!
• We completely missed it..
• Biopsy did reveal lymphoma

Ahmed Koriesh, MD