ABSTRACT
Primary central nervous system lymphoma (PCNSL) is a rare type of non-Hodgkin lymphoma, which uncommonly presents with optic nerve infiltration (ONI). ONI has been reported mostly in relapse cases of PCNSL and is rarely the sole manifestation of the disease at the time of diagnosis. We report a case of a 69-year-old female who presented with progressive visual impairment with relative afferent pupillary defect (RAPD) on examination. Orbital and cranial magnetic resonance imaging (MRI) revealed bilateral optic nerve sheath contrast enhancement with an incidental finding of a right frontal lobe mass. Routine cerebrospinal fluid analysis and cytology were unremarkable. Excision biopsy of the frontal lobe mass yielded the diagnosis of a diffuse B-cell lymphoma. Intraocular lymphoma was excluded on ophthalmologic workup. Whole body positron emission tomography scan did not reveal extracranial involvement establishing the diagnosis of PCNSL. Chemotherapy was initiated with rituximab, methotrexate, procarbazine, and vincristine as induction regimen and cytarabine as consolidation therapy. On follow-up, the visual acuity of both eyes significantly improved with the resolution of RAPD. Repeat cranial MRI did not show a recurrence of the lymphomatous process. To the best of the authors' knowledge, ONI as the initial presentation at the time of PCNSL diagnosis has only been reported three times. The present case's unusual presentation highlights the need to consider PCNSL as a differential diagnosis in patients who present with visual deterioration and optic nerve involvement. Prompt evaluation and treatment of PCNSL are essential for improving the visual outcomes of patients.
ABSTRACT
Charles Bonnet syndrome occurs in the setting of visual impairment with subsequent complex and repetitive visual hallucinations confined in the area of visual loss, with intact cognition and insight. It has been described as a sequelae of ischemic stroke affecting the visual pathway. We report a case of a male presenting with right homonymous hemianopsia secondary to acute left occipital lobe infarct of cardioembolic etiology. He then developed visual hallucinations on the side of the visual loss. MRI showed hemorrhagic conversion of the occipital lobe infarct. Electroencephalogram showed focal and intermittent slowing of the anterior temporal and frontal region. Charles Bonnet syndrome may signify the worsening or progression of a structural lesion affecting the visual pathway, such as hemorrhagic conversion, and warrants prompt and thorough evaluation. Understanding these conditions is crucial for healthcare professionals and caregivers to provide effective support and interventions for those affected.
