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Villasenor-Park J, Chung J, Kim EJ. Cutaneous B-Cell Lymphomas. Hematol Oncol Clin North Am 2024; 38:1111-1131. [PMID: 39048407 DOI: 10.1016/j.hoc.2024.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Primary cutaneous B-cell lymphomas represent a type of non-Hodgkin's lymphoma of the skin without evidence of extracutaneous involvement at the time of diagnosis. According to the 2018 World Health Organization-the European Organization for Research and Treatment of Cancer classification, primary cutaneous B-cell lymphomas include primary cutaneous marginal zone lymphoma, primary cutaneous follicle center lymphoma, primary cutaneous diffuse large B-cell lymphoma, leg type, intravascular large B-cell lymphoma, and Epstein-Barr virus+ mucocutaneous ulcer (provisional). Herein, we provide a comprehensive review of the updated literature on these entities, including clinical presentation, histopathology, immunophenotype, molecular genetics, prognosis, and treatment.
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Affiliation(s)
- Jennifer Villasenor-Park
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Jina Chung
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, 2 Maloney Building, 3600 Spruce Street, Philadelphia, PA 19104, USA
| | - Ellen J Kim
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Boulevard, Room 721, 7th floor, Philadelphia, PA 19104, USA.
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Oerding C, Niederstrasser O, Kaden I, Lepadatu A, Sorge E, Bethmann D, Wohlfarth K, Harder A. Rare intravascular large B-cell lymphoma (IVLBCL) can cause atypical intracerebral haemorrhage and mislead diagnostics. BMJ Case Rep 2024; 17:e260498. [PMID: 39306339 PMCID: PMC11418499 DOI: 10.1136/bcr-2024-260498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2024] [Indexed: 09/25/2024] Open
Abstract
Intravascular large B-cell lymphoma (IVLBCL) is a rare type of non-Hodgkin's lymphoma. Common neurological symptoms are cognitive impairment and dementia. Only a few cases have been published reporting intracranial haemorrhage due to IVLBCL. We present a case of a female patient in her late 60s who presented with an atypical intracerebral haemorrhage as the first major complication of an IVLBCL. The patient's condition declined rapidly. She died several weeks later due to haemorrhagic shock. The definitive diagnosis was achieved postmortem. Due to aggressive disease progression, the diagnosis of IVLBCL is still challenging and can therefore lead to incorrect or delayed treatment, especially in cases of unusual manifestations like lobar intracranial haemorrhage.
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Affiliation(s)
- Clemens Oerding
- Department of Neurology, BG-Hospital Bergmannstrost, 06112 Halle (Saale), Germany
| | - Olaf Niederstrasser
- Department of Neurology, BG-Hospital Bergmannstrost, 06112 Halle (Saale), Germany
| | - Ingmar Kaden
- Institute of Radiology and Neuroradiology of Radiology, BG-Hospital, Bergmannstrost, 06112 Halle (Saale), Germany
| | - Adina Lepadatu
- Institute of Neuropathology, University Medical Center, 55131 Mainz, Germany
| | - Eberhard Sorge
- Cure NF Research Group, Medical Faculty, Martin Luther University Halle-Wittenberg, 06108 Halle (Saale), Germany
| | - Daniel Bethmann
- Institute of Pathology, Sana-Klinikum, Berlin-Lichtenberg, 10365 Berlin-Lichtenberg, Germany
- Institute of Pathology, Faculty of Medicine, Martin Luther University Halle-Wittenberg, 06120 Halle, Germany
| | - Kai Wohlfarth
- Department of Neurology, BG-Hospital Bergmannstrost, 06112 Halle (Saale), Germany
| | - Anja Harder
- Cure NF Research Group, Medical Faculty, Martin Luther University Halle-Wittenberg, 06108 Halle (Saale), Germany
- Institute of Pathology, Faculty of Medicine, Martin Luther University Halle-Wittenberg, 06120 Halle, Germany
- Institute of Neuropathology, University of Münster, 48149 Muenster, Germany
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3
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Wei C, Zhai F, Jia C, Zhang W, Zhou D, Zhang Y. Immunochemotherapy triggered reversible cerebral vasoconstriction syndrome in a patient with intravascular large B-cell lymphoma. Leuk Lymphoma 2024; 65:848-851. [PMID: 38385620 DOI: 10.1080/10428194.2024.2316252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 02/03/2024] [Indexed: 02/23/2024]
Affiliation(s)
- Chong Wei
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Feifei Zhai
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Congwei Jia
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Wei Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Daobin Zhou
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Yan Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
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Bentivenga GM, Baiardi S, Righini L, Ladogana A, Capellari S, Sabattini E, Parchi P. Rapidly progressive dementia due to intravascular lymphoma: A prion disease reference center experience. Eur J Neurol 2024; 31:e16068. [PMID: 37738529 PMCID: PMC11235973 DOI: 10.1111/ene.16068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 09/05/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Intravascular large B-cell lymphoma (IVLBCL) is a rare extranodal lymphoma that is characterized by the selective growth of neoplastic cells in blood vessels, representing a potentially treatable cause of rapidly progressive dementia (RPD). Given its diverse clinical and instrumental presentation, it is often misdiagnosed with more common RPD causes, for example, Creutzfeldt-Jakob disease (CJD) or vascular dementia. METHODS This study presents the clinical and histopathological characteristics of four IVLBCL cases that we diagnosed post-mortem over 20 years among over 600 brain samples received as suspected CJD cases at our prion disease reference center. RESULTS Our patients exhibited various presenting symptoms, including behavioral disturbances, disorientation, and alertness fluctuations. The diagnostic tests performed at the time, including blood work, cerebrospinal fluid (CSF) analyses, electroencephalography, and neuroimaging, yielded nonspecific and occasionally misleading results. Consequently, the patients were repeatedly diagnosed as variably having CJD, epilepsy, vascular dementia, and encephalitis. The stored CSF samples of two patients tested negative at prion real-time quaking-induced conversion (RT-QuIC), which we performed afterwards for research purposes. Neuropathological analysis revealed a differential involvement of various brain areas, with frontotemporal neocortices being the most affected. CONCLUSIONS Our results confirm the significant clinical and instrumental heterogeneity of IVLBCL. Neuropathological evidence of the preferential involvement of frontotemporal neocortices, potentially conditioning the clinical phenotype, could be relevant to reach an early diagnosis. Finally, given the therapeutic implications of its misdiagnosis with CJD, we emphasize the utility of prion RT-QuIC as a test for ruling out CJD in these patients.
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Affiliation(s)
| | - Simone Baiardi
- Department of Biomedical and Neuromotor Sciences (DiBiNeM)University of BolognaBolognaItaly
- IRCCS, Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Lorenzo Righini
- Department of Biomedical and Neuromotor Sciences (DiBiNeM)University of BolognaBolognaItaly
| | - Anna Ladogana
- Department of NeuroscienceIstituto Superiore di SanitàRomeItaly
| | - Sabina Capellari
- Department of Biomedical and Neuromotor Sciences (DiBiNeM)University of BolognaBolognaItaly
- IRCCS, Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Elena Sabattini
- Haematopathology UnitIRCCS Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly
| | - Piero Parchi
- Department of Biomedical and Neuromotor Sciences (DiBiNeM)University of BolognaBolognaItaly
- IRCCS, Istituto delle Scienze Neurologiche di BolognaBolognaItaly
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Bhagat R, Shahab A, Karki Y, Budhathoki S, Sapkota M. Intravascular Lymphoma-Associated Stroke: A Systematic Review of Case Studies. Cureus 2023; 15:e50896. [PMID: 38249220 PMCID: PMC10799653 DOI: 10.7759/cureus.50896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
Intravascular lymphoma (IVL) is an aggressive systemic large B-cell lymphoma that is a rare cause of stroke. The clinical characteristics of stroke associated with IVL remain underexplored, contributing to diagnostic complexities and a high mortality rate. This study endeavors to elucidate the salient clinical and investigative features of stroke linked to this condition. A systematic review was performed using the PubMed database from the incident to August 2023 including search categories for IVL and stroke. All studies, excluding review articles, were included in this study. There were 58 cases with a confirmed diagnosis of IVL associated with stroke, with a mean age of 62.9 ± 9.6 years (female 50%). Classical lateralizing stroke symptoms were noted in only 69% of cases. Other clinical syndromes included altered sensorium (31%), rapidly progressive cognitive impairment (23%), seizures (22%), and gait disturbances (19%). Common hematological abnormalities included elevated lactate dehydrogenase (LDH, 97%), erythrocyte sedimentation rate (ESR, 79%), C-reactive protein (CRP, 61%), interleukin-2, microglobulins, and cerebrospinal fluid (CSF) protein. CSF flow cytometry was not diagnostic, and cytology was mostly negative. The dynamic pattern for DWI/T2 lesions was predominant and primarily located in the subcortical regions. Diffuse background slowing (64%) was a major finding in the electroencephalogram. Seventy-one percent of cases died (n=45) mostly due to delayed diagnosis. Only 31% were treated with first-line R-CHOP (rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine, prednisone) chemotherapy, among whom 25% died. This study suggests that IVL-associated strokes carry a high mortality rate, largely due to challenges in timely diagnosis and therapy. Unlike classical stroke syndrome, key indicators to aid in early diagnosis include a clinical syndrome of multiple non-lateralizing neurological symptoms, dynamic MRI DWI/T2-lesions primarily located in subcortical regions, elevated serum LDH, ESR, CRP, interleukins, microglobulin, CSF protein, and CSF polymerase chain reaction analysis, apart from tissue examination. Larger studies should be performed to establish diagnostic and predictive scores.
