Cerebellar Large B-cell Lymphoma: A Case Report

Malik Ghannam; Shaden Mansour; Fareed Jumah; Brent Berry; Albertine Beard


J Med Case Reports. 2018;12(341) 

In This Article

Case Presentation

A 71-year-old Caucasian man presented to the emergency department of our hospital with a 1-week history of abrupt-onset blurry vision, dizziness, nausea, vomiting, and ataxia initially thought consistent with a posterior circulation stroke. The patient denied associated vertigo or headache. He had no prior history of stroke and had been taking prophylactic aspirin for years for a patent foramen ovale. Noncontrast head computed tomography (CT) performed in the emergency department demonstrated no visible masses or hemorrhage. A shrapnel adjacent to the patient's eyes precluded the possibility of further visualization with magnetic resonance imaging (MRI). He was admitted for further workup and treatment. Carotid Doppler ultrasound showed no stenosis. Subsequent CT angiography did not clearly visualize the brain parenchyma but showed no vascular compromise. The initial working diagnosis was of a cerebellar stroke, and the patient was transferred to the acute inpatient stroke rehabilitation service.

Despite participation in rehabilitation therapies, his symptoms progressively worsened, prompting repeat noncontrast head CT 9 days after admission, which demonstrated indistinct, masslike lesions in the cerebellum, one with evidence of hemorrhage and surrounding vasogenic edema and mild hydrocephalus. Contrast-enhanced CT performed later that day revealed three intensely enhancing masses in the right cerebellar hemisphere (Figure 1). The patient was started empirically on steroids for his vasogenic edema, which produced rapid improvement in his symptoms. Because these cerebellar lesions appeared most consistent with metastatic disease, the neurosurgery service recommended metastatic cancer workup without immediate surgical intervention. CT with contrast enhancement and whole-body positron emission tomography failed to demonstrate a primary tumor of origin outside the central nervous system (Figure 2). The patient underwent right suboccipital craniotomy with partial resection of the visible tumor in the right cerebellum. Histopathology revealed diffuse large B-cell lymphoma, non-germinal center type (Figs. 3 and 4).

Figure 1.

CT with contrast showing enhancing cerebellar lesion (yellow arrow) and vasogenic edema (red arrow)

Figure 2.

PET scan showing cerebellar hypermetabolic lesions (orange arrow)

Figure 3.

Histopathological slide showing diffuse infiltrate of large, atypical lymphocytes with brisk mitotic activity of the cerebellar lesion

Figure 4.

Slide showing that ~ 100% of cells are positive for Ki-67 immunostaining (a proliferation marker) and that lymphocytes are positive for CD-20 immunostaining (a B-cell marker) of the cerebellar lesion

Bone marrow biopsy and testicular ultrasound demonstrated no evidence of lymphoma in these sites. The result of human immunodeficiency virus (HIV) testing was negative. The patient elected to pursue induction chemotherapy. Because of his age, the radiation oncology service recommended against whole-body irradiation to minimize neurotoxicity. The patient was started on the MATRix regimen (methotrexate, cytarabine, and rituximab), which the patient has tolerated well thus far, with no residual disease seen on contrast-enhanced head CT scans. The patient has experienced marked improvement in his symptoms with treatment and is able to ambulate with a walker, but he still reports balance problems and blurry vision.