SUBACUTE PARANEOPLASTIC RADICULOMYELITIS ASSOCIATED WITH HODGKIN LYMPHOMA

Sirs: Spinal cord lesions associated with Hodgkin lymphoma (HL) include epidural and intramedullary tumours, ischaemic myelopathies related to paravertebral lymphoma, radiation myelopathy, toxic myelopathy due to intrathecal chemotherapy, viral myelitis and paraneoplastic myelopathy. We report a patient who developed simultaneously a HL and a probably immune-mediated paraneoplastic subacute radiculomyelitis. A previously healthy 28-year-old man presented on 6 October 1994 with a 1-month history of progressive weakness, numbness and dysaesthesias of the lower limbs. He also complained of retrosternal pain and cough in the right lateral decubitus position. He developed urinary retention, left footdrop and paraesthesias in the cutaneous distribution of the C8 nerve roots. The clinical examination a week later revealed a mild distal paraparesis, predominantly in the left foot extensors and flexors (grade 2/5 weakness). The left ankle jerk and the right abdominal and left plantar cutaneous responses were absent. Diffuse hypaesthesia for touch and pinprick was observed below the T10 level. Vibratory hypaesthesia of the left lower limb was also found. No lymph nodes were palpable. Magnetic resonance imaging (MRI) of the spine (Fig. 1) showed increased signal on T2-weighted images within the cord, which was not widened, from T4 to T10. This lesion appeared as slightly decreased signal on T1 weighting, with discrete enhancement with gadolinium. These MRI findings were consistent with myelitis. The tibial nerve somatosensory evoked potentials showed a bilateral and symmetrical increase in central conduction time (spinal N24-parietal P40: 29.8ms), consistent with thoracic spinal cord dysfunction. EEG, brain-stem auditory, pattern visual and median-nerve somatosensory evoked potentials were unremarkable. Nerve conduction studies and EMG (needle examination) were normal in the upper limbs. Sural and superficial peroneal sensory nerve action potentials were normal, bilaterally. The left peroneal nerve was inexcitable. Diminished amplitude of the compound muscle action potentials and absent F waves were observed after stimulation of the right peroneal and left posterior tibial nerves. EMG of the lower limbs showed fibrillation potentials and positive sharp waves at rest in the bilateral L5 and left S 1 nerve-root innervated muscles. Large-amplitude, long-duration, polyphasic motor unit action potentials with diminished recruitment were observed in the bilateral L4-S 1 nerve-root innervated