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Affiliation(s)
- Riwaj Bhagat
- Neurology, Conemaugh Memorial Medical Center, Johnstown, USA
| | - Asna Shahab
- Internal Medicine, Conemaugh Memorial Medical Center, Johnstown, USA
| | - Yukesh Karki
- Internal Medicine, Kathmandu Medical College, Kathmandu, NPL
| | - Samip Budhathoki
- Internal Medicine, Conemaugh Memorial Medical Center, Johnstown, USA
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Imaoka S, Maegaki M, Son D, Hamada T, Taniguchi SI. A Case of Weight Gain and Edema With Difficulty in Moving Legs Due to Intravascular Large B-cell Lymphoma Diagnosed by Skin Biopsy. Cureus 2023; 15:e51051. [PMID: 38269220 PMCID: PMC10805623 DOI: 10.7759/cureus.51051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2023] [Indexed: 01/26/2024] Open
Abstract
We report a case of intravascular large B-cell lymphoma (IVL) with spinal cord involvement. A 76-year-old woman was referred to our department due to generalized edema and weight gain. She also had difficulty moving her legs. She had no superficial lymphadenopathy upon examination. Her laboratory tests showed a markedly elevated blood lactate dehydrogenase (LDH) level. Although heart failure or interstitial lung disease was initially suspected, she was diagnosed with IVL by skin biopsy. An MRI revealed spinal cord involvement. Post-hospitalization, she began rituximab-combined chemotherapy. In this case, we considered that the spinal cord involvement of the lymphoma caused the neurogenic bladder and leg weakness. IVL often infiltrates the central nervous system and presents with neurological symptoms, including neurogenic bladder. Therefore, imaging studies should be planned to search for the involvement of the central nervous system in lymphoma if accompanied by neurological symptoms. In addition, in patients with a markedly elevated LDH or soluble interleukin-2 receptor level without lymphadenopathy, IVL should be suspected, and consultation with hematologists should be considered.
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Affiliation(s)
- Shintaro Imaoka
- Department of Community-Based Family Medicine, Tottori University, Yonago, JPN
| | - Masaya Maegaki
- Department of Hematology, Tottori University, Yonago, JPN
| | - Daisuke Son
- Department of Community-Based Family Medicine, Tottori University, Yonago, JPN
| | - Toshihiro Hamada
- Department of Community-Based Family Medicine, Tottori University, Yonago, JPN
| | - Shin-Ichi Taniguchi
- Department of Community-Based Family Medicine, Tottori University, Yonago, JPN
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Lee YP, Son SM, Kwon J. Asian variant intravascular large B-cell lymphoma with highly suspected central nervous system involvement: A case report. World J Clin Cases 2023; 11:8058-8064. [DOI: 10.12998/wjcc.v11.i33.8058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 11/01/2023] [Accepted: 11/10/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Intravascular large B-cell lymphoma (IVLBCL) is a rare subtype of extranodal lymphoma. In particular, the Asian variant of IVLBCL is characterized by hemophagocytic lymphohistiocytosis along with bone marrow involvement. However, central nervous system (CNS) involvement is uncommon in this variant compared to the Western variant. Here, we report a case of typical Asian variant IVLBCL with highly suspected CNS involvement and discuss the nature of the disease and its genetic aberration.
CASE SUMMARY A 67-year-old female patient complained of gradually worsening cognitive impairment. While hospitalized, she developed a high fever and showed marked bicytopenia. Intracranial imaging revealed a suspected leptomeningeal disease. Although no malignant cells were found in the cerebrospinal fluid (CSF), the protein and lactate dehydrogenase levels in CSF were increased. Bone marrow examination revealed an increased number of hemophagocytic histiocytes, and 18F-fluorodeoxyglucose (FDG) positron emission tomography with computerized tomography scan revealed increased FDG uptake in both adrenal glands, the liver, and the right ethmoid sinus. A tissue biopsy showed atypical large lymphoid cells with prominent nucleoli in the vessels, and the tumor cells were positive for CD20, BCL2, BCL6, and IRF4/MUM1. In addition, targeted sequencing identified MYD88, TET2, and PIM1 mutations. Consequently, we diagnosed the patient with the Asian variant of IVLBCL with highly suspected CNS involvement.
CONCLUSION Suspicion of IVLBCL and immediate diagnosis lead to timely treatment. Moreover, careful CNS examination at diagnosis is recommended.
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Affiliation(s)
- Yong-Pyo Lee
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju 28644, South Korea
| | - Seung-Myoung Son
- Department of Pathology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju 28644, South Korea
| | - Jihyun Kwon
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju 28644, South Korea
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Kitahara S, Kanazawa M, Natsumeda M, Sato A, Ishikawa M, Hara K, Tabe H, Makino K, Okamoto K, Fujita N, Kakita A, Fuji Y, Onodera O. Progressive conus medullaris lesions are suggestive of intravascular large B-cell lymphoma. Eur J Neurol 2023; 30:3236-3243. [PMID: 37350144 DOI: 10.1111/ene.15941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND AND PURPOSE Spinal cord lesions are observed in 40% of all central nervous system lesions in intravascular large B-cell lymphoma (IVLBCL). However, because IVLBCL is a very rare disease, its clinical features are not well defined, which may delay appropriate diagnosis and treatment, whilst the acute to subacute course of brain lesions in patients with IVLBCL is well established. Therefore, this study aimed to clarify the clinical features of spinal cord lesions in patients with IVLBCL. METHODS The medical records of patients with IVLBCL admitted to our hospital between 2010 and 2020 were searched. The inclusion criteria were preceding neurological symptoms without non-neurological symptoms and pathologically confirmed IVLBCL in various organs. Clinical features of spinal cord involvement in patients with IVLBCL were assessed and distinguished from those of brain involvement. RESULTS Sixteen consecutive patients with IVLBCL were divided into two groups: six patients with spinal involvement (spinal cord type) and 10 patients with brain involvement (brain type). In the spinal cord type, four patients had chronic progression and two had subacute progression. Acute progression (0% vs. 80.0%) and sudden onset (0% vs. 50.0%) occurred significantly less frequently in the spinal cord than in the brain. All spinal cord lesions involved the conus medullaris. CONCLUSIONS Spinal cord involvement in IVLBCL has a predominantly chronic progressive course that is exclusive to brain involvement. Conus medullaris lesions are suggestive of IVLBCL and are useful for early and accurate diagnosis and treatment.
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Affiliation(s)
- Sho Kitahara
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Masato Kanazawa
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Manabu Natsumeda
- Department of Neurosurgery, Brain Research Institute, Niigata University, Niigata, Japan
| | - Aki Sato
- Department of Neurology, Niigata City General Hospital, Niigata, Japan
| | - Masanori Ishikawa
- Department of Neurology, Niigata Prefectural Central Hospital, Niigata, Japan
| | - Kenju Hara
- Department of Neurology, Akita Red Cross Hospital, Akita, Japan
| | - Hiroyuki Tabe
- Department of Neurology, Niigata Prefectural Central Hospital, Niigata, Japan
| | - Kunihiko Makino
- Department of Neurology, Niigata Prefectural Shibata Hospital, Niigata, Japan
| | - Kouichirou Okamoto
- Department of Translational Research, Brain Research Institute, Niigata University, Niigata, Japan
| | - Nobuya Fujita
- Department of Neurology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Akiyoshi Kakita
- Department of Pathology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Yukihiko Fuji
- Department of Neurosurgery, Brain Research Institute, Niigata University, Niigata, Japan
| | - Osamu Onodera
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
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Stamm B, DiBiase R, Lee J, Primdahl D, Malavia T, Dixit K, Horbinski C, Kostelecky N, Elhodaky M, Potts MB, Caprio FZ, Bernstein RA, Urday S. A Woman With Multifocal Ischemic Strokes and Progressive Cognitive Impairment due to Intravascular Lymphoma. Stroke 2023; 54:e448-e451. [PMID: 37534510 DOI: 10.1161/strokeaha.123.043934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Affiliation(s)
- Brian Stamm
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL (B.S., R.D., J.L., D.P., T.M., K.D., M.B.P., F.Z.C., R.A.B., S.U.)
- Department of Neurology, University of Michigan, Ann Arbor (B.S.)
| | - Rebecca DiBiase
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL (B.S., R.D., J.L., D.P., T.M., K.D., M.B.P., F.Z.C., R.A.B., S.U.)
| | - Jessica Lee
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL (B.S., R.D., J.L., D.P., T.M., K.D., M.B.P., F.Z.C., R.A.B., S.U.)
| | - Ditte Primdahl
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL (B.S., R.D., J.L., D.P., T.M., K.D., M.B.P., F.Z.C., R.A.B., S.U.)
| | - Tulsi Malavia
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL (B.S., R.D., J.L., D.P., T.M., K.D., M.B.P., F.Z.C., R.A.B., S.U.)
| | - Karan Dixit
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL (B.S., R.D., J.L., D.P., T.M., K.D., M.B.P., F.Z.C., R.A.B., S.U.)
| | | | | | | | - Matthew B Potts
- Departments of Neurosurgery and Radiology (M.B.P.)
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL (B.S., R.D., J.L., D.P., T.M., K.D., M.B.P., F.Z.C., R.A.B., S.U.)
| | - Fan Z Caprio
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL (B.S., R.D., J.L., D.P., T.M., K.D., M.B.P., F.Z.C., R.A.B., S.U.)
| | - Richard A Bernstein
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL (B.S., R.D., J.L., D.P., T.M., K.D., M.B.P., F.Z.C., R.A.B., S.U.)
| | - Sebastian Urday
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL (B.S., R.D., J.L., D.P., T.M., K.D., M.B.P., F.Z.C., R.A.B., S.U.)
