When Pain Unveils Hidden Challenges: A Multidisciplinary Journey Through Radiculopathy and Lymphoma
Narges Rahimi1, Shikhar Khurana2, Varsha Muddasani3, Aparna Prabhu1, Saman Zafar4
1Albert Einstein Medical Center, 2Jefferson Einstein Hospital, 3Einstein Medical Center, 4Einstein Medical Center Philadelphia
Objective:
In cases involving underlying malignancy or an immunocompromised state, when a patient presents with radiculopathic pain, it is crucial to consider the potential contributions of both malignancy and infection to the symptoms.
Background:
Post-Transplant-Lymphoproliferative-Disorder occurs in less than 2% post kidney transplant cases. Occurrence of radiculopathy is rarer and not been reported in the literature.
Results:
A 47-year-old woman with a history of ESRD status post kidney-transplant (on tacrolimus and azathioprine),and B-cell lymphoma(PTLD) status post 5-cycles of chemotherapy, DVT/PE, and cardiac pacemaker (lymphoma compression on her neck vasculature), presented with acute bilateral leg pain (right > left) and weakness, which progressed to paraplegia, saddle numbness/tingling in the right buttock radiating to the calf, gait abnormalities, and urine retention. Her pain was increasingly severe, necessitating IV opiates. The differential diagnosis was radiculopathy due to DJD, pathological fracture of spine, Guillian-Barre-Syndrome, Pain-seeking-behavior, Lymphoma. No fractures were seen on CT-Thoracic spine. MRI of the lumbar spine demonstrated intradural enhancing masses at L2-L3 with nodular enhancement of the cauda equina roots concerning for leptomeningeal carcinomatosis. MRI brain revealed an enhancing hyperintense lesion in the medulla. EMG/NCS of the bilateral lower extremities ruled out GBS. Lumbar puncture revealed abnormal CSF values: WBC 250, Protein 375.2, Glucose 43. Cytology/Flow cytometry was positive for CD19 and CD20.The patient was diagnosed with primary refractory post-transplant high-grade B cell non-Hodgkin's lymphoma(PTLD) with CNS involvement. Her azathioprine and tacrolimus were stopped. She was planned for intrathecal methotrexate/ autologous stem cell transplant, and transferred to the Inpatient Lymphoma Service for further management.
Conclusions:
Severe radiculopathic pain may deter from the actual clinical diagnosis of underlying structural lesion – especially in patients with underlying malignancy or immunosuppression. Adequate imaging with CSF studies including flowcytometry and cytology is essential for timely diagnosis.