Intravascular malignant lymphomatosis diagnosed in both skeletal muscle and nerve biopsies

Neurologic manifestations of intravascular large B-cell lymphoma

PURPOSE OF REVIEW

Intravascular large B-cell lymphoma is a rare subtype of large B-cell lymphoma that affects various organs including the nervous system. The diagnosis is challenging and frequently made at autopsy.

RECENT FINDINGS

We report 5 cases with an array of neurologic manifestations. All patients were initially evaluated for alternative diagnoses. Three patients were diagnosed at autopsy, one with brain biopsy, and another with muscle biopsy. Muscle was involved in all 3 patients who had muscle tissue available for analysis.

SUMMARY

Our observations suggest that random open muscle biopsy may present a high-yield, less invasive option for the diagnosis of this disorder.

Clinical Neuropathology practice guide 3-2014: combined nerve and muscle biopsy in the diagnostic workup of neuropathy - the Bordeaux experience

Simultaneous combined superficial peroneal nerve and peroneous brevis muscle biopsy, via the same cutaneous incision, allows examination of several tissue specimens and significantly improves the diagnosis of systemic diseases with peripheral nerve involvement. Vasculitides are certainly the most frequently diagnosed on neuro-muscular biopsies, but this procedure is also well advised to asses a diagnosis of sarcoidosis or amyloidosis. More occasionally, combined nerve and muscle biopsy may reveal an unpredicted diagnosis of cholesterol embolism, intra-vascular lymphoma, or enables complementary diagnosis investigations on mitochondrial cytopathy or storage disease.

Malignant cell infiltration in the peripheral nervous system

The peripheral nervous system can be affected by malignancies involving different mechanisms. Neoplastic nerve lesion by compression, invasion, and infiltration is rare and occurs in particular in leukemia (neuroleukemiosis) and lymphoma (neurolymphomatosis). Its occurrence is much rarer in cancer, and even less so in sarcoma. The neoplastic infiltration of peripheral nerves by solid tumors is characterized by specific topographical sites such as the base of the skull, the ear, nose and throat region, and the cervico-brachial plexus as well as the lumbar and sacral plexus. Rarely malignant invasion affects the cranial nerves of the face where it can spread centripetally. Autonomic nerves and ganglia can also be affected. The retrograde spread of cancer in nerves is a bad prognostic sign. The clinical diagnosis is determined by tumor type, the pattern of involvement, and often pain.

Disseminated intravascular large-cell lymphoma with initial presentation mimicking Guillain-Barré syndrome

We report a patient with intravascular large B-cell lymphoma who initially presented with acute ascending weakness and sensory changes. Electrodiagnostic testing and cerebral spinal fluid (CSF) studies were initially suggestive of a demyelinating polyneuropathy. Further clinical evaluation and testing were consistent with mononeuropathy multiplex. Autopsy revealed disseminated intravascular large-cell lymphoma. Intravascular large-cell lymphoma should be considered in the differential diagnosis of a rapidly evolving neuropathy associated with other organ involvement.

Myopathy secondary to intravascular large B-cell lymphoma

We report a case of a 78-year-old woman presenting with progressive proximal muscle weakness mainly to lower limbs and myopathic EMG associated with intravascular large B-cell lymphoma. Muscle biopsy showed myopathic changes, intravascular large B-cell lymphoma but no inflammation or fibre necrosis; the patient's serum cross-reacted with an unidentified nuclear antigen of approximately 45 kDa present in muscle and lymphoma cells. Our case illustrates a myopathy associated with intravascular large B-cell lymphoma probably mediated by antibodies cross-reacting with a nuclear protein expressed by neoplastic cells and normal muscle. The nature of this nuclear antigen remains unidentified.