Introduction: Neurologic deficits can present at any stage of diffuse large B-cell lymphoma (DLBCL) based on current literature. Acute hypoxic respiratory failure (AHRF) secondary to tumor-induced phrenic nerve dysfunction is quite rare and requires aggressive treatment of underlying malignancy to improve patient outcomes.
Description: A 61 year old male presents with progressively worsening bilateral upper and lower extremity weakness. CT imaging found a C4-C5 cervical epidural abscess necessitating emergent surgical decompression and debridement. He was stable to discharge to inpatient rehab thereafter, however two weeks later redeveloped upper extremity weakness along with AHRF requiring intubation and mechanical ventilation (MV). Repeat MRI of the spine depicted a paraspinal mass along T8-T9 with invasion into eighth and ninth ribs. MRI also showed moderate spinal canal stenosis upwards of T2-T3, along with new C3-C6 marrow replacing lesion. Given localization of this new marrow replacing lesion and continued spinal compression, the patient was determined to have diaphragmatic paralysis requiring MV, failed multiple extubation attempts and thus needed a tracheostomy. Lesion biopsy showed DLBCL with aggressive features and began treatment with R-CHOP along with Ommaya reservoir placement for intrathecal therapy given CSF involvement. Patient’s respiratory status continued to improve while on chemo and was able to cap tracheostomy with plans to decannulate in the future.
Discussion: Lymphoma is often referred to as the oncologist's “great imitator” due to its varied manifestations and ability to mimic other disease processes. This case serves to highlight the importance of including lymphoma on the differential diagnosis for any undifferentiated mass lesion. The initial culprit of this patient’s neurological deficits was suspected to be the cervical abscess, however the incidental paraspinal mass was later found which exacerbated the narrowing of the cervico-thoracic canal. Once biopsy pathology indicated aggressive DLBCL, the plan was to optimize systemic and intrathecal chemotherapy to relieve spinal cord compression and subsequent phrenic nerve dysfunction which had led to bilateral diaphragmatic paralysis. His AHRF had resolved and allowed our team to help wean off trach collar effectively.
