Patient 1 was a 54 year old male who developed gradual onset of right leg weakness, dysarthria, dysphagia and blurred vision. MRI showed T2/FLAIR hyperintensities with scattered enhancement along bilateral corticospinal tracts radiating from the centrum semiovale into bilateral thalami. CSF was unremarkable. His symptoms were attributed to an autoimmune etiology and initially improved with plasmapharesis and corticosteroids however symptoms worsened. Biopsy was performed confirming diffuse large B-cell lymphoma. He received high-dose methotrexate with complete resolution of the corticospinal enhancement.
Patient 2 is a 46 year old male who presented with episodic alternating left and right sided weakness with headache and slurred speech. MRI showed mild left white matter T2/FLAIR hyperintensities. CSF showed monocytic pleocytosis with oligoclonal bands concerning for multiple sclerosis. He initially improved with steroids but declined after steroids were tapered. ESR and CRP were elevated suggesting vasculitis. Cerebral conventional angiography was unremarkable. Biopsy was then performed off steroids which confirmed diagnosis of CNS lymphoma. He improved after treatment with whole brain radiation and rituximab.