A 71-year-old female presented with episodic non-specific vertigo and diplopia. Neurological examination revealed left CN IV and VII palsies. MRI brain showed diffuse brainstem leptomeningeal enhancement. CSF studies revealed lymphocytic predominance, and negative ACE, IgG synthesis, paraneoplastic panel, and cytology. She was treated with pulse steroids but presented to the hospital nearly monthly with progression. On the fifth admission, repeat CSF analysis revealed cytology consistent with large B-cell lymphoma. She underwent chemotherapy with symptom resolution.
A 31-year-old female presented with 9 months of progressive dizziness, visual blurring, hearing loss, tremors, headaches, gait instability, and hemiplegia. MRI brain revealed an acute infarction in the left medulla. CSF had elevated opening pressure, lymphocytic predominance, positive myelin basic protein, positive oligoclonal bands, elevated CSF ACE 10, elevated IgG index 0.77, with negative cytology and flow cytometry. Contrast MRI of the brain and spine revealed enhancement of CN II, VII, VIII, leptomeninges of brainstem, and spinal nerve roots. Leptomeningeal biopsy was inconclusive. She was managed as probable neurosarcoidosis, and treated with pulse steroids, cyclophosphamide, and infliximab. CSF ACE improved (3.7). She stabilized clinically.
A 64-year-old male presented with progressive bilateral lower motor facial palsy and lower extremity hyperreflexia, with remote tick-bite history. MRI brain revealed left CN VII, VIII, and XII enhancement, and increased T2 signal in thoracic cord suggesting longitudinally extensive transverse myelitis. Lyme IgG was positive. IgM was equivocal. p41 was reactive on IgM immunoblot and p18, p23, p41, p45, p93 on IgG Immunoblot. Patient was treated with pulse steroids and IV ceftriaxone as CNS Lyme. The facial palsy improved dramatically.