Angiotropic large cell lymphoma with mononeuritis multiplex mimicking systemic vasculitis

Mononeuropathy multiplex as an uncommon presentation of intravascular lymphoma: A case report

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.

Involvement of the Peripheral Nervous System in Polyarteritis Nodosa and Antineutrophil Cytoplasmic Antibodies-Associated Vasculitis

Peripheral nerve involvement is common in polyarteritis nodosa and the antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitides. The underlying mechanism is arteritis of the vasa nervorum, leading to ischemic neuropathy. The classic presentation is stepwise involvement of peripheral nerves with ongoing antecedent constitutional symptoms. This article reviews the pathologic findings, clinical syndromes, diagnosis, and treatment of ANCA-associated vasculitides.

Neuromuscular complications in cancer

Cancer is becoming a treatable and even often curable disease. The neuromuscular system can be affected by direct tumor invasion or metastasis, neuroendocrine, metabolic, dysimmune/inflammatory, infections and toxic as well as paraneoplastic conditions. Due to the nature of cancer treatment, which frequently is based on a DNA damaging mechanism, treatment related toxic side effects are frequent and the correct identification of the causative mechanism is necessary to initiate the proper treatment. The peripheral nervous system is conventionally divided into nerve roots, the proximal nerves and plexus, the peripheral nerves (mono- and polyneuropathies), the site of neuromuscular transmission and muscle. This review is based on the anatomic distribution of the peripheral nervous system, divided into cranial nerves (CN), motor neuron (MND), nerve roots, plexus, peripheral nerve, the neuromuscular junction and muscle. The various etiologies of neuromuscular complications - neoplastic, surgical and mechanic, toxic, metabolic, endocrine, and paraneoplastic/immune - are discussed separately for each part of the peripheral nervous system.

Neuropathies associated with lymphoma†

Neuropathy occurs with various manifestations as a consequence of lymphoma, and an understanding of the etiology is necessary for proper treatment. Advances in medical imaging have improved the detection of peripheral nerve involvement in lymphoma, yet tissue diagnosis is often equally important. The neoplastic involvement of the peripheral nervous system (PNS) in lymphoma can occur within the cerebrospinal fluid (CSF), inside the dura, or outside of the CSF space, affecting nerve root plexuses and peripheral nerves. The infiltration of either cranial or peripheral nerves in lymphoma is termed neurolymphomatosis (NL). These infiltrations can occur as mononeuropathy, multifocal neuropathy, symmetric neuropathies, or plexopathies. In rare cases, intravascular lymphoma (IL) can affect the PNS and an even rarer condition is the combination of NL and IL. Immune-mediated and paraneoplastic neuropathies are important considerations when treating patients with lymphoma. Demyelinating neuropathies, such as Guillain-Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy, occur more frequently in non-Hodgkin's lymphoma than in Hodgkin's disease. Paraproteinemic neuropathies can be associated with lymphoma and paraneoplastic neuropathies are rare. While the treatment of lymphomas has improved, a knowledge of neurotoxic, radiotherapy, neoplastic, immune-mediated and paraneoplastic effects are important for patient care.

Isolated mononeuropathy multiplex--a rare manifestation of intravascular large B-cell lymphoma

Intravascular large B-cell lymphoma, also known as angiotrophic large cell lymphoma, is a rare disorder where neoplastic lymphoid cells proliferate within the walls of small- to medium-sized blood vessels. Peripheral neuropathy and other neurological manifestations, including stroke and dementia, are common, but cases of isolated multiple mononeuropathies in the absence of systemic symptoms are distinctly rare. We present an unusual case of biopsy-proved angiotrophic large cell lymphoma presenting exclusively with multiple mononeuropathies.

Malignant cell infiltration in the peripheral nervous system

The peripheral nervous system can be affected by malignancies involving different mechanisms. Neoplastic nerve lesion by compression, invasion, and infiltration is rare and occurs in particular in leukemia (neuroleukemiosis) and lymphoma (neurolymphomatosis). Its occurrence is much rarer in cancer, and even less so in sarcoma. The neoplastic infiltration of peripheral nerves by solid tumors is characterized by specific topographical sites such as the base of the skull, the ear, nose and throat region, and the cervico-brachial plexus as well as the lumbar and sacral plexus. Rarely malignant invasion affects the cranial nerves of the face where it can spread centripetally. Autonomic nerves and ganglia can also be affected. The retrograde spread of cancer in nerves is a bad prognostic sign. The clinical diagnosis is determined by tumor type, the pattern of involvement, and often pain.

