Delayed Diagnosis of Brachial Plexus Neurolymphomatosis in Post-transplant Patient with Diffuse Large B-cell Lymphoma (P7.017)

OBJECTIVE: Diagnosis of brachial plexus neurolymphomatosis in post-transplant patients could be delayed BACKGROUND: Involvement of brachial plexus in diffuse large B cell lymphoma is rare presenting feature. Diagnosis requires repeated multimodality testing DESIGN/METHODS: Case report with retrospective collection of data RESULTS: 62-year-old male with systemic large B-cell lymphoma since 2001, with CNS involvement (right eye, s/p radiation in 2008; right parietal lesion, s/p craniotomy with systemic chemo with methotrexate, vincristine and high dose Rituxan). Patient subsequently underwent double cord transplant. For graft vs host disease (GVHD) patient was given tacrolimus and Cellcept. Seventy days post-transplant patient presented with right scapular and arm pain, with associated shoulder/arm weakness and numbness. On exam there was weakness in the right triceps, wrist/finger extensors, and marked muscular atrophy of right triceps. Patient had slow smoldering symptoms of at least 5-6 months with recent worsening that initiated current neurologic workup. Diagnostic tests prior to these symptoms onset were negative (lumbar puncture, brain MRI, PET scans). EMG/NCS was obtained and showed right cervical radiculo-neuritis (C7, C8 and T1) with subacute on chronic axonal involvement, moderate-to-severe degree, with concern for right brachial plexus involvement. Cervical and thoracic spine MRIs were unremarkable. Brain MRI showed 1 cm nodularity anterior to the prior right resection cavity. There were atypical large lymphoid cells in CSF and flow cytometry confirmed aberrant large B cells. MRI of right brachial plexus showed enlargement, enhancement and edema of the C6, C7, C8 nerve roots, and brachial plexus. PET/CT scan on day 97 post-transplant demonstrated lymphoma involvement of brachial plexus. Biopsy was not performed. Pt was started on salvage radiation therapy to the right fronto-parietal tumor and right brachial plexus CONCLUSIONS: Diagnosis of brachial plexus neurolymphomatosis in post-transplant patient may require multimodality approach and repeated testing. Medications used for GVHD can mask acute-subacute presentation as in this patient who had evidence of long-standing plexopathy on EMG/NCS Study Supported by: none Disclosure: Dr. Stosic has nothing to disclose. Dr. Tummala has nothing to disclose.