Case report
Posterior reversible encephalopathy syndrome (PRES): An unusual primary manifestation of a diffuse large B-cell lymphoma

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Introduction

Posterior reversible encephalopathy syndrome (PRES), is a clinical entity characterized by headache, nausea, vomiting, seizures, conscious disturbance, and visual disorder associated with neuroradiological findings, predominantly white matter abnormalities of the parieto-occipital lobes [1]. It has been recognized in a wide range of conditions, including hypertensive encephalopathy, organ transplantation, uremia, preeclampsia/eclampsia, connective tissue diseases, systemic lupus erythematosus, thrombotic thrombocytopenic purpura, cerebral angiograms, hypertension-inducing treatments such as erythropoietin, blood transfusions, or immunosuppressive therapy particularly with cyclosporine A and tacrolimus, and immunoglobulin, as well as various chemotherapeutic agents such as cisplatin [2].

Usually, if treated early there is a good short-term and long-term prognosis, with complete restitution of clinical and neuroimaging abnormalities in the majority of cases. Occurrence of PRES in association with hematologic disorders has been attributed to effects of administered chemotherapeutic agents [2]. Here, we report on a case with severe PRES as an unusual primary clinical manifestation of an infiltrating diffuse large B-cell lymphoma (DLBCL).

Section snippets

Clinical history

A 53-year old Caucasian male was submitted to the neurological emergency department at Rostock University with a first generalized convulsive seizure. The patient's history included diabetes mellitus and hypertension. On admission, physical examination was unremarkable, a moderate psychomotor slowing was considered as being a postictal symptom. Blood pressure was 150/90 mmHg, heart rate 90 bpm and body temperature 36.9 °C. Neither enlarged lymph nodes nor hepatosplenomegaly was observed. The

Discussion

We consider this case of severe PRES to be the unusual primary clinical manifestation of an infiltrating DLBCL. This case is quite unusual in two respects. First, while extranodal manifestations of DLBCL are not infrequent, the apparently exclusive involvement of the bone marrow seen in this case is a rare event, indeed. Second, though clearly not a multiple myeloma, this neoplasm was endowed with osteolytic activity that explains very well the increase in serum calcium which, in turn, in an

Acknowledgment

We are grateful to the patient for the permission to publish this paper.

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Cited by (11)

  • Posterior reversible encephalopathy syndrome (PRES) complicating newly-diagnosed diffuse large B-cell lymphoma

    2014, Clinical Lymphoma, Myeloma and Leukemia
    Citation Excerpt :

    Underlying diseases such as hypertension and collagen vascular disorders have also been associated.1,2,8 DLBCL and hypercalcemia have previously been described as causing PRES.9-11 Hypercalcemia might contribute to the pathogenesis of PRES via inducing cerebrovascular vasospasm, and the mechanism for DLBCL precipitating PRES is unknown. This case illustrates that PRES should be considered in the differential diagnosis of cancer patients presenting with altered mental status, visual hallucinations, and seizures.

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1

Both authors contributed equally to this manuscript.

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