Case Report

A 56-year-old male patient presented with a 14 days history of bladder dysfunction and deteriorating mobility on a background of intrathecal pump (SynchroMedTM II: Medtronic; Minneapolis, USA) insertion two months prior for failed back surgery syndrome pain. Neurological examination revealed a sensory deficit to T6. Urodynamics showed an atonic bladder, requiring catheterization. Biochemical and hematological blood results were unremarkable.
Spinal MRI revealed a high T6-T8 cord signal surrounding a left T7 intradural lesion (mildly hyperintense with postcontrast enhancement on T1-imaging; centrally hyperintense with a peripherally hypointense rim on T2-imaging) (Figure 1). The adjacent cord showed significant oedema. A catheter-associated granuloma was considered likely. Cerebrospinal (CSF) cytometry flow showed lymphocytosis with no evidence of pathogens.
After refilling the pump with saline, the patient was commenced on a methylprednisolone infusion (5.4 mg/kg/hour) to reduce cord oedema. Neurosurgery were consulted for removal of the apparent granuloma. However, MRI two days later revealed considerable oedema resolution and the T7 lesion was now felt to be a flow defect rather than a granuloma. Upon review, surgery was no longer indicated. Transverse myelitis was now considered the likely diagnosis and investigation into its cause was commenced. CT-TAP to out rule malignancy was normal. A repeat CSF sample demonstrated lymphocytosis (833/cm3) with 74% CD4 T-lymphocytes. CSF IgG was elevated (174 mg/l) with no oligoclonal banding found in serum. Biochemical and hematological bloods remained unremarkable.
The patient was discharged with no symptoms following two weeks of steroids. He returned five weeks later with weight loss, odynophagia and night sweats. Neck MRI was subsequently performed and a metabolically active large volume tumour mass arising in right tonsil was identified (Figure 2). It was associated with active right and left cervical nodes. Small subcentimetre active foci in liver were suspicious for further malignant disease. There were no active nodal or extranodal malignant disease elsewhere. Fine needle biopsy demonstrated a high-grade diffuse large B-cell lymphoma. PET-CT confirmed no spread and bone marrow biopsy was unremarkable. The patient is currently receiving R-CHOP regimen chemotherapy.