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Zhao CW, Fan TH, Denize T, Coraini A, Kraft A, Kumar AM, Gao LG, Lorenzo ME, Duncan LM, Camargo Faye EC, Lin DJ. Intravascular Lymphoma as a Cause of Recurrent Strokes - Case Report and Review of the Literature. Neurohospitalist 2023; 13:419-424. [PMID: 37701250 PMCID: PMC10494820 DOI: 10.1177/19418744231183483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Background Intravascular lymphoma is an uncommon cause of ischemic strokes. Because of its rarity and atypical pattern, most diagnoses are made post-mortem. Case study We present a case of a 68-year-old male with multiple cardiovascular risk factors and recent SARS-CoV-2 infection who presented with recurrent strokes. Because of his stroke risk factors, he was initially managed with a sequentially escalating antithrombotic regimen. A malignant process was low on the differential at this point given his lack of systemic symptoms. When he continued to have new strokes despite these measures, including a spinal cord infarct, a broad workup was sent including for hypercoagulable states, vasculitis, and intravascular lymphoma. Eventually, a skin biopsy of a cherry angioma returned positive for lymphoma cells. He was treated with methotrexate followed by chemotherapy and rituximab. Unfortunately, he did not improve and was made comfort measures only by his family. Conclusion This case illustrates the importance of considering intravascular lymphoma as a potential etiology of recurrent strokes, as early diagnosis and treatment are important for preventing irreversible neurological damage.
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Affiliation(s)
- Charlie Weige Zhao
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Tracey H. Fan
- Neurosciences Critical Care Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas Denize
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Alba Coraini
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew Kraft
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Anusha M. Kumar
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
| | - Lucy G. Gao
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Mayra E. Lorenzo
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
| | - Lyn M. Duncan
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | | | - David J. Lin
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Neurosciences Critical Care Unit, Massachusetts General Hospital, Boston, MA, USA
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11
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Haqi‐Ashtiani B, Moghaddam P, Barzkar F, Zare Mehrjerdi A, Almasi‐Dooghaee M. Mononeuropathy multiplex as an uncommon presentation of intravascular lymphoma: A case report. Clin Case Rep 2023; 11:e7575. [PMID: 37346885 PMCID: PMC10279939 DOI: 10.1002/ccr3.7575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/13/2023] [Accepted: 06/02/2023] [Indexed: 06/23/2023] Open
Abstract
Key Clinical Message Although intravascular lymphoma rarely presents with peripheral neuropathy, learning about this presentation can lead to timely diagnosis and improved prognosis in patients with intravascular lymphoma. Abstract A 64-year-old man presented with asymmetric paresthesia and subsequent weakness of his feet and a 10 kg weight loss over 40 days. Electrodiagnostic studies revealed distal axonal sensory-motor polyneuropathy with ongoing axonal loss. A peroneal nerve biopsy showed intravascular proliferation of CD-20 positive lymphocytes, which suggested intravascular large B-cell lymphoma.
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Affiliation(s)
- Bahram Haqi‐Ashtiani
- Firoozgar Hospital, School of MedicineIran University of Medical SciencesTehranIran
| | - Parichehr Moghaddam
- Firoozgar Hospital, School of MedicineIran University of Medical SciencesTehranIran
| | - Farzaneh Barzkar
- Center for Educational Research in Medical Sciences(CERMS), School of MedicineIran University of Medical SciencesTehranIran
| | - Ali Zare Mehrjerdi
- Firoozgar Clinical Research Development Center (FCRDC), Department of PathologyIran University of Medical SciencesTehranIran
| | - Mostafa Almasi‐Dooghaee
- Firoozgar Hospital, School of MedicineIran University of Medical SciencesTehranIran
- Firoozgar Clinical Research Development Center (FCRDC), Department of NeurologyIran University of Medical SciencesTehranIran
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Mesbah-Oskui L, Cairns J, Marzoughi S, Chen T. Ascending paralysis, seizure and reduced consciousness. Pract Neurol 2023; 23:178-181. [PMID: 35534194 DOI: 10.1136/practneurol-2022-003383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Lia Mesbah-Oskui
- Division of Neurology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - James Cairns
- Division of Neurology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sina Marzoughi
- Division of Neurology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tychicus Chen
- Division of Neurology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Pons-Escoda A, Naval-Baudin P, Velasco R, Vidal N, Majós C. Imaging of Lymphomas Involving the CNS: An Update-Review of the Full Spectrum of Disease with an Emphasis on the World Health Organization Classifications of CNS Tumors 2021 and Hematolymphoid Tumors 2022. AJNR Am J Neuroradiol 2023; 44:358-366. [PMID: 36822829 PMCID: PMC10084903 DOI: 10.3174/ajnr.a7795] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 01/19/2023] [Indexed: 02/25/2023]
Abstract
Lymphomas of the CNS are the second most frequent primary brain malignancy in adults after gliomas. Presurgical suspicion of lymphoma greatly impacts patient management. The radiologic features of this tumor have been widely covered in the literature for decades, but under current classifications, mainly corresponding to the most common presentations of the most frequent type: primary diffuse large B-cell lymphoma of the CNS. Nevertheless, rarer presentations of this specific lymphoma and of other World Health Organization lymphoma subtypes with different imaging features are rarely treated. Moreover, important advances in imaging techniques, changing epidemiologic factors with relevant impact on these tumors (eg, immunodeficiency/dysregulation), and recent updates of the World Health Organization Classification of CNS Tumors 2021 and Hematolymphoid Tumors 2022 may have rendered some accepted concepts outdated. In this article, the authors aim to fulfill a critical need by providing a complete update-review, emphasizing the latest clinical-radiologic features of the full spectrum of lymphomas involving the CNS.
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Affiliation(s)
- A Pons-Escoda
- From the Radiology (A.P.-E., P.N.-B., C.M.)
- Neurooncology Unit (A.P.-E., R.V., N.V., C.M.), Institut d'Investigació Biomèdica de Bellvitge, Barcelona, Spain
| | | | - R Velasco
- Neurooncology Unit (A.P.-E., R.V., N.V., C.M.), Institut d'Investigació Biomèdica de Bellvitge, Barcelona, Spain
- Institute of Neurosciences and Department of Cell Biology, Physiology and Immunology (R.V.), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - N Vidal
- Pathology Departments (N.V.), Hospital Universitari de Bellvitge, Barcelona, Spain
- Neurooncology Unit (A.P.-E., R.V., N.V., C.M.), Institut d'Investigació Biomèdica de Bellvitge, Barcelona, Spain
| | - C Majós
- From the Radiology (A.P.-E., P.N.-B., C.M.)
- Neurooncology Unit (A.P.-E., R.V., N.V., C.M.), Institut d'Investigació Biomèdica de Bellvitge, Barcelona, Spain
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14
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Puente-Hernandez M, Rivero-de-Aguilar A, Varela-Lema L. Cancer-associated spinal cord infarction: A systematic review and analysis of survival predictors. J Neurol Sci 2023; 446:120580. [PMID: 36764185 DOI: 10.1016/j.jns.2023.120580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/09/2022] [Accepted: 01/31/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVE The association between spinal cord infarction (SCI) and cancer is an infrequent condition but requires an accurate diagnosis to establish the appropriate treatment. Clinical features and prognosis of cancer-associated SCI have never been assessed. The aim of this systematic review is to describe the characteristics and outcomes of patients with cancer-associated SCI. Illustratively, a case of ovarian cancer-related SCI is presented. MATERIAL AND METHODS Two authors independently analysed three different bibliographic databases looking for cancer-associated SCI case reports and case series. Data regarding age, sex, cardiovascular risk factors (CVRF), history of known cancer, infarction localization, spinal cord syndrome, Zalewski criteria classification, mechanism of ischemia, diagnostic tests, treatment and functional outcome were registered. A statistical analysis was carried out to identify factors related to mortality and survival time. RESULTS A total of 48 articles met the inclusion criteria and 52 patients were identified. The median age was 62 years. The most frequent neoplasm was intravascular large B-cell lymphoma. The median survival time was 17.4 weeks and the cumulative probability of survival at 12 months was 16.3%. In the group of deceased patients there was a higher proportion of malignant neoplasms than in those who survived (94.7% vs. 5.3%, p < 0.01). There were no statistically significant differences in terms of mortality or survival time depending on age, previously known cancer or CVRF. CONCLUSION Cancer-associated SCI entails a poor outcome. Mortality is increased in patients with malignant neoplasm. No other prognosis factors could be identified.
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Affiliation(s)
| | - Alejandro Rivero-de-Aguilar
- Department of Neurology, University Hospital of the Canary Islands, carretera Ofra S/N, La Laguna, Tenerife, Spain
| | - Leonor Varela-Lema
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, Praza do Obradoiro, Santiago de Compostela, A Coruña, Spain; Consortium for Biomedical Research in Respiratory Diseases (CIBER de Enfermedades Respiratorias/CibeRes), Av. de Monforte de Lemos 3-5, Madrid, Spain
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15
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Magriço M, Ventura R, Sobral-Pinho A, Pinto DG, Marto JP. Intravascular lymphoma presenting as longitudinally extensive myelitis: a remarkable diagnostic challenge. Acta Neurol Belg 2023:10.1007/s13760-023-02224-y. [PMID: 36869210 DOI: 10.1007/s13760-023-02224-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 02/21/2023] [Indexed: 03/05/2023]
Affiliation(s)
- Marta Magriço
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Rua da Junqueira 126, 1349-019, Lisbon, Portugal.
