Teaching NeuroImages: Presentation of diffuse large B-cell lymphoma with bilateral sequential oculomotor neuropathy

A 56-year-old man with HIV on combination antiretroviral therapy (CD4 count 368 cells/μL; HIV-RNA < 20 copies/mL) had sequential, bilateral oculomotor nerve palsy after recent travel to Africa. Nonexpansile enhancement of the oculomotor nerves was noted on MRI (figure 1). Multiple CSF studies showed lymphocytic pleocytosis without neoplastic cells. Molecular testing on the serum was positive for Plasmodium falciparum by PCR early in the course of presentation but symptoms progressed despite treatment for P falciparum . Infectious etiologies including Cryptococcus neoformans , histoplasmosis, varicella-zoster virus, herpes simplex virus, and JC virus were ruled out. He developed multiple cranial neuropathies (bilateral 3rd, 5th, 9th, and 10th) and encephalopathy and died of cytomegalovirus-related cardiopulmonary complications. Lymphadenopathy was not observed during the course of his illness. Autopsy revealed intracranial and pericardial diffuse large B-cell lymphoma (DLBCL) (figure 2). Isolated oculomotor palsy is a rare presentation of DLBCL, with fewer than 20 reported cases.1,2 The risk for DLBCL, an AIDS-defining illness, increases with decreasing CD4 counts; however, it can occur in HIV despite normal CD4 counts.3