LESSON OF THE MONTH Non-Hodgkin’s lymphoma presenting with spinal involvement

Case report 1 The case concerns a 38 year old woman with a one year history of a low grade non-Hodgkin’s lymphoma stage 4 (disseminated involvement of one or more extralymphatic organs with or without lymph node involvement). At the time of diagnosis, nodal involvement was found in the supraclavicular and axillar regions and in the neck; the abdomen presented marked splenomegaly and sternal puncture revealed bone marrow involvement. Restaging after treatment with cyclofosfamide-vincristineprednisone (CVP) and cyclofosfamideepirubicine-vincristine-prednisone (CEOP) chemotherapy during 10 months showed the absence of pathological node with computed tomography (CT). One year after diagnosis, the patient consulted the department of haematology with sudden onset of low back pain and sciatica in the right leg. The complaints resolved after treatment with non-steroidal antiinflammatory drugs (NSAIDs). Three weeks later, she presented a relapse of the sciatica with dysaesthesia and sensory deficit of the right leg and progressive paresis of the right leg, however no systemic features at that time. According to the clinical stigmata, the diagnosis of acute sciatica was made and treatment with oral prednisolone 20 mg daily was started. Despite treatment, she was admitted urgently with acute paresis of the right leg. Clinical examination revealed a paresis of the right quadriceps muscle and tibialis anterior muscle. This is compatible with involvement of the L4, L5 and S1-level. The sciatic nerve stretch test was positive at 30° (right side) and 50° (left side), and the patellar reflex at the right side was absent, with indiVerent Babinsky sign, and sensory deficit at the right calf and heel. Percussion of the spine revealed pain from the fifth lumbar vertebra to the presacral region; anteflexion of the spine was limited by pain. Radiographic examination showed a normal lumbar spine; no herniation was seen on CT of the lumbar intervertebral discs and Tc total body bone scintigraphy was normal. Electromyography of the lower legs revealed an acute denervation L4-L5-S1 at the right side and L5-S1 at the left side, compatible with polyradiculopathy in combination with an underlying polyneuropathy, most probably attributable to previous chemotherapy. A lumbar puncture showed malignant cells with high grade histology. At that moment, magnetic resonance imaging (MRI) of the spine revealed diVuse arachnoiditis from level D11-D12 to the lumbosacral region. MRI of the brain was normal. A treatment with high doses corticoids and spinal therapy (methotrexate, Ara-C) induced regression of the number of malignant cells, but failed to control the disease. The radiation therapy of the spine was interrupted because the patient developed a right peripheral paresis of the facial nerve. The patient died four months after the occurrence of the sciatica.