| | - Rita Ventura
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Rua da Junqueira 126, 1349-019, Lisbon, Portugal
| | - André Sobral-Pinho
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Rua da Junqueira 126, 1349-019, Lisbon, Portugal
| | - Daniel Gomes Pinto
- Department of Anatomic Pathology, Hospital Garcia de Orta, Almada, Portugal.,NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - João Pedro Marto
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Rua da Junqueira 126, 1349-019, Lisbon, Portugal.,NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
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16
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Puac-Polanco P, Zakhari N, Jansen GH, Torres C. Case 309: Autoimmune Glial Fibrillary Acidic Protein Astrocytopathy. Radiology 2023; 306:293-298. [PMID: 36534605 DOI: 10.1148/radiol.211954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
HISTORY A 64-year-old man presented with a 6-month history of lightheadedness and intermittent balance and coordination difficulties. Two months before admission, symptoms became more substantial and persistent, with a worsening sense of disequilibrium and unsteady gait. He reported difficulties pronouncing words and mild word-finding difficulties. His wife noted a change in his cognition and memory over the same time. His medical history included well-controlled chronic obstructive pulmonary disease (COPD) secondary to a long history of smoking with associated unintentional 30-lb (13.6-kg) weight loss over the previous 3 years, for which chest CT scanning was performed, revealing no abnormality. On clinical examination, the patient was alert and oriented but had slurred speech. A positive Romberg sign was noted, finger-to-nose and hand rapid alternating movement tests revealed impairment on the right side, and his gait was ataxic. The motor examination revealed normal muscle tone, bulk, and power in the upper and lower extremities. Sensory testing results were normal. Initial MRI of the brain at admission revealed abnormal findings in the left supratentorial brain. Of note, this patient's presentation predated the COVID-19 pandemic. Cerebrospinal fluid (CSF) analysis revealed predominant pleocytosis (23 × 106/L; normal range, [0-5] × 106/L) (78% lymphocytes, 22% monocytes), elevated protein level (1.23 g/L; normal range, 0.19-0.64 g/L), oligoclonal bands (faint one or two), and a high immunoglobulin G (IgG) index (0.130 g/L; normal reference, ≤0.059 g/L). Despite extensive initial work-up for inflammatory, infectious, autoimmune, or neoplastic causes, a definitive diagnosis was not reached. Thus, repeat MRI of the brain was performed 2 weeks after admission.
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Affiliation(s)
- Paulo Puac-Polanco
- From the Division of Neuroradiology, Department of Radiology, Radiation Oncology, and Medical Physics (P.P.P., N.Z., C.T.), and Department of Pathology and Laboratory Medicine (G.H.J.), University of Ottawa, The Ottawa Hospital Civic Campus, 1053 Carling Ave, Ottawa, ON, Canada K1Y 4E9; and Neuroscience Program, The Ottawa Hospital Research Institute, Ottawa, Canada (C.T.)
| | - Nader Zakhari
- From the Division of Neuroradiology, Department of Radiology, Radiation Oncology, and Medical Physics (P.P.P., N.Z., C.T.), and Department of Pathology and Laboratory Medicine (G.H.J.), University of Ottawa, The Ottawa Hospital Civic Campus, 1053 Carling Ave, Ottawa, ON, Canada K1Y 4E9; and Neuroscience Program, The Ottawa Hospital Research Institute, Ottawa, Canada (C.T.)
| | - Gerard H Jansen
- From the Division of Neuroradiology, Department of Radiology, Radiation Oncology, and Medical Physics (P.P.P., N.Z., C.T.), and Department of Pathology and Laboratory Medicine (G.H.J.), University of Ottawa, The Ottawa Hospital Civic Campus, 1053 Carling Ave, Ottawa, ON, Canada K1Y 4E9; and Neuroscience Program, The Ottawa Hospital Research Institute, Ottawa, Canada (C.T.)
| | - Carlos Torres
- From the Division of Neuroradiology, Department of Radiology, Radiation Oncology, and Medical Physics (P.P.P., N.Z., C.T.), and Department of Pathology and Laboratory Medicine (G.H.J.), University of Ottawa, The Ottawa Hospital Civic Campus, 1053 Carling Ave, Ottawa, ON, Canada K1Y 4E9; and Neuroscience Program, The Ottawa Hospital Research Institute, Ottawa, Canada (C.T.)
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17
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Schattner A, Dubin I, Iluz M, Glick Y. Diffuse large B-cell lymphoma presenting with paraparesis. QJM 2022; 115:629-630. [PMID: 35608308 DOI: 10.1093/qjmed/hcac132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- A Schattner
- Department of Medicine, Laniado Hospital, Sanz Medical Centre, Netanya, Israel
- Faculty of Medicine, Hebrew University and Hadassah Medical School, Jerusalem, 91120, Israel
| | - I Dubin
- Department of Medicine, Laniado Hospital, Sanz Medical Centre, Netanya, Israel
| | - M Iluz
- Department of Radiology, Tel Aviv Sourasky Medical Center, Jerusalem, Israel
| | - Y Glick
- Department of Imaging, Laniado Hospital, Sanz Medical Centre, Netanya, Israel
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18
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Rehabilitation Course and Management of Intravascular Lymphoma Presenting as Recurrent Strokes: A Case Report. REHABILITATION ONCOLOGY 2022. [DOI: 10.1097/01.reo.0000000000000319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Kaji FA, Martinez‐Calle N, Sovani V, Fox CP. Rare central nervous system lymphomas. Br J Haematol 2022; 197:662-678. [PMID: 35292959 PMCID: PMC9310777 DOI: 10.1111/bjh.18128] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/15/2022] [Accepted: 02/23/2022] [Indexed: 11/29/2022]
Abstract
Central nervous system (CNS) lymphomas are rare malignancies characterised by lymphoid infiltration into the brain, spinal cord, cranial nerves, meninges and/or eyes in the presence or absence of previous or concurrent systemic disease. Most CNS lymphomas are of the diffuse large B-cell lymphoma (DLBCL) subtype for which treatment strategies, particularly the use of high-dose methotrexate-based protocols and consolidation with autologous stem cell transplantation, are well established. Other histopathological subtypes of CNS lymphoma are comparatively less common with published data on these rare lymphomas dominated by smaller case series and retrospective reports. Consequently, there exists little clinical consensus on the optimal methods to diagnose and manage these clinically and biologically heterogeneous CNS lymphomas. In this review article, we focus on rarer CNS lymphomas, summarising the available clinical data on incidence, context, diagnostic features, reported management strategies, and clinical outcomes.
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Affiliation(s)
- Furqaan Ahmed Kaji
- Clinical HaematologyNottingham University Hospitals NHS TrustNottinghamUK
| | | | - Vishakha Sovani
- Department of HistopathologyNottingham University Hospitals NHS TrustNottinghamUK
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20
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Tsukamoto E, Tanei T, Kato T, Hasegawa T. Intravascular Large B-Cell Lymphoma Diagnosed by Open Brain Biopsy and Achievement of Remission After Early Initiation of Chemotherapy: Case Report. Cureus 2022; 14:e21971. [PMID: 35282552 PMCID: PMC8905658 DOI: 10.7759/cureus.21971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2022] [Indexed: 12/26/2022] Open
Abstract
A 60-year-old man presented with progressive disturbance of consciousness. His father had died of malignant lymphoma, while his mother and sister died of acute leukemia. Magnetic resonance imaging (MRI) revealed multiple high-intensity lesions in the bilateral cerebral hemispheres on diffusion-weighted images. Serum soluble interleukin 2 receptor was 5,640 U/mL. Screenings of blood antibodies known to rise in autoimmune diseases were all normal. Cerebrospinal fluid examinations demonstrated slight elevation of protein and glucose, while the oligoclonal band and myelin basic protein were not elevated. Biopsies of bone marrow and random skin did not show any malignant features. His consciousness gradually deteriorated over a week, with lesions in his right frontal, left temporal, and bilateral parietal lobes shown to be growing. Therefore, open brain biopsy was performed, and one block of the right frontal lesion was harvested. Histological examination revealed atypical large cells only in the capillaries. Although immunohistochemical examinations showed positive staining for CD20, they were negative for CD3. Histopathological diagnosis was intravascular large B-cell lymphoma. After undergoing six cycles of intravenous chemotherapy with rituximab, cyclophosphamide, doxorubicin, and prednisone, his consciousness and neurological symptoms improved, and he appeared to achieve remission. Two years later, there have been no apparent recurrences, and the brain lesions have disappeared.
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21
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Wu M, Lin Y, Huang X, Zhang B. Intravascular large B-cell lymphoma presenting as rapidly progressive dementia and stroke: A case report. Medicine (Baltimore) 2021; 100:e27996. [PMID: 35049207 PMCID: PMC9191555 DOI: 10.1097/md.0000000000027996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/11/2021] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Intravascular large B-cell lymphoma (IVLBCL) is a rare form of large B-cell non-Hodgkin lymphoma. The diagnosis is challenging and frequently made at biopsy. Here we reported a case of IVLBCL limited to the central nervous system (CNS) presenting with progressive dementia and acute stroke, who was diagnosed by brain biopsy. PATIENT CONCERNS A 47-year-old woman was transferred to our hospital with a 6-month history of rapidly progressive dementia, and left limb weakness and numbness for 3 days. She was successively misdiagnosed with inflammatory demyelinating disease and stroke. Her condition deteriorated with elevated lactate dehydrogenase and multiple hyperintense lesions on the brain. DIAGNOSIS She was diagnosed with IVLBCL limited to the CNS by brain biopsy. INTERVENTIONS Bone marrow puncture and incisional random skin biopsy were not found neoplastic cells. Computed tomography scans were normal with no evidence of disease outside the CNS. OUTCOMES The patient died due to rapid clinical aggravation. LESSONS IVLBCL limited to the CNS is an aggressive disease with high mortality. Making a timely and correct diagnosis is crucial for early appropriate treatment in IVLBCL patients.
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Affiliation(s)
- Ming Wu
- Department of Neurology, Longgang District People's Hospital of Shenzhen, China
| | - Yinyao Lin
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, China
| | - Xuehong Huang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, China
| | - Bingjun Zhang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, China
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22
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Neurologic complications in patients with lymphoid cancer. Blood 2021; 139:1469-1478. [PMID: 34479368 DOI: 10.1182/blood.2019003690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 02/09/2021] [Indexed: 11/20/2022] Open
Abstract
Neurologic complications of lymphoid cancer can be challenging to recognize and treat. The nervous system can be affected directly by hematogenous or local spread of lymphoma. Indirect neurologic effects of lymphoma include paraneoplastic syndromes and vascular complications. Lymphoma treatments can also cause neurologic complications. Early identification and treatment are crucial to stabilize or reverse neurologic deficits, prevent further nervous system injury, and to optimize overall oncologic therapy. This article provides an overview of different neurologic complications of lymphoma and its treatments, in addition to presentation of case studies that emphasize commonly encountered clinical scenarios.
