A 75-Year-Old Man With 5 Days of Progressive Gait Difficulties and Confusion

A 75-year-old man with a history of chronic obstructive pulmonary disease and ischemic cardiomyopathy was brought to the emergency department after a fall at home. He had a 5-day history of progressive gait disturbance, right-sided weakness, and confusion. He had reported floaters in the right eye for the past month. He was previously well with no history of trauma, fever, anorexia, or change in body weight. Cerebrospinal fluid evaluation showed an increased protein concentration, normal glucose level, no red blood cells, and 4 white blood cells/µL. Cytologic and flow cytometry evaluations were negative. Computed tomograph of the chest, abdomen, and pelvis indicated no adenopathy or visceral lesions. Slitlamp examination of the right eye showed clumps of cells in the vitreous. Vitrectomy was performed, and analysis showed atypical monoclonal B cells consistent with large B-cell lymphoma. The patient was diagnosed with primary central nervous system lymphoma. The patient had an excellent initial clinical response to intravenous corticosteroids (dexamethasone) administered after vitrectomy. Subsequent staging showed no systemic lymphoma. He had hematology-oncology evaluations and was treated with chemotherapy (high-dose intravenous methotrexate, temozolomide, and rituximab) together with intravitreal rituximab for 1 year. He had an excellent clinical and radiographic response to treatment. He remained in complete remission until his death 6 years later (age 81 years) of pneumonia. Primary central nervous system lymphoma accounts for approximately 4% of primary brain tumors and occurs more commonly in persons older than 60 years and those with compromised immune systems. The tumor represents an extranodal form of non-Hodgkin lymphoma and is typically of the diffuse large B-cell type.