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Proceedings SNO “Percorsi clinici in Neuroscienze”
Case report V SESSIONE
“PERCORSI CLINICI COMPLESSI”
Multiple nerves involvement hiding something else
E. AGAZZI*, M. SESSA*, G. PEZZETTI**, S. GEREVINI**
* UOC di Neurologia, Ospedale “Papa Giovanni XXIII”, Bergamo, Italy
** UOC di Radiologia diagnostica per immagini 2 - Neuroradiologia, Ospedale “Papa Giovanni XXIII”,
Bergamo, Italy
CASE REPORT Negative total body PET scan, negative salivary biop-
sy, negative autoantibodies panel and negative ACE
A Caucasian 52 years healthy old man showed were performed. A clinical stabilization was observed
episodes of lower left inferior limb weakness, few with anti EBV therapy (acyclovir and valaciclovir),
weeks before his Emergency Department access, asso- although after a while progressive worse tinnitus pre-
ciated with light walking motor impairment, following sented with progressive deafness, starting on the
disturbance voiding and light weight loss, saddle hy- right, and brain MRI showed eight right cranial nerve
poesthesia, dysgeusia, left front-orbital headache and enhancement. Steroid and subsequent immunoglobu-
occasional tinnitus. During his hospitalization, various lin therapy were performed, with no clinical re-
investigations were performed: spinal fluid showed sponse. Other spinal fluids exams were always nega-
lymphocytic pleocytosis, high protein level and EBV tive for clonal cells, and three moths later total body
positive PCR while brain spine MRI evidenced only PET exam and total body CT scan were persistently
caudal roots enhancement (left more than right). negative. Finally sacral roots biopsy was performed
Specific EBV therapy was performed and a second showed aspecific T-cell infiltrate; afterwards bowel
spinal fluid showed lower lymphocytic pleocytosis and paresis started with liver failure and ascites, that was
negative EBV PCR; therefore the patient was dis- drained several times, with persistently negative
missed with EBV meningoradiculitis diagnosis. monoclonal cell abdominal liquid, but always signi-
Almost three weeks later, meanwhile the persistence ficative EBV positive liquid. Because of the persis-
of distal lower limbs weakness, hypoesthesia of right tency of EBV positive results in different fluids, fol-
trigeminal nerve appeared, together with right hand lowing haematological suggestion of a possible lym-
paresthesia and, finally, paralysis of the right facial phoma causing the entire clinical picture, a rituximab
nerve and floating diplopia appeared as distal limbs first line off label treatment was performed, but rapid
paresthesia. Cerebral MRI showed bilateral intra- worsening of patient picture was observed due to
meatal and intrapetrosous bilateral facial nerve en- thrombocytopenia, T cell leukopenia AIDS like, sep-
hancement. At this point a third spinal fluid exam tic status, with final renal failure and end stage mul-
showed positive EBV DNA, persistence of lympho- tiorgan failure with patient’s death.
cytic pleocytosis with always absence of tumoral Autopsy showed extranodal T/NK cell lymphoma,
cells. nasal type (section WHO 2017).
Corrispondenza: Dr.ssa Emanuela Agazzi, UOC di Neurologia, Ospedale Papa Giovanni XXIII, piazza Organizzazione Mondiale
della Sanità, 24127 Bergamo (BG), e-mail: eagazzi@asst-pg23.it
Percorsi clinici in Neuroscienze. Clinical Round SIN e SNO Lombardia, 21 gennaio 2022, Desio (Monza e Brianza)
Atti a cura di Paolo Ferroli, Alessandra Protti, Andrea Salmaggi, Ignazio Michele Santilli, Luca Valvassori
Copyright © 2022 by new Magazine edizioni s.r.l., Trento, Italia. www.newmagazine.it ISBN: 978-88-8041-135-2
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