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23
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1214] [Impact Index Per Article: 404.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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24
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Klotz S, Gelpi E. [Neuropathology of dementia]. Wien Med Wochenschr 2021; 171:257-273. [PMID: 34129141 PMCID: PMC8397629 DOI: 10.1007/s10354-021-00848-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 04/14/2021] [Indexed: 11/09/2022]
Abstract
Demenz ist die klinische Folge verschiedener neurologischer Erkrankungen mit einer Vielzahl von Ätiologien. Dabei ist die genaue Kenntnis der zugrunde liegenden pathologischen Veränderungen entscheidend für die passgenaue Versorgung der Patienten und für die Entwicklung geeigneter Krankheitsbiomarker. Eine definitive Diagnose vieler dieser Erkrankungen, insbesondere der neurodegenerativen Formen, kann nur nach gründlicher postmortaler neuropathologischer Untersuchung gestellt werden. Dies unterstreicht die Wichtigkeit der Durchführung einer Gehirnautopsie und die Relevanz einer engen Zusammenarbeit zwischen Klinikern, Neuroradiologen und Neuropathologen sowie mit Grundlagenforschern. Ziel der vorliegenden Arbeit ist es, einen kurzen Überblick über die Neuropathologie der Demenz mit Schwerpunkt auf neurodegenerative Erkrankungen zu geben, um die interdisziplinäre Zusammenarbeit weiter zu fördern.
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Affiliation(s)
- Sigrid Klotz
- Abteilung für Neuropathologie und Neurochemie, Universitätsklinik für Neurologie, Medizinischer Universitätscampus Wien, Ebene 4J, Währinger Gürtel 18-20, 1090, Wien, Österreich.,Österreichisches Referenzzentrum zur Erfassung und Dokumentation menschlicher Prionen-Erkrankungen (ÖRPE), Wien, Österreich
| | - Ellen Gelpi
- Abteilung für Neuropathologie und Neurochemie, Universitätsklinik für Neurologie, Medizinischer Universitätscampus Wien, Ebene 4J, Währinger Gürtel 18-20, 1090, Wien, Österreich. .,Österreichisches Referenzzentrum zur Erfassung und Dokumentation menschlicher Prionen-Erkrankungen (ÖRPE), Wien, Österreich.
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25
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Maiese A, La Russa R, De Matteis A, Frati P, Fineschi V. Post-mortem diagnosis of intravascular large B-cell lymphoma. J Int Med Res 2021; 48:300060520924262. [PMID: 32485117 PMCID: PMC7273565 DOI: 10.1177/0300060520924262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Intravascular large B-cell lymphoma (IVLBCL) is a rare (<1%), typically aggressive
extranodal variant of mature non-Hodgkin B-cell lymphoma. IVLBCL is characterized by
malignant lymphoid cells lodged within blood vessels, particularly capillary channels.
Herein, we present a case of a 50-year-old man with a history of myeloradiculitis (∼1
year) and paraparesis requiring hospitalization. During the course of his hospital stay,
computed tomography (CT), magnetic resonance imaging, CT-positron emission tomography, and
biopsy failed to establish a diagnosis. The patient died 2 months later from bilateral
pneumonia. Postmortem examination was undertaken to determine the cause of death.
Histologic sections of the patient’s brain, heart, lung, and liver showed aggregates of
highly atypical cells bearing enlarged, pleomorphic, and hyperchromatic nuclei. Strong
intravascular positivity for CD45 and CD20 markers indicated the cells were of B-cell
origin, supporting a diagnosis of IVLBCL.
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Affiliation(s)
- Aniello Maiese
- Section of Legal Medicine, Department of Surgical Pathology, Medical, Molecular and Critical Area, University of Pisa, Pisa, Italy
| | - Raffaele La Russa
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Alessandra De Matteis
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome, Italy.,IRCCS Neuromed, Pozzilli, Italy
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26
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Turin CG, Ting K, Bradshaw A, Dunham SR, Nunez-Wallace K, Patel SM, Dangayach P, Holdener S, Lin WC. Central nervous system intravascular lymphoma leading to rapidly progressive dementia. Proc (Bayl Univ Med Cent) 2021; 34:373-375. [PMID: 33953465 DOI: 10.1080/08998280.2020.1866943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Intravascular lymphoma is an uncommon subtype of B-cell lymphoma with neoplastic cells limited to the lumen of small blood vessels. We report a case of a 52-year-old man who presented with constitutional symptoms and rapidly progressive dementia. He was found to have diffuse leptomeningeal and faint parenchymal enhancement on magnetic resonance imaging and was subsequently diagnosed with intravascular lymphoma following a brain biopsy. He responded remarkably well to systemic and intrathecal chemotherapy. The diagnosis and treatment of intravascular lymphoma have been guided by a few case reports and are largely based on expert opinion.
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Affiliation(s)
- Christie G Turin
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Kevin Ting
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Anthony Bradshaw
- Department of Neurology, Baylor College of Medicine, Houston, Texas
| | - S Richard Dunham
- Department of Neurology, Baylor College of Medicine, Houston, Texas
| | | | - Shital M Patel
- Division of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Priti Dangayach
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Stephanie Holdener
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas
| | - Weei-Chin Lin
- Department of Medicine, Baylor College of Medicine, Houston, Texas.,Division of Hematology-Oncology, Department of Medicine, Baylor College of Medicine, Houston, Texas
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27
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Affiliation(s)
- Kenta Orimo
- Department of Neurology, Yokohama Rosai Hospital, Japan
| | - Takuya Sasaki
- Department of Neurology, Yokohama Rosai Hospital, Japan
| | - Yukio Kakuta
- Department of Pathology, Yokohama Rosai Hospital, Japan
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28
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Liu Z, Zhang Y, Zhu Y, Zhang W. Prognosis of Intravascular Large B Cell Lymphoma (IVLBCL): Analysis of 182 Patients from Global Case Series. Cancer Manag Res 2020; 12:10531-10540. [PMID: 33122951 PMCID: PMC7591067 DOI: 10.2147/cmar.s267825] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/08/2020] [Indexed: 01/10/2023] Open
Abstract
Purpose This study provides an overview of the prognosis of intravascular large B cell lymphoma (IVLBCL) over the past 10 years and analyzes the possible relevant factors. Patients and Methods We conducted a literature search of case reports, case series, and retrospective studies of IVLBCL published from January 2008 to July 2018. After excluding inappropriate data, 103 publications were selected for the analysis. Statistical analyses of different treatment modalities, the effect of blood–brain barrier (BBB)-penetrating drugs, and prognostic factors for outcomes were performed. Results In total, 182 pathologically confirmed cases of IVLBCL were included in our study. The results revealed that the 1- and 3-year overall survival rates were 42.3 and 11.5%, respectively, whereas the median overall survival was 340 days. Overall survival (450 days vs 180 days) and progression-free survival (420 days vs 150 days) were significantly longer in patients who received rituximab-containing regimens than in those treated with other regimens. For IVLBCL involving the CNS, regimens containing BBB-penetrating drugs failed to provide an additional survival benefit. In addition, lactic dehydrogenase levels ≥700 U/L, CNS involvement, and hemophagocytic syndrome were identified as unfavorable risk factors in patients with IVLBCL, whereas skin involvement appeared to be a protective factor. Conclusion Rituximab-containing chemotherapy can improve the outcomes of patients with IVLBCL, but the prognosis remains unsatisfactory. Treatment regimens containing BBB-penetrating drugs failed to improve outcomes in patients with CNS-involved IVLBCL. Several factors affect the prognosis of patients with IVLBCL, and further research on the underlying mechanisms is needed.
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Affiliation(s)
- Ziyue Liu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yuelun Zhang
- Central Research Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yicheng Zhu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Wei Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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29
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Psychiatric Disturbance or Parkinsonism as a Presentation of CNS Lymphoma: Observational Retrospective Study and Review of Literature. Am J Clin Oncol 2020; 43:727-733. [PMID: 32694297 DOI: 10.1097/coc.0000000000000738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the incidence of and characterize the presentation of neuropsychiatric symptoms and/or Parkinsonism as a presentation of central nervous system lymphoma (CNSL) in either its primary CNSL form or when it spreads to the brain in systemic diffuse large B-cell lymphoma (secondary CNSL). PATIENTS AND METHODS With Institutional Review Board approval we identified patients who had been treated at Mayo Clinic from 1998 to 2018 and were recorded to have a combination of ICD 9/10 codes for CNSL and various psychiatric diagnoses. RESULTS A total of 20 of the 232 patients (9%) were noted to have neuropsychiatric symptoms preceding diagnosis. The average age at diagnosis was 62, with even split for sex. The majority (85%) of patients had primary CNSL. The average duration of symptoms before the diagnosis was 4.8 months. Confusion (80%), depression (40%), apathy (30%), anxiety (30%), and agitation (30%) were the most common symptoms identified. The majority (65%) of patients had subcortical lesions followed by the frontal lobe (50%). Parkinsonism was identified in 5 of the 20 patients with 4 demonstrating resolution of symptoms with treatment of the lymphoma. CONCLUSIONS Neuropsychiatric symptoms are a rare but notable symptom before the presentation of CNSL. There is an increasing awareness of neurological illness presenting as pure psychiatric disturbance, prompting the need to exclude organic and treatable diseases, particularly in elderly patients. Acknowledgment and diagnosis are important for an appropriate management as there is a significant impact on patient and caregiver quality of life.
