Primary Central Nervous System Lymphoma with Peripheral Nerve Involvement: Case Report.

A 50-year-old man presented with dizziness and hearing disturbance in the right ear. Magnetic resonance imaging (MRI) revealed a well-enhanced mass lesion in the right cerebellopontine (CP) angle that appeared to originate in the cerebellum. A surgical specimen obtained at the subtotal resection with craniotomy revealed a diffuse large B-cell lymphoma (DLBCL). During the three courses of chemotherapy with high-dose methotrexate (MTX) with leucovorin rescue, he developed a right abducens palsy, left oculomotor palsy, left facial palsy, right trigeminal sensory disturbance, and paraparesis. Although the brain MRI showed that the CP angle tumor had disappeared completely following chemotherapy, enhanced lesions along the cauda equina were detected on a lumbar spine MRI. FDG-PET (18 F-fluorodeoxyglucose positron emission tomography) revealed multiple high-uptake abnormalities in the cranial nerves and spinal nerves. Tumor cells were found in the cerebrospinal fluid specimen from a lumbar puncture. Craniospinal irradiation was performed, including all the abnormal FDG high-uptake areas, and was effective in relieving the patient's symptoms. On FDG-PET, the high-uptake abnormalities in the peripheral nerves disappeared. However, five weeks after the irradiation, he developed right trigeminal sensory disturbance, hoarseness, dysphagia, and right arm pain. FDG-PET disclosed multiple high-uptake abnormalities in more peripheral portions of the cranial nerves and spinal nerves. Chemotherapy with rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine (Oncovin®), and prednisolone (R-CHOP) was then resorted to which mitigated his symptoms. On follow-up FDG-PET, the high-uptake abnormalities in the peripheral nerves disappeared again.

[A case of Evans syndrome in a long-term hemodialysis patient].

A 75-year-old woman, who had been on maintenance hemodialysis (HD) from 2000, was receiving erythro- poiesis stimulating agent (ESA) for renal anemia. In November 2013, although still continuing ESA, she was admitted to our hospital due to worsening anemia. Since blood tests suggested the possibility of hemolytic anemia, we consulted,with hematologists, and she was transferred to another hospital. Differential diagnosis for anemia revealed that she had newly developed Evans syndrome, which is the complication of autoimmune hemolytic ane- mia (AIHA) and idiopathic thrombocytopenic purpura(ITP). She was successfully treated for AIHA with blood transfusion and administration of steroids, and for ITP by eradicating Melicobacter pylort. Anemia is commonly seen in HD patients, and the majority of anemia cases are diagnosed as renal anemia; however, hemolytic anemia should be considered in order to make a differential diagnosis. There are few reports of Evans syndrome in HD, and the pathogenesis of Evans syndrome is largely unknown. Further accumulation of clinical reports is needed to clarify its etiology.