Intravascular malignant lymphomatosis diagnosed in both skeletal muscle and nerve biopsies

Intravascular malignant lymphomatosis (IML) is a lymphoma, usually of B-cell phenotype, confined to intravascular spaces. IML is a relatively rare disease that is usually diagnosed at autopsy. We report a biopsy-proven case and review 15 published cases that were diagnosed antemortem by muscle, nerve biopsy, or both.

Neuromuscular complications

Although direct neoplastic involvement of muscle tis-sue is surprisingly rare, considering the large amount of body mass that is represented by muscle tissue, the most important and unresolved muscle effect is muscle cachexia.Other associations, such as inflammatory, paraneo-plastic, toxic, and several extremely rare associations,have been described. Drug-induced toxicity and radiation recall syndrome need to be taken into consideration when muscle symptoms appear in patients with cancer.

Isolated CNS vasculitis: unusual presentation of relapsed Ewing sarcoma

We describe a 12-year-old boy male who presented with an expressive dysphasia after completion of treatment for unifocal Ewing sarcoma. CNS vasculitis was diagnosed by MRI/MRA and cerebral angiography. Extensive rheumatologic work-up failed to identify an underlying primary process. Restaging studies showed no evidence of tumor. Complete neurologic recovery was achieved on prednisone. Four months later the patient developed overt, extensive metastases, confirmed by biopsy to represent recurrent Ewing sarcoma. Despite intensive therapy the patient succumbed 6 months later. This case demonstrates the unique finding of isolated CNS vasculitis as a presenting sign of Ewing sarcoma.

Headache as the only presentation of intravascular lymphoma

Intravascular lymphoma (IVL) is a rare extranodal lymphoma, presenting with confusing clinical presentations and most cases have been diagnosed during the postmortem review. We report a case of IVL diagnosed by cerebrospinal fluid (CSF) examination and bone marrow biopsy in a patient with a daily headache from onset. In case of a daily headache from onset with normal neuroimagings, CSF examination may give any significant diagnostic clue and should be a consideration to exclude such causes as hematolymphoid malignancies, including the very rare IVL.

Skin manifestations of intravascular lymphoma mimic inflammatory diseases of the skin

BACKGROUND

Intravascular lymphoma (IVL) is fatal when it is diagnosed late in the course. Sometimes skin lesions enable early diagnosis, but criteria for diagnosis are not well established.

OBJECTIVES

To demonstrate the clinical spectrum of skin lesions of IVL and to correlate it with clinical outcome; to identify features differentiating between B-cell and T-cell IVL with skin involvement.

METHODS

Review of 97 articles reporting on total of 224 patients with IVL.

RESULTS

Skin lesions were mentioned in 90 of 224 patients. They were nodules and/or plaques (49%) or macules (22.5%) of red (31%) or blue to livid (19%) colour on the leg (35%), the thigh (41%) and the trunk (31%). Telangiectases were present in only 20% of the patients. Oedema (27.5%) of the legs and pain (24%) were often accompanying. No criteria enabled distinction between lesions restricted to the skin and skin lesions concurrent with IVL in other organs, but when the disease was restricted to the skin, the prognosis was favourable (10% vs. 85% fatal outcome). Skin lesions of T-cell IVL are indistinguishable from those of B-cell IVL.

CONCLUSIONS

Forty per cent of all patients with IVL have skin lesions, these being red, sometimes painful plaques located typically on the lower extremities, accompanied by oedema. A clinician risks misinterpreting these changes as thrombophlebitis, erythema nodosum or erysipelas. Neither clinical course nor differentiation of the lymphoma can be predicted from the morphology of skin lesions, but involvement of other organs at the time of diagnosis indicates a poor prognosis.

Lymphomes malins non Hodgkiniens du système nerveux périphérique

INTRODUCTION

Identifying tumor infiltration or compression in patients with non-Hodgkin's malignant lymphoma presenting peripheral neuropathy can be a difficult task.