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Lun R, Niznick N, Padmore R, Mack J, Shamy M, Stotts G, Blacquiere D. Clinical Reasoning: Recurrent strokes secondary to unknown vasculopathy. Neurology 2020; 94:e2396-e2401. [PMID: 32414879 DOI: 10.1212/wnl.0000000000009534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Ronda Lun
- From the Divisions of Neurology (R.L., N.N., M.S., G.S., D.B.) and Hematology (J.M.), Department of Medicine, and Division of Hematopathology, Department of Pathology and Laboratory Medicine, Ottawa and Eastern Ontario Regional Laboratory Association (R.P.), The Ottawa Hospital, Canada.
| | - Naomi Niznick
- From the Divisions of Neurology (R.L., N.N., M.S., G.S., D.B.) and Hematology (J.M.), Department of Medicine, and Division of Hematopathology, Department of Pathology and Laboratory Medicine, Ottawa and Eastern Ontario Regional Laboratory Association (R.P.), The Ottawa Hospital, Canada
| | - Ruth Padmore
- From the Divisions of Neurology (R.L., N.N., M.S., G.S., D.B.) and Hematology (J.M.), Department of Medicine, and Division of Hematopathology, Department of Pathology and Laboratory Medicine, Ottawa and Eastern Ontario Regional Laboratory Association (R.P.), The Ottawa Hospital, Canada
| | - Jonathan Mack
- From the Divisions of Neurology (R.L., N.N., M.S., G.S., D.B.) and Hematology (J.M.), Department of Medicine, and Division of Hematopathology, Department of Pathology and Laboratory Medicine, Ottawa and Eastern Ontario Regional Laboratory Association (R.P.), The Ottawa Hospital, Canada
| | - Michel Shamy
- From the Divisions of Neurology (R.L., N.N., M.S., G.S., D.B.) and Hematology (J.M.), Department of Medicine, and Division of Hematopathology, Department of Pathology and Laboratory Medicine, Ottawa and Eastern Ontario Regional Laboratory Association (R.P.), The Ottawa Hospital, Canada
| | - Grant Stotts
- From the Divisions of Neurology (R.L., N.N., M.S., G.S., D.B.) and Hematology (J.M.), Department of Medicine, and Division of Hematopathology, Department of Pathology and Laboratory Medicine, Ottawa and Eastern Ontario Regional Laboratory Association (R.P.), The Ottawa Hospital, Canada
| | - Dylan Blacquiere
- From the Divisions of Neurology (R.L., N.N., M.S., G.S., D.B.) and Hematology (J.M.), Department of Medicine, and Division of Hematopathology, Department of Pathology and Laboratory Medicine, Ottawa and Eastern Ontario Regional Laboratory Association (R.P.), The Ottawa Hospital, Canada
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Koujanian S, Al-Rawaf S, Zang E, Provias J. Intravascular large B-cell lymphoma of the central nervous system, a masquerader on radiography and clinical presentation: A case report. HUMAN PATHOLOGY: CASE REPORTS 2020. [DOI: 10.1016/j.hpcr.2019.200297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Yaura K, Watanabe G, Nakamura T, Tsukita K, Suzuki H, Suzuki Y. [Intravascular large B-cell lymphoma with multiple intracranial hemorrhages diagnosed by brain biopsy]. Rinsho Shinkeigaku 2020; 60:206-212. [PMID: 32101844 DOI: 10.5692/clinicalneurol.cn-001373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Central nervous system intravascular lymphoma sometimes includes multiple lesions mimicking cerebral infarction. Herein, we report our experience with a case of intravascular large B-cell lymphoma (IVLBCL) with multiple hemorrhages. A 53-year-old woman was admitted to our hospital with clonic convulsions of the left upper limb. Brain MRI revealed a large number of high-intensity areas on FLAIR and low-intensity areas on susceptibility-weighted imaging (SWI). Chest CT showed bilateral multiple high-density lesions in the lungs. Biopsy of pulmonary lesions revealed no abnormal cells. Levetiracetam was administered to prevent the seizures that were assumed to occur due to the cerebral cortex lesions; however, convulsive seizure recurred with a depressed level of consciousness. On a repeat brain MRI examination, severe, multiple new lesions were shown to have developed bilaterally in the cerebral cortex and white matter, exhibiting spotty low intensities on SWI. Biopsy of a new cerebral lesion was carried out and the lesion was pathologically diagnosed as IVLBCL with hemorrhages. IVLBCL should be noted as one of the differential diagnoses not only in case with multiple infarct lesions, but also in case with multiple hemorrhages.
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Affiliation(s)
- Kazuma Yaura
- Department of Neurology, National Hospital Organization, Sendai Medical Center
| | - Genya Watanabe
- Department of Neurology, National Hospital Organization, Sendai Medical Center
| | - Takaaki Nakamura
- Department of Neurology, National Hospital Organization, Sendai Medical Center
| | - Kenichi Tsukita
- Department of Neurology, National Hospital Organization, Sendai Medical Center
| | - Hiroyoshi Suzuki
- Department of Pathology, National Hospital Organization, Sendai Medical Center
| | - Yasushi Suzuki
- Department of Neurology, National Hospital Organization, Sendai Medical Center
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Wong C, Wills AJ, Samarasekera N, Noble D, Smith C, Davenport R. Elderly woman with subacute lower limb weakness and rapid systemic decline. Pract Neurol 2020; 20:168-174. [PMID: 32001663 DOI: 10.1136/practneurol-2019-002476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2020] [Indexed: 11/04/2022]
Abstract
A 74-year-old woman developed bilateral leg weakness, with fluctuating cognitive and systemic symptoms that progressed despite treatment. Her diagnosis was confirmed at autopsy. Her case was discussed at the Edinburgh Clinical Neurology Course 2019 Clinicopathological Conference.
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Affiliation(s)
- Charis Wong
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK .,Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK
| | - Adrian J Wills
- Department of Neurology, Queens Medical Centre, Nottingham, UK
| | | | - Donald Noble
- Department of General Medicine, St John's Hospital, Livingston, UK
| | - Colin Smith
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.,Department of Neuropathology, University of Edinburgh, Edinburgh, UK
| | - Richard Davenport
- Centre of Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.,Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
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Intravascular Lymphoma with Progressive CNS Hemorrhage and Multiple Dissections. Case Rep Neurol Med 2020; 2020:6134830. [PMID: 32547798 PMCID: PMC7201472 DOI: 10.1155/2020/6134830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/22/2019] [Accepted: 09/10/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction Intravascular lymphoma (IVL) is an uncommon and often fatal disease characterized by intraluminal proliferation of lymphomatous cells within blood vessels. Because of a heterogeneous clinical presentation and lack of sensitive diagnostic protocols, diagnosis of IVL is most often made at autopsy. However, with early diagnosis and appropriate chemotherapy, the prognosis is greatly improved and complete remission is possible. In order to broaden the possible presentations of IVL, we present a patient with an atypical manifestation of biopsy-proven intravascular large B-cell lymphoma who suffered dissections of both intracranial and extracranial arteries in addition to progressive intracranial hemorrhages. Case Report. A 47-year-old woman presented with unilateral paresthesias. She developed progressive multifocal infarcts and hemorrhage with dissections of both intracranial and extracranial arteries, resulting in coma. Brain biopsy revealed IVL. She received aggressive chemotherapy and remains in complete remission with good neurologic recovery. Conclusion IVL is known to exert its pathology on small arteries and capillaries, but is not known to cause dissections of large vessels. The diagnosis should be considered in cases with unexplained arterial dissections and progressive strokes. Early diagnosis with appropriate laboratory screening and tissue confirmation by biopsy can lead to greatly improved outcomes.
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Singhal A, Kharal GA, Sylaja PN. A 66 Year Old Woman with Recurrent Stroke. Neurol India 2020; 68:17-19. [DOI: 10.4103/0028-3886.279684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Seizure Induced by Defecation in a 15-Year Old Autistic Patient: A Case Report and Literature Review. IRANIAN JOURNAL OF CHILD NEUROLOGY 2020; 14:83-88. [PMID: 32952585 PMCID: PMC7468083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 09/28/2019] [Accepted: 10/02/2019] [Indexed: 11/04/2022]
Abstract
Epilepsy in autism is a relatively common phenomenon. However, reflex seizures provoked by multifactorial stimuli are rare in these patients. We here reported the first case of defecation-induced seizure in a 15-year old autistic girl. The patient had been diagnosed with epilepsy within the first year after birth; however, seizures induced by bowel movements were observed at the age of 15. Reflex seizures showed a myoclonic pattern represented with one-sided neck deflection. EEG showed an abnormal polyspike and wave pattern during defecation while the patterns were normal between the attacks. The patient was partially responsive to adrenocorticotropic hormone therapy with a reduced frequency of both reflexes and generalized seizures. Phenobarbital therapy was effective to manage recurrent seizure attacks. Although seizure is commonly encountered in autism, reflex seizures induced by defecation have not been previously reported in this condition.
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Verma A, Sharma A, Robetorye R, Porter A, Hilal T. Intravascular Large B-cell Lymphoma Associated with Systemic and Central Nervous System Hemophagocytic Lymphohistiocytosis: A Case Report. Perm J 2019; 24:19.105. [PMID: 31852057 DOI: 10.7812/tpp/19.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We present a case of an Asian variant of intravascular large B-cell lymphoma associated with systemic and central nervous system hemophagocytic lymphohistiocytosis (HLH) with multiple neurologic manifestations. CASE PRESENTATION A 68-year-old, previously healthy, Korean woman presented with a 4-week history of fever and weight loss. She had pancytopenia with neutropenia, a ferritin level of 5030 μg/L, and elevated liver enzyme levels. Bone marrow, liver biopsy specimens, and cerebrospinal fluid demonstrated hemophagocytosis. The patient was treated with the HLH-2004 protocol, but her disease relapsed 3 months later. A repeated liver biopsy specimen confirmed the initially missed diagnosis of intravascular large B-cell lymphoma, a known driver of HLH in patients of Asian origin. She was then treated with lymphoma-directed therapy and had a prompt resolution of fever and neurologic symptoms as well as normalization of her blood cell counts and ferritin level. DISCUSSION This case serves as a reminder that patients with an Asian variant of intravascular large B-cell lymphoma frequently present with HLH and neurologic manifestations, including seizures, strokes, and cognitive deficits. A high index of suspicion is needed for prompt diagnosis and initiation of lymphoma-directed therapy.
