Abstract Details

A 65-year-old woman with a history of diffuse large B-cell lymphoma presented with new left arm weakness and pain. Five months prior, she had completed six cycles of R-CHOP and achieved complete remission. One month ago, she began having trouble gripping items and typing with her left hand. On presentation, there was left wrist drop, wrist pain, numbness, and tingling. Neurologic examination showed 1/5 strength with wrist extension and 0/5 with finger extension. Sensation was diminished in a C6-C7 dermatome. Deep tendon reflexes were brisk throughout the left upper extremity. There was slight improvement with oral corticosteroids.

To teach the importance of clinical localization in cancer patients presenting with wrist drop and demonstrate the role of tissue biopsy when non-invasive diagnostic testing is uncertain.

PET/CT suggested a deep venous thrombosis (DVT); but upper extremity venous duplex was negative for DVT. NCV localized the wrist drop to the spiral groove and MRI imaging suggested the possibility of a peripheral nerve sheath tumor. Ultimately, open surgical resection of the axillary mass revealed perineural spread of diffuse large B-cell lymphoma within the lateral cord of the brachial plexus consistent with neurolymphomatosis. The patient was treated with R-DHAC and is currently awaiting an autologous stem cell transplant. Her wrist drop has remained stable.

Peripheral nervous system involvement of non-Hodgkin lymphoma includes chemotherapy induced peripheral neuropathy, nerve compression from neoplastic masses, immune-mediated polyneuropathy, and rarely direct infiltration of the nerves, termed neurolymphomatosis. This case reinforces three important teaching points including (1) localization of new onset wrist drop to the spiral groove should prompt imaging evaluation for an etiology, (2) in a cancer patient, when non-invasive imaging is inconclusive biopsy should be performed to obtain tissue, and (3) perineural spread of lymphoma is a rare presentation of peripheral nerve involvement of non-Hodgkin's lymphoma.