METHODS

We collected a series of patients with peripheral neuropathy with demonstrated lymphomatous infiltration or compression managed between October 1977 and October 2001 to search for clinico-pathological correlations.

RESULTS

Ten cases were reviewed. Neurological manifestations were the inaugural symptom of the disease in 7 patients. Clinical presentations included 5 focal (3 cranial nerve palsies, 2 brachial radiculopathies) and 5 diffuse neuropathies (3 polyradiculoneuropathies, 1 polyneuropathy and 1 mononeuritis multiplex). The mechanisms of peripheral nerve involvement were classified into lymphomatous meningoradiculitis (5 cases), involvement of cranial nerves or spinal roots in their extraneuraxial course (3 cases) and infiltration of distal peripheral nerves (2 cases). Four long lasting survivals after treatment were observed.

CONCLUSIONS

Prognosis depends much more on the haematological disease than on the neurological symptoms or tumor location.

Neurological presentation of intravascular lymphoma: report of two cases and discussion of diagnostic challenges

About a third of patients with intravascular lymphoma (IVL) present to the neurologist with symptoms mimicking thromboembolic events. Diagnosis is difficult, and often made postmortem. As remission may be induced in almost half of patients with combination chemotherapy, early diagnosis of this rare disease is essential. We report two cases of IVL. A 62-year-old male presented with hyperacute myelopathy followed by cortical ischaemic events. The diagnosis was reached with frontal cortical and meningeal biopsy. A 56-year-old female had symptoms of transient ischaemic events, subacute dementia, weight loss and fever. As the disease progressed, she developed nephrotic syndrome and thrombocytopenia. Diagnosis was made postmortem. Our cases illustrate that IVL should be considered in the differential diagnosis of cerebral and systemic vasculitis and subacute bacterial endocarditis. Literature suggests IVL can also mimic Creutzfeld-Jakob disease and paraneoplastic encephalomyelitis.

Signs of rapidly progressive dementia in a case of intravascular lymphomatosis

Intravascular lymphomatosis (IVL), a rare type of non-Hodgkin's lymphoma, is an uncommon cause of progressive dementia, usually followed by death within a few months of onset of clinical disease. Often this aggressive tumor is only diagnosed at autopsy, because of misleading clinical features mimicking a broad spectrum of syndromes and the absence of circulating lympoma cells in the blood, bone marrow or cerebrospinal fluid in many cases. Here we present IVL in a 78-year-old woman with findings leading to the clinical diagnosis of vascular dementia with sudden beginning and positive 14-3-3 protein in the CSF, commonly reported in Creutzfeldt-Jakob disease (CJD).

Central nervous system vasculitis in children

PURPOSE OF THE REVIEW

To summarize the current literature on central nervous system vasculitis in childhood because this condition remains a diagnostic and therapeutic challenge.

RECENT FINDINGS

Central nervous system vasculitis in childhood may be primary or secondary to a variety of conditions including infections, collagen vascular diseases, systemic vasculitides, and malignancies. Conditions that result in vasospasm or are associated with noninflammatory vasculopathies may mimic the features of central nervous system vasculitis. Recent studies have described the clinical spectrum of CNS vasculitis in childhood. The most common presenting features are headaches and focal neurologic deficits. The diagnosis of central nervous system vasculitis remains particularly difficult because the available investigative modalities have limited sensitivities and specificities. The most helpful diagnostic tests include cerebrospinal fluid analysis, MRI of the brain, and angiography. However, brain biopsy may be required to diagnose small vessel vasculitis.

SUMMARY

This review summarizes recent data on primary central nervous system vasculitis and some of the secondary CNS vasculitides in children. Awareness of the presenting clinical features of CNS vasculitis should lead to consideration of the diagnosis. Awareness of the sensitivity and specificity of the various diagnostic tests should lead to the more prudent use of invasive diagnostic tests including angiography and brain biopsy.

