Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 8-1995. A 75-year-old man with multiple cranial-nerve defects and weakness and pain in the extremities

Neurolymphomatosis: a single-center experience of neuromuscular manifestations, treatments, and outcomes

OBJECTIVES

Neurolymphomatosis (NL) is a disease characterized by the infiltration of malignant lymphocytes into the peripheral nervous system. We report clinical features, radiographic findings, modes of treatment, and outcomes of patients with NL.

METHODS

We retrospectively investigated patients with NL. We extracted data, including clinical features, magnetic resolution imaging (MRI), ¹⁸F-fludeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) scans, cerebrospinal fluid cytology findings, the results of electrodiagnostic studies, as well as patient treatments and outcomes.

RESULTS

Ten NL patients were identified. All patients reported pain/paresthesia and weakness in the affected area. The MRI scans were abnormal in eight out of nine patients with an enhancement of the spinal nerve root, plexus, peripheral nerve trunk, and cranial nerve. The FDG PET/CT scans were positive in all patients. Radiculopathy or radiculoplexopathy was the most common electrodiagnostic finding. Neurological improvement was observed in only three patients. The condition of the nine patients who underwent multimodality treatments for cancer eventually deteriorated and the patients died.

CONCLUSIONS

NL should be considered in the differential diagnosis of any type of neuropathy in patients with lymphoma. Because it could be confused with other neuropathies in lymphoma and various musculoskeletal diseases, a high index of suspicion and familiarity with clinical manifestation of NL are key. FDG PET/CT was the most sensitive diagnostic imaging modality to detect relevant neural invasion. The root within the spinal neural foramen was the most frequently affected neural structure. Early diagnosis of this rare neurologic manifestation of lymphoma may improve treatment outcomes.

Neurolymphomatosis presenting as mononeuritis multiplex

We report the case of a 60-year-old man who presented with a mononeuritis multiplex-type illness, beginning cranially and then sequentially involving peripheral nerves in all four limbs and torso. Despite extensive investigation, including multiple lumbar punctures and tissue biopsies, the diagnosis was not made until his death 10 months after presentation. Post mortem revealed lymphocytic infiltration of multiple peripheral nerves and radicules with minimal central nervous system involvement, consistent with neurolymphomatosis. Except for the pericardium, there was no other evidence of systemic lymphoma. Recent similar case reports highlight the value of magnetic resonance imaging of plexi and peripheral nerves, which may increase the chance of an antemortem diagnosis in this typically elusive disorder.

Neurolymphomatosis in Waldenström's macroglobulinaemia

We report four patients with Waldenström's macroglobulinaemia with an unusual neurologic complication, neurolymphomatosis, characterized by meningeal and root nerve infiltration by lymphoplasmacytic cells. Patients presented with rapidly progressive leg proximal weakness. Examination of cerebrospinal fluid disclosed lymphoplasmacytic cells. Magnetic resonance imaging of the lumbar spine was suggestive of a tissular infiltration of leptomeninges and nerve roots. Chemotherapy and irradiation of involved tissues led to a remarkable and sustained neurological improvement.

Mononeuropathy multiplex due to infiltration of lymphoma in hematologic remission

We report a case of progressive mononeuropathy multiplex in a patient with lymphoma in hematologic remission. At the time of presentation there was no evidence of meningeal or central nervous system metastasis. At autopsy, extensive infiltration of tumor cells was found in both femoral nerves. We review the literature pertaining to multifocal malignant lymphoid infiltration of peripheral nerves, which can occur during hematologic remission or in the absence of any evidence of systemic lymphoma.