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Affiliation(s)
| | | | | | - Alyx Porter
- Department of Neurology, Mayo Clinic, Phoenix, AZ
| | - Talal Hilal
- Division of Hematology and Medical Oncology, Mayo Clinic, Phoenix, AZ
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Zhu F, Pan H, Xiao Y, Li Q, Liu T, Liu X, Wu G, Li J, Zhang L. A case report of primary prostate intravascular large B cell lymphoma presenting as prostatic hyperplasia. Medicine (Baltimore) 2019; 98:e18384. [PMID: 31852153 PMCID: PMC6922597 DOI: 10.1097/md.0000000000018384] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONAL Intravascular large B-cell lymphoma (IVLBCL) is a rare condition with a poor prognosis. The clinical presentation of primary lymphoma of the prostate is non-specific and it is difficult to distinguish from other prostatic diseases. The primary prostate IVLBCL is very rare, the diagnosis and treatment of which remains unclear. We reported a rare case to explore the diagnosis and treatment for the primary prostate IVLBCL. PATIENTS CONCERNS This report described a case of a 71-year-old male diagnosed as primary prostate IVLBCL who presented with prostatic hyperplasia. DIAGNOSIS The patient first visited an outpatient clinic of urinary surgery because of urinary urgency and frequency and was diagnosed as benign prostatic hyperplasia in about January 2010. Four years later, the symptoms worsened quickly within two months. The diagnosis was still prostatic hyperplasia according to the physical examination and imaging. However, histopathology showed IVLBCL of prostate after transurethral resection of the prostate. INTERVENTIONS With the clear diagnosis of primary prostate stage I IVLBCL, the patient received immunochemotherapy of R-CHOP (rituximab, cyclophosphamide, adriamycin, vincristine, and prednisolone) for 4 cycles and intensity-modulated radiation therapy (IMRT) including the region of prostate with the dose of 45Gy/25f. OUTCOMES The response was complete remission after all treatment. The last follow-up time of the patient was June 20th, 2019, and no evidence of disease progression was observed. The progression-free survival of the patient was about 49 months until now. LESSONS The biopsy of prostate by prostatectomy plays an important role in the diagnosis and removal of the original lesion of primary prostate lymphoma. There is no consensus on therapeutic modalities for the treatment of primary prostate IVLBCL till now. Individual treatments include immunochemotherapy and/or radiotherapy according to the National Comprehensive Cancer Network (NCCN) practice guideline of diffuse large B cell lymphoma (DLBCL) based on the performance status and tumor staging of the patient. Timely and accurate diagnosis as well as the appropriate treatment may improve the clinical outcome.
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Affiliation(s)
| | - Huaxiong Pan
- Department of Pathology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Abstract
PURPOSE OF REVIEW To review the latest information about the interactions between cancer and cerebrovascular disease. RECENT FINDINGS Additional data support the finding that both ischemic and hemorrhagic stroke are important complications of cancer or its treatment. Reperfusion therapy is being given successfully to patients with stroke complicating cancer. Hemorrhagic stroke may occur with metastatic disease to the brain, coagulopathies from cancer, in particular leukemia, or as complications of chemotherapy. Ischemic stroke also may be a complication of metastatic disease with local invasion of vessels, a pro-thrombotic disorder such as non-bacterial thrombotic endocarditis (NBTE) or disseminated intravascular coagulation (DIC), or secondary to chemotherapy. Stroke also is a potential consequence of radiation therapy to the head and neck. Venous sinus thrombosis may develop with hematologic malignancies or chemotherapy. Although many patients will have a history of cancer at the time of stroke, a cerebrovascular event may be the initial manifestation of a malignancy.
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40
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Pituitary Gland and Neurological Involvement in a Case of Hemophagocytic Syndrome Revealing an Intravascular Large B-Cell Lymphoma. Case Rep Hematol 2019; 2019:9625075. [PMID: 31183225 PMCID: PMC6512020 DOI: 10.1155/2019/9625075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 03/04/2019] [Indexed: 12/26/2022] Open
Abstract
Intravascular large B-cell lymphoma is a rare entity characterized by the proliferation of neoplastic lymphocytes in the lumen of small blood vessels and high mortality. Diagnosis of intravascular lymphoma is often delayed or established postmortem. Here, we report the case of a 48-year-old woman presenting hemophagocytic syndrome, with pituitary gland and neurological involvement. Diagnosis of intravascular large B-cell lymphoma was made on perisplenic vessels, while liver and bone marrow biopsy was noncontributive. This case demonstrates the importance of thorough histopathologic investigations in the setting of high suspicion.
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Woo KA, Yoo D, Jung KH. Intravascular lymphoma as a Potential Cause of Recurrent Embolic Stroke of Undetermined Source. J Clin Neurol 2019; 15:415-417. [PMID: 31286720 PMCID: PMC6620460 DOI: 10.3988/jcn.2019.15.3.415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/02/2019] [Accepted: 04/02/2019] [Indexed: 11/17/2022] Open
Affiliation(s)
- Kyung Ah Woo
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Dallah Yoo
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Keun-Hwa Jung
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
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42
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Yomo S, Tsutsumi K, Yako T, Sato H, Hashimoto T, Oguchi K. Accurate Detection of Tumor Infiltration by 11C-Methionine Positron Emission Tomography in a Patient with Central Nervous System Intravascular Lymphoma: A Case Report. Case Rep Oncol 2018; 11:577-584. [PMID: 30186143 PMCID: PMC6120372 DOI: 10.1159/000492465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 07/26/2018] [Indexed: 12/22/2022] Open
Abstract
Intravascular lymphoma (IVL) is a rare and clinically devastating subtype of extranodal diffuse large B-cell lymphoma with a distinct presentation. Diagnostic difficulty derives from marked variability in clinical presentations and nonspecific laboratory and radiological findings, especially when central nervous system (CNS) symptoms are the only manifestation. Establishing the diagnosis premortem thus remains a major challenge. We describe a 70-year-old male with CNS IVL. He presented with acute onset of neurocognitive impairments. Diffusion-weighted magnetic resonance imaging (MRI) showed multiple high-intensity areas suggesting occlusive cerebrovascular disease due to emboli, but extensive investigations detected no embolic sources. Intracranial neoplasm was included in a differential diagnosis based on elevated serum lactate dehydrogenase and interleukin 2 receptor levels. Gadolinium-enhanced MRI or 18-fluorodeoxyglucose positron emission tomography (PET) failed to demonstrate specific findings leading to a definite diagnosis, while 11C-methionine PET (MET-PET) distinctively demonstrated an area of focally increased MET uptake in the frontal cortex, suggesting the extent of tumor infiltration. Stereotactic biopsy was conducted under MET-PET imaging guidance and immunohistological examinations confirmed the proliferation and aggregation of CD20-positive lymphoma cells within the lumina of small blood vessels. The findings of the present case first suggest that MET-PET may provide important information on the diagnosis of CNS IVL and on the selection of the optimal site for brain biopsy. Further investigation is necessary to clarify whether positive findings on MET-PET are truly specific and pathognomonic for CNS IVL.