A new approach to the diagnosis and treatment of intravascular lymphoma

In intravascular lymphoma (IVL) tumor cells are initially restricted to vascular lumina. Neurological syndromes predominate and are caused by ischemia as well as tumor infiltration into the nervous system. Ante mortem diagnosis is challenging and frequently impossible. Chemotherapy is effective if started prior to ischemic damage. Over a three year period, we have diagnosed IVL in seven patients. Tissue diagnosis could be accomplished in only three cases. Forthose in whom tissue diagnosis failed we based our diagnosis on clinical presentation, typical magnetic resonance imaging findings, spinal fluid cytopathology, and molecular analyses. Six patients were treated with methotrexate chemotherapy alone or in combination with CHOP. Three patients are in complete remission 9-20 months after initial diagnosis. Another patient achieved a partial response. Two patients died due to progressive disease shortly after initiation of treatment. Grade III toxicity was observed in only 4 of 61 cycles. Based on a small retrospective series of patients, we conclude that methotrexate is a well tolerated and effective agent for the treatment of IVL.

Intravascular B-cell lymphoma

Intravascular (angiotropic) lymphoma is a unique and rare cutaneous lymphoma in which the malignant T or B lymphoid cells proliferate within the lumens of small blood vessels, primarily in the skin and central nervous system. Erythematous, tender nodules, tumors, and telangiectases are the most common skin symptoms in addition to various neurologic signs. Progression of the disease produces secondary organ involvement with variable symptoms and can be fatal. We describe a case of a 74-year-old woman with edematous, infiltrated, orange-like skin with multiple telangiectases, generalized edema, severe weakness, and extremely high values of lactate dehydrogenase. Skin biopsy specimens revealed atypical large cells filling up the lumens of dermal capillaries. Immunohistochemical investigation results identified them as B cells with CD20, CD45, CD79a, Ki-67, and HLA-DR positivity. After administration of diuretics, colchicine, and systemic PUVA therapy, the patient lost her edema, her skin became tender and free of telangiectases, and laboratory alterations normalized. Because of heavy neuralgia in her legs, oral monochemotherapy was introduced with chlorambucil, and now the patient is in remission.

Angiotropic large cell lymphoma with imaging characteristics of CNS vasculitis

This report documents a case of angiotropic large cell lymphoma (ALCL) with imaging characteristics of CNS vasculitis. A 47-year-old man was unresponsive after a 5-month progression of neurologic deterioration and intermittent fevers. MR imaging revealed multiple areas of abnormally increased T2 signal intensity in the cerebral cortex and subcortical white matter. Despite corticosteroid treatment for presumed CNS vasculitis, the patient died. Necropsy revealed a diffuse intravascular malignant mononuclear proliferation consistent with ALCL.

Intravascular large cell lymphoma: a patient with asymptomatic purpuric patches and a chronic clinical course

Intravascular large cell lymphoma (malignant angioendotheliomatosis) is a rare, multifocal, intravascular neoplasm of lymphoid cells that preferentially involves the vasculature of the skin and central nervous system. We describe a 54-year-old man with asymptomatic purpuric patches on the lower extremities for 10 years duration and a more recent lesion on the right arm. A biopsy specimen showed intravascular collections of tumor cells with irregular nuclear contours and prominent nucleoli. These cells were leukocyte common antigen (CD45), CD20, and CDW75 positive, but CD3, CD43, CD45RO, and cytokeratin negative. Polymerase chain reaction analysis of the skin for immunoglobulin heavy chain gene rearrangement detected a clonal population of B cells, supporting the diagnosis of a B-cell lymphoma. Peripheral blood showed no abnormal circulating cells. This case of malignant angioendotheliomatosis is unusual for its prolonged clinical course and presence of purpuric patches.

[Malignant endovascular large-cell lymphoma: disclosing central nervous system involvement confirmed by cerebral biopsy]

Intravascular malignant lymphomatosis (IML) is characterised by proliferation of tumoral cells within small vessels. Angiotropic large cell lymphoma commonly affects the central nervous system and the skin, although any organ may be involved. Few cases are diagnosed ante mortem. We report a new case of IML in a 62-year-old woman who presented with the main clinical features of central nervous system involvement: cerebrovascular events, epileptic seizures, subacute dementia and spinal cord syndrome. Cranial magnetic resonance imaging demonstrated increased periventricular signal on T2-weighted images. Diagnosis was established by brain biopsy. Despite corticosteroid and radiation therapy no improvement occurred and the patient died 14 months after the onset of the first symptoms.