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.