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IMAGES IN NEUROLOGY
Year : 2021  |  Volume : 24  |  Issue : 1  |  Page : 85-86
 

Bilateral facial palsy in lymphomatous meningitis


1 Child Neurology Division, Center of Excellence & Advanced Research on Childhood Neurodevelopmental Disorders, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
2 Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
3 Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India

Date of Submission25-May-2020
Date of Acceptance04-Jun-2020
Date of Web Publication24-Jul-2020

Correspondence Address:
Prof. Sheffali Gulati
Department of Pediatrics, Child Neurology Division, Center of Excellence & Advanced Research on Childhood Neurodevelopmental Disorders, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aian.AIAN_514_20

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How to cite this article:
Madaan P, Jauhari P, Chakrabarty B, Kumar A, Tripathy S, Damle N, Gulati S. Bilateral facial palsy in lymphomatous meningitis. Ann Indian Acad Neurol 2021;24:85-6

How to cite this URL:
Madaan P, Jauhari P, Chakrabarty B, Kumar A, Tripathy S, Damle N, Gulati S. Bilateral facial palsy in lymphomatous meningitis. Ann Indian Acad Neurol [serial online] 2021 [cited 2021 Mar 3];24:85-6. Available from: https://www.annalsofian.org/text.asp?2021/24/1/85/290564




A 9-year-old boy presented with bilateral lower-motor-neuron facial-palsy, progressive hearing-loss, and radiating-pains in legs for 2 months. Neuroimaging revealed bilateral VII and VIII cranial-nerve enhancement with arachnoiditis [Figure 1]. Cerebrospinal fluid (CSF) was meningitic [70 cells (60% lymphocytes, no blasts), protein: 194 mg/dl, sugar: 59 mg/dl (RBS: 120 mg/dl)]. Etiological workup for chronic meningitis—bacterial, fungal, viral, tuberculous, sarcoid, and lupus—was noncontributory. CSF serology was positive for Lymes disease (IgM). The child received ceftriaxone and doxycycline for a month and methylprednisolone pulse for arachnoiditis with marginal improvement. While on antibiotics, he developed paraparesis and bowel-bladder incontinence. Repeat CSF was meningitic (without malignant cells). Serum lactate dehydrogenase (LDH) was elevated (2234 IU/l). A whole-body PET scan revealed a presacral and left paravertebral mass with increased uptake [Figure 2]. Also noted were multifocal uptake in meninges (at D1, D2, D12, L1, L2 level) and multiple areas of skeletal involvement. Ultrasound-guided biopsy of the mass revealed lymphoid blast cells with immunohistochemistry corroborating with T-cell anaplastic lymphoma. The child received chemotherapy but succumbed to febrile neutropenia. Parents refused autopsy.
Figure 1: MRI brain and spine of the index patient. (a) Contrast-enhanced axial T1 weighted MRI brain at the level of posterior fossa shows enhancement of bilateral 7th and 8th nerve complexes (arrows in a). (b) Contrast-enhanced sagittal T1 weighted MRI spine shows dense enhancement of the CSF arachnoid space in the lumbar region (arrow in b) consistent with arachnoiditis

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Figure 2: FDG-PET (whole body) of the index patient. (a) FDG PET-CT maximum intensity projection image showing increased FDG uptake in the pelvic region. (b and c) Coronal and axial fused PET-CT images showing presacral soft tissue mass in the left paravertebral region (arrowhead in b) and pelvis (arrow in c) with increased FDG uptake

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Progressive cranial nerve involvement and arachnoiditis necessitates investigation for malignancy (primary or systemic) besides infectious, inflammatory, and connective-tissue disorders.[1] T-cell lymphoma is notorious for neurological involvement.[2] It may present as tumoral masses at unusual sites.[3],[4] Elevated LDH levels may be a diagnostic clue; hence, they should be a part of the etiological workup for arachnoiditis.

Acknowledgements

Authors are grateful to the patient and his family.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Watson J. Office evaluation of spine and limb pain: Spondylotic radiculopathy and other nonstructural mimickers. Semin Neurol 2011;31:85-101.  Back to cited text no. 1
    
2.
Bassuk AG, Mohile NA, Stack C. T-Cell lymphoma presenting with neurologic features in immunocompetent children. Pediatr Neurol 2006;35:314-7.  Back to cited text no. 2
    
3.
Norwood VF, Haller JS. Gradenigo syndrome as presenting sign of T-cell lymphoma. Pediatr Neurol 1989;5:377-80.  Back to cited text no. 3
    
4.
Taylor JW, Schiff D. Metastatic epidural spinal cord compression. Semin Neurol 201030:245-53.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]



 

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