Diffuse large B-cell lymphoma presenting with central pontine myelinolysis: a case report

Osmotic demyelination syndrome in cancer patients: Risk even without rapid sodium correction - a scoping review

OBJECTIVE

To describe the clinical characteristics, therapeutic approaches, and prognostic outcomes of osmotic demyelination syndrome (ODS) in cancer patients.

METHODS

A comprehensive literature search (January 1950-March 2024) using PubMed, Embase, Cochrane Library, and Web of Science. Keywords included "osmotic demyelination and cancer", "central pontine myelinolysis and cancer", and "extrapontine myelinolysis and cancer", "Osmotic demyelination and malignancy," "Central pontine myelinolysis and malignancy," and "Extrapontine myelinolysis and malignancy." References from selected articles were manually reviewed for inclusion. Studies involving benign lesions, surgical interventions, non-malignant ODS, and ODS of unknown etiology without malignancy were excluded.

RESULTS

A total of 22 cases of cancer-complicated ODS were identified in the literature. The median age of onset was 55 years, with no observed gender differences. Clinical presentations ranged from completely asymptomatic (4.5 %,1/22) to disorders of consciousness (27.3 %, 6/22). Notably, 22.7 % (5/22) of patients initially presented with either no symptoms or non-specific symptoms (seizures, abnormal mental behavior) that could be mistaken for hyponatremia itself. Furthermore, 90 % of patients did not experience rapid sodium correction, and 59.1 % received only symptomatic therapy or treatment of the primary cancer. Only 9.1 % of patients received immunoglobulin or plasma exchange, which may improve outcomes.

CONCLUSIONS

Osmotic demyelination syndrome represents a potential complication in cancer patients, potentially arising from complex interactions. Clinical manifestations are highly variable and often under-recognized, particularly by non-neurologists. Traditional sodium correction protocols may still induce ODS in cancer patients, suggesting a need for cautious sodium management. Timely diagnosis and appropriate intervention are crucial for determining patient prognosis.

An Unusual Case of a Central Pontine Myelinolysis Associated with Primary Splenic Diffuse Large B-cell Lymphoma

A 54-year-old woman with persistent fatigue and a high fever presented with central pontine myelinolysis (CPM) on brain imaging, despite the absence of neurological symptoms. The patient had a slightly low serum sodium concentration. Further investigation led to a diagnosis of primary splenic diffuse large B-cell lymphoma (PS-DLBCL). Brainstem auditory-evoked potentials (BAEP) indicated minor abnormalities. CPM was successfully resolved after splenectomy and immunochemotherapy. This is the first reported case of CPM in a patient with PS-DLBCL confirmed by a pathological diagnosis following splenectomy and BAEP-detected abnormalities that improved with immunochemotherapy.

Osmotic demyelination syndrome in patients with non-Hodgkin lymphoma: a case report and literature review

INTRODUCTION

Osmotic demyelination syndrome (ODS) is a non-inflammatory process of the central nervous system caused by extracellular osmotic changes, which leads to oligodendrocyte apoptosis and disruption of myelin sheaths, usually affecting patients with underlying systemic conditions that impose susceptibility to osmotic stress. Description of ODS in patients with non-Hodgkin lymphoma (NHL) is limited to a few case reports.

METHODS

Here, we report a 44-year-old man with NHL that had an incidental diagnosis of ODS. We conducted a literature review of the published cases of ODS in NHL patients from 1959 to 2020, aiming to describe the characteristics of these patients.

RESULTS

A total of seven patients were summarized (four men and three women), including our case and six patients from published reports. Risk factors such as weight loss and alcoholism were reported in five (71.4%) patients. Hyponatremia was found in six (85.7%) of the cases, and none of them had overly rapid sodium correction. Four cases were asymptomatic, and diffuse large B-cell lymphoma was the most common subtype of NHL (85.7%). The outcome was favorable in most cases; only two deaths not directly related to ODS were reported.

CONCLUSION

We wish to suggest that systemic and metabolic stress induced by NHL may be associated with the development of central osmotic demyelination, and therefore, NHL may be a novel risk factor for ODS. Clinicians should be aware of ODS in patients with hematological malignancies, even in the absence of traditional risk factors.

Rare case of diffuse large B-cell lymphoma presenting with central pontine myelinolysis

Central pontine myelinolysis (CPM) is commonly associated with osmotic stress and rapid correction of hyponatraemia. It has rarely been reported in conjunction with malignancies. We report a case where CPM was not only associated with a new diagnosis of diffuse large B-cell lymphoma but was also a key presenting feature.

Intravascular lymphoma mimicking multiple sclerosis

Diagnosis of relapsing-remitting multiple sclerosis requires demonstration disseminated symptoms in time and space on the basis of neurological assessment or magnetic resonance imaging findings. In addition, the diagnosis is conditioned by ruling out other conditions that may explain the clinical symptoms. We describe the patient presenting in the initial stage of the disease neurological symptoms and magnetic resonance imaging lesions, that met criteria for relapsing-remitting multiple sclerosis diagnosis. The patient was administered immunomodulatory treatment. However, the subsequent course of the disease tended to verify the diagnosis. Finally, the patient was diagnosed with intravascular B-cell lymphoma. Intravascular lymphoma is a rare form of lymphoma characterized by the development of cancerous cells in the lumen of small and medium-sized blood vessels. Due to the lack of characteristic biomarkers in laboratory tests and neuroimaging, the diagnosis is based on histopathological examination of the sample of the affected organ taken by biopsy. It should be consider in all cases of central nervous system damage of unknown, undiagnosed etiology.

Central Pontine Myelinolysis with Minimal Hyponatremia in the Setting of AIDS

Central pontine myelinolysis (CPM) is classically attributed to overly rapid correction of profound hyponatremia. However, there are case reports of this disease in the setting of normal serum sodium or minimal hyponatremia. These cases have been hypothesized to be secondary to other metabolic disturbances such as hyperglycemia or hypophosphatemia. Eunatremic CPM has also been described in patients with advanced acquired immune deficiency syndrome (AIDS). The mortality risk in this special population is significantly higher than those with hyponatremia-associated CPM, but the mechanisms are unclear. We discuss a case of a man with AIDS who developed CPM with minimal hyponatremia and no other metabolic disturbances. Common variables within this population, such as hypoalbuminemia and lymphoma, are discussed as potential factors contributing to the pathophysiology. Reporting these atypical cases is crucial to our understanding of how to prevent future cases.