A 76-year-old Chinese woman was admitted to the Department of Neurology and Neuroscience Center in the First Hospital of Jilin University, Changchun, China. She had been healthy until five months earlier when progressive weakness of her left lower limb was noticed. She reported no significant changes of her body weight recently. Brain MRI demonstrated lesions in the right temporal and occipital lobes. The lesions showed hypointense signal on T1-weighted images, hyperintense signal on T2-weighted images and fluid attenuated inversion recovery (FLAIR) sequence (Fig. 1: ABC). A clinical diagnosis of tumor was originally considered by the local hospital and the patient was therefore received radiotherapy. One week after treatment, her strength of lower limbs started to improve. Two months later after radiotherapy, repeated brain MRI revealed the lesions were ameliorated compared with the initial scans (Fig. 1: DEF). She was admitted to our hospital due to acute onset of lower limbs weakness and bladder dysfunction that quickly culminated within 2 days. Physical examinations reflected the features of the spinal cord shock stage, concretely showing retardant paralysis and anesthesia below T10. Deep tendon reflexes were disappeared in both lower limbs, while normal in the upper extremities. Bilateral Babinski signs were negative. Urinary catheter was used due to urinary retention. Other physical examination results were unremarkable.
Routine laboratory investigations such as C-reactive protein, complete blood count, blood biochemical analysis, Vitamin B12 level, human immunodeficiency virus (HIV), syphilis and circulating tumor markers were normal. Serological assays for autoimmune diseases and connective tissue diseases such as thyroid status, antinuclear antibodies were also negative. Aquaporin-4 (AQP4) antibody, MOG-antibody and paraneoplastic antibodies including CV2/collapsin response mediator protein5 (CRMP5), Ma2, RI, Yo, Hu and Amphiphys in both serum and CSF were negative. CSF analysis showed 36 × 106/L of cell number, 0.67 g/L of protein and no oligoclonal bands. Brain MRI showed lesions in the right parietal lobe (Fig. 2: ABC). The lesions were nodular enhancement on T1-weighted contrast enhanced images (Fig. 2: D). MRI of the spinal cord showed a longitudinally extensive hypointensive lesion from thoracic 4 (T4) to lumbar 1 (L1) vertebral level on T1-weighted images, hyperintensive signal on T2-weighted images and T2 fat-suppressed images, respectively (Fig. 3: ABC). Axial thoracic MRI images showed a mass lesion located in the ventral part of the cord (Fig. 3: E). Post contrast-enhanced MRI revealed an enhanced nodular lesion (Fig. 3: DF). In support of MRI results, 18F-FDG-PET/CT demonstrated hypermetabolism lesions (Fig. 3: GH). Then, the patient received a tumor resection 8 days after admission. Spinal cord biopsy was performed at around T10-T11 level, confirming the diagnosis of diffuse large B cell lymphoma. Hematoxylin and eosin-staining staining showed diffuse proliferation of large atypical lymphocytes. Immunohistochemical studies demonstrated that neoplastic lymphocytes are positive for B-cell lymphoma-2 (Bcl-2), CD20 and c-Myc (Fig. 4). Thus, the patient received high-dose methotrexate (HD-MTX) combined with Rituximab chemotherapy. The patient discharged from the hospital after the first chemotherapy. The patient was followed up by phone. Unfortunately, the patient could not tolerate high-dose chemotherapy drugs after receiving three rounds of chemotherapy, therefore she decided to forgo her fourth chemotherapy. Until now, the symptoms of flaccid paralysis, sensory disorder and persistent bladder dysfunction did not alleviate significantly during four months follow-up period.