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JAMA Neurology Clinical Challenge |

Leptomeningeal Enhancement in a Patient With Progressive Cranial Neuropathies and Lumbosacral Radiculopathies QUIZ

Treasach C. Vargas, DO1 ; Richard L. Thomas, DO2; Jay C. Erickson, MD, PhD1
[+] Author Affiliations
1 Department of Neurology, Madigan Army Medical Center, Tacoma, Washington
2Madigan Army Medical Center, Tacoma, Washington
JAMA Neurol. 2016;73(3):345-346. doi:10.1001/jamaneurol.2015.3965.
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A 69-year-old white man presented to the emergency department reporting 2 months of progressive bilateral lower extremity weakness, left facial weakness, and diplopia in the setting of a 20.4-kg weight loss over the previous 6 months and new onset urinary incontinence. What is your diagnosis?

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Figure 1.

Sagittal T1-weighted MRI of the lumbar spine without (A) and with (B) contrast showing leptomeningeal enhancement of the lumbar spinal cord, cauda equina, and multilevel postsurgical changes.

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Figure 2.

Cross-section of decedent's lumbar spine, showing multifocal infiltration of neural tissue by pockets of medium-to-large atypical lymphoid cells with open chromatin, increased cytoplasm, and variable mitotic activity on hematoxylin-eosin stain (original magnification ×10). Additional immunohistochemical staining revealed a predominance of CD20-positive cells, with a small amount of admixed CD-3 positive cells, and also detected CD 10, Bcl-6 and MUM1 a pattern consistent with a diagnosis of diffuse large B-cell Lymphoma.

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