Abstract: Primary spinal epidural diffuse large B-cell lymphoma (DLBCL) is rare and often easily misdiagnose. Here, we presented a case of primary spinal epidural DLBCL with paraplegia as the first manifestation. He was misdiagnosed as thoracic disc herniation and thoracic tuberculosis successively. DLBCL was confirmed after surgery ultimately. After 6 cycles of chemotherapy with R-CHOPE, the patient went back to normal life without relapse during 2-year follow-up. Primary spinal epidural lymphoma should be suspected in patients with spinal cord compression with imaging showing isointense, homogeneous extradural contiguous level compressive soft‑tissue lesion without bony involvement and previous history of cancer.


Keywords: epidural, diffuse large B-cell lymphoma


INTRODUCTION


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Primary spinal epidural lymphoma (PSEL) is an entity of lymphomas located in epidural without any other recognizable sites of lymphomas at diagnosis.1 An epidural location for lymphoma is observed in 0.1–6.5% of all the lymphomas;1 thus, it is challenging at diagnosis and may easily be misdiagnosed. Here, we presented a case of primary spinal epidural DLBCL with paraplegia as the first manifestation.

CASE PRESENTATION

A 39-year-old man was admitted to our hospital on December 23, 2015, with back pain, numbness and weakness of lower limbs for 2 months. Thoracic disc herniation was considered in local hospital 2 months ago; however, conservative treatment did not work. Moreover, the disease quickly progressed to paraplegia on December 24, 2015. The neurologic examination demonstrated a minor motor impairment of lower limbs and reflexes were hyperactive. Anal sphincter tone was without damage, negative Hoffman, Trömner and Babinski’s sign. He presented a sensory level of hypoesthesia and loss of thermalgesia at T7. T-SPOT.TB was positive. The enhanced magnetic resonance imaging (MRI) of thoracic vertebra on December 24, 2015 (Figure 1), suggested that thoracic 7 vertebral body, the thoracic 7 and 8 vertebral body accessory tuberculosis was considered, accompanied by intraspinal abscess formation. He was misdiagnosed with thoracic tuberculosis. Posterior pedicle screw fixation + spinal canal decompression + lesion clearance + bone grafting and fusion was performed on December 25, 2015. Surgical pathology suggested DLBCL. The immunohistochemical (Figure 2) hinted tumor cells CD20 (+), CD79a (+), PAX-5 (+), Bob-1 (+), Oct2 (+), CD10 (+), BcL-2 (+), Bcl-6 (+), CD15 (-), CD30 (+), CD23 (+), CD21 (+), MUM1 (+) and Ki-67 (+ >30%). Reactive cells CD3 (+), CD5 (+), CD43 (+), CD45RO (+); CDla (-), ALK (-), EMA (-), TdT (-), CD117 (-), HMB45 (-), S100 (-), CD31 (-), CK (-) and EBER (-). 18F-fluorodeoxyglucose (18F-FDG)-positron emission tomography/computed tomography (PET/CT) imaging on January 14, 2016 (Figure 3A and B) showed T8–10 vertebral body, retroperitoneal enlarged lymph nodes, left iliac bone and left femur with increased uptake of 18F-FDG. Based on these, systemic chemotherapy with rituximab + CHOPE (R-CHOPE) was determined as an appropriate treatment for the patient since January 20, 2016. After four cycles of chemotherapy with R-CHOPE, PET/CT on May 12, 2016 (Figure 3C and D) suggested that, compared with PET/CT on January 14, 2016, 18F-FDG uptake concentration in the original area all disappeared, suggesting that the tumor was relieved. Then, the strength of both lower extremities gradually recovered, and he could walk. After another two cycles of chemotherapy with R-ECHOP on May 14, 2016, and on June 11, 2016, respectively, the patient went to follow-up time. During the nearly 2-year follow-up, the disease still has no relapse.



Ethical approval was not necessary for the case report. The patient has consented for the publication of the present case report.

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