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Affiliation(s)
- Shoji Yomo
- Jisenkai Brain Imaging Research Center, Aizawa Hospital, Matsumoto, Japan
| | - Keiji Tsutsumi
- Department of Neurosurgery, Aizawa Hospital, Matsumoto, Japan
| | - Takehiro Yako
- Department of Neurosurgery, Aizawa Hospital, Matsumoto, Japan
| | - Hiromasa Sato
- Department of Neurology, Aizawa Hospital, Matsumoto, Japan
| | - Takao Hashimoto
- Jisenkai Brain Imaging Research Center, Aizawa Hospital, Matsumoto, Japan.,Department of Neurology, Aizawa Hospital, Matsumoto, Japan
| | - Kazuhiro Oguchi
- Jisenkai Brain Imaging Research Center, Aizawa Hospital, Matsumoto, Japan.,Positron Imaging Center, Aizawa Hospital, Matsumoto, Japan
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Affiliation(s)
- Miroslav Sekulic
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Suzanne Martin
- Department of Nephrology, Saint Vincent Hospital, Worcester, Massachusetts, USA
| | - Amos Lal
- Department of Medicine, Saint Vincent Hospital, Worcester, Massachusetts, USA
| | - Astrid Weins
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Duchesne M, Roussellet O, Maisonobe T, Gachard N, Rizzo D, Armand M, Viala K, Richard L, Delage-Corre M, Jaccard A, Corcia P, Vallat JM, Magy L. Pathology of Nerve Biopsy and Diagnostic Yield of PCR-Based Clonality Testing in Neurolymphomatosis. J Neuropathol Exp Neurol 2018; 77:769-781. [DOI: 10.1093/jnen/nly055] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Mathilde Duchesne
- Service et Laboratoire de Neurologie, Centre National de Référence “Neuropathies Périphériques rares”, CHRU Limoges, Limoges, France
- Laboratoire d'Anatomie Pathologique, CHRU Limoges, Limoges, France
| | - Olivier Roussellet
- Service et Laboratoire de Neurologie, Centre National de Référence “Neuropathies Périphériques rares”, CHRU Limoges, Limoges, France
| | - Thierry Maisonobe
- Département de Neurophysiologie Clinique, CHU Pitié-Salpêtrière, Paris, France
| | | | - David Rizzo
- Service d'Hématologie Biologique, CHRU Limoges, Limoges, France
| | - Marine Armand
- Service d'Hématologie Biologique, CHU Pitié-Salpêtrière, Paris, France
| | - Karine Viala
- Département de Neurologie Clinique, CHU Pitié-Salpêtrière, Paris, France
| | - Laurence Richard
- Service et Laboratoire de Neurologie, Centre National de Référence “Neuropathies Périphériques rares”, CHRU Limoges, Limoges, France
| | | | - Arnaud Jaccard
- Service d'Hématologie Clinique et Thérapie Cellulaire, CHRU Limoges, Limoges, France
| | | | - Jean-Michel Vallat
- Service et Laboratoire de Neurologie, Centre National de Référence “Neuropathies Périphériques rares”, CHRU Limoges, Limoges, France
| | - Laurent Magy
- Service et Laboratoire de Neurologie, Centre National de Référence “Neuropathies Périphériques rares”, CHRU Limoges, Limoges, France
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Small Cell Variant of Intravascular Large B-Cell Lymphoma: Highlighting a Potentially Fatal and Easily Missed Diagnosis. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9413015. [PMID: 29850589 PMCID: PMC5903319 DOI: 10.1155/2018/9413015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 01/23/2018] [Accepted: 03/04/2018] [Indexed: 11/18/2022]
Abstract
Context Intravascular large B-cell lymphoma (IVLBCL) is a rare non-Hodgkin B-cell lymphoma with a poor prognosis. While typically described as comprising large atypical cells restricted to the lumina of small blood vessels, it can show variability in cell size. Objective To report the clinicopathologic features of the IVLBCL with small cell morphology and discuss the practical implications of our findings. Design We searched our archives for all IVLBCL diagnosed in our institution for the last 25 years (1992–2017). Slides were reviewed independently by two hematopathologists. Results We found a total of 11 cases of IVLBCL. Bone marrow, brain, lymph node, pericardium, small bowel, and fallopian tube and ovary were the organs in which the lymphoma was initially diagnosed. One of the cases initially diagnosed in the marrow showed intrasinusoidal involvement by a small cell lymphoma; the diagnosis was confirmed by random skin biopsies showing intravascular large cells with the same phenotype. Retrospective review of the liver on this case also showed the intrasinusoidal involvement by the disease consisting of small cells. In another case, IVLBCL that was initially diagnosed in a small bowel biopsy was retrospectively found in a breast biopsy, but with small cell morphology. Conclusions Our findings suggest that, in the presence of high clinical suspicion, IVLBCL should be high in the differential diagnosis when lymphoma is predominantly intravascular, even when the tumor cells are small. A timely diagnosis of this entity can be critical. Hence, awareness of a small cell variant of IVLBCL should be increased.
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Kumarapeli AR, Gokden M. Utility of autopsy brain imprint and squash cytology for detection of lymphoma/leukemia emboli in select patients presenting with rapid decline in mental status. Diagn Cytopathol 2018; 46:694-697. [PMID: 29575593 DOI: 10.1002/dc.23927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 03/06/2018] [Indexed: 11/09/2022]
Abstract
Central nervous system (CNS) hematologic malignancies, whether primary or secondary, are uncommon and their clinical presentations vary. Intravascular lymphoma (IVL) is a very rare, aggressive systemic malignancy that is often difficult to diagnose and susceptible to early CNS involvement. Blast crisis in myeloid leukemias can cause widespread neoplastic emboli. Here, we report two adult patients (72 years and 22 years of age) who presented with altered mental status followed by rapid decline in their conditions leading to death. No prior significant medical history was present for either patient, while acute myeloid leukemia was diagnosed in the younger patient immediately before death. During autopsy, we performed imprint and squash preparations, and frozen sections of representative cerebral cortex, cerebellum, leptomeninges, and the pituitary gland. In the older patient, presence of IVL was readily detected on cytologic preparations. Diffuse involvement of brain vasculature and perivascular parenchyma with acute myeloid leukemia was identified in the other patient. Although examination of the fresh brain is not routinely performed during autopsy, these cases are presented to illustrate that imprint and squash preparations can provide a rapid and reliable provisional autopsy diagnosis in select patients.
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Affiliation(s)
- Asangi R Kumarapeli
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Murat Gokden
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Abraham L, Kreipe H, Raab P, Hussein K. [Clinical and pathological characteristics of intravascular lymphomas]. DER PATHOLOGE 2018. [PMID: 29541829 DOI: 10.1007/s00292-018-0427-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Intravascular B‑cell lymphomas (IVL) are rare neoplasms that can manifest at any age (mean age ~62-63 years). About half of the cases are associated with Epstein-Barr virus. The most common sites of manifestation are the brain, skin, and bone marrow. The diagnosis is difficult due to unspecific clinical presentation and laboratory changes. FACS (fluorescence-activated cell sorting) and clonality analysis from peripheral blood and radiological findings are often not diagnostic. The most sensitive and most specific diagnostic method is the histopathological and immunohistochemical evaluation of a tissue biopsy. Because of the rarity of this disease, little is known about therapy and prognosis, whereby therapy is mainly similar to non-IVL lymphomas. The prognosis is poor; median survival after diagnosis is approximately one year.
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Affiliation(s)
- L Abraham
- Institut für Pathologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - H Kreipe
- Institut für Pathologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - P Raab
- Institut für Diagnostische und Interventionelle Neuroradiologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - K Hussein
- Institut für Pathologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
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48
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Pearce C, Hope S, Butchart J. Intravascular lymphoma presenting with postural hypotension. BMJ Case Rep 2018; 2018:bcr-2017-221803. [PMID: 29378736 DOI: 10.1136/bcr-2017-221803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
An 84-year-old woman presented with severe postural hypotension. Further assessment revealed weight loss, fatigue and fever at night. On examination, she had bilateral skin lesions on the inner thighs and skin biopsy revealed intravascular high grade B cell lymphoma. This was successfully treated with curative chemotherapy. The cause of the postural hypotension in this case was felt likely to be autonomic neuropathy caused by neurovascular infiltration by intravascular lymphoma. Treatment of the lymphoma has resolved the postural hypotension, although some symptoms of postural instability persist.
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Affiliation(s)
- Catharine Pearce
- Healthcare for Older People Department, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Suzy Hope
- Healthcare for Older People Department, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.,Diabetes and Vascular Research Centre, University of Exeter Medical School, Exeter, UK
| | - Joseph Butchart
- Healthcare for Older People Department, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
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Geschwind MD, Murray K. Differential diagnosis with other rapid progressive dementias in human prion diseases. HANDBOOK OF CLINICAL NEUROLOGY 2018; 153:371-397. [PMID: 29887146 DOI: 10.1016/b978-0-444-63945-5.00020-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Prion diseases are unique in medicine as in humans they occur in sporadic, genetic, and acquired forms. The most common human prion disease is sporadic Creutzfeldt-Jakob disease (CJD), which commonly presents as a rapidly progressive dementia (RPD) with behavioral, cerebellar, extrapyramidal, and some pyramidal features, with the median survival from symptom onset to death of just a few months. Because human prion diseases, as well as other RPDs, are relatively rare, they can be difficult to diagnose, as most clinicians have seen few, if any, cases. Not only can prion diseases mimic many other conditions that present as RPD, but some of those conditions can present similarly to prion disease. In this article, the authors discuss the different etiologic categories of conditions that often present as RPD and also present RPDs that had been misdiagnosed clinically as CJD. Etiologic categories of conditions are presented in order of the mnemonic used for remembering the various categories of RPDs: VITAMINS-D, for vascular, infectious, toxic-metabolic, autoimmune, mitochondrial/metastases, iatrogenic, neurodegenerative, system/seizures/sarcoid, and demyelinating. When relevant, clinical, imaging, or other features of an RPD that overlap with those of CJD are presented.
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Affiliation(s)
- Michael D Geschwind
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, CA, United States.
| | - Katy Murray
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, United Kingdom
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50
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Ohya Y, Osaki M, Sakai S, Kimura S, Shimogamo T, Ago T, Kitazono T, Arakawa S. A Case of Recurrent Ischemic Stroke due to Intravascular Lymphomatosis, Undiagnosed by Random Skin Biopsy and Brain Imaging. Case Rep Neurol 2017; 9:234-240. [PMID: 29279711 PMCID: PMC5731158 DOI: 10.1159/000478996] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 06/26/2017] [Indexed: 12/14/2022] Open
Abstract
Intravascular lymphoma (IVL) is a rare disease characterized by the proliferation of lymphoma cells in the lumen of the small blood vessels. Although early diagnosis of IVL is important to prolong survival of the patients, its atypical symptoms and clinical course often delay its diagnosis. More than half of the patients are diagnosed at autopsy. We report a 68-year-old man who presented with transient ideomotor apraxia and mildly elevated soluble interleukin-2 receptor levels. He was initially diagnosed with aortogenic embolic stroke. He developed rapidly progressive neurological manifestations with enlargement of brain lesions on brain computed tomography and magnetic resonance imaging and died 3 months after symptom onset. The diagnosis of IVL could not be made by random skin biopsy, but was finally made at autopsy. For the early diagnosis, sufficient random skin biopsy or brain biopsy should be planned when suspected.
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Affiliation(s)
- Yuichiro Ohya
- Department of Cerebrovascular Medicine, Stroke Center, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Masato Osaki
- Department of Cerebrovascular Medicine, Stroke Center, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Shouta Sakai
- Department of Cerebrovascular Medicine, Stroke Center, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Shunsuke Kimura
- Department of Cerebrovascular Medicine, Stroke Center, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Tatsuro Shimogamo
- Department of Pathology, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Tetsuro Ago
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shuji Arakawa
- Department of Cerebrovascular Medicine, Stroke Center, Steel Memorial Yawata Hospital, Kitakyushu, Japan
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