59 yo man KT was diagnosed with MF by skin biopsy (3/2016). During chemotherapy, the patient developed dysarthria. Brain MRI (8/2016) showed 25.5 mm x 13.3 mm x 15 mm of vasogenic edema with 1 cm of ring enhancement in the right pons. Overall, findings were most consistent with metastatic disease: patient had active cutaneous lesions, and the T-cell CD4:CD8 ratio in CSF cytology matched that of the previous skin biopsy.  Patient was initially misdiagnosed and treated with steroids only, with temporary resolution of symptoms and imaging abnormalities.

Patient had cutaneous relapse (2/2017), and chemotherapy was restarted; patient developed gait imbalance, and brain MRI showed new 17 mm of vasogenic edema with contrast enhancement in the left cerebellum and extra-axial enhancement extending to the pons. CSF cytology was supportive of T-cell lymphoma. Patient completed six cycles of high-dose methotrexate, alternating with romidepsin. Brain MRI showed resolution in 4/2017. Patient continued to have cutaneous involvement; to treat systemic disease, methotrexate was discontinued.  Patient’s last MRI (8/2017) shows no CNS involvement 12 months after initial scan, and patient remains neurologically intact 24 months after initial CNS disease.