This is a 52–year–old man with a history of Stage 1A Hodgkin lymphoma diagnosed at age 18 successfully treated with mantle radiation. He recurred at age 48 and underwent chemotherapy and autologous stem cell transplant in 2008. Post transplantation in 2011, surveillance studies showed no evidence of disease. However, the patient’s history was complicated by severe, new–onset bilateral lower extremity parasthesias for which he required a cane to ambulate. Electromyography and nerve conduction studies failed to demonstrate evidence of neuropathy. Initial imaging of the cervical, thoracic and lumbar spine were unremarkable. Symptoms were refractory to gabapentin, pregabalin, amitriptyline, and duloxetine medical management. Over 2 weeks, the patient developed worsening lower extremity paresthesias and hyperesthesia and was unable to walk prompting hospitalization. On admission, he also complained of cutaneous anesthesia of the left thigh, groin and caudal chest to the level of T5, as well constipation and incomplete voiding. Within 72 h of admission he developed acute onset right lower extremity paralysis that descended from the level of the hip with new intermittent sharp abdominal wall pain. Repeat MRI of the thoracic spine noted an intramedullary enhancing lesion along the central–dorsal aspect of T9–T10. Topping our differential was a secondary malignancy versus a glioma as a consequence of the mantle radiation he had received 34 years earlier versus an infection. CSF analysis including cytology was unremarkable. A trial of high dose decadron over 48 h resulted in little clinical improvement and the lesion remained unchanged as noted by repeat MRI. Neurosurgery was consulted to biopsy the lesion. A 10% risk of permanent paralysis was discussed with the patient and after consideration of the risk versus benefit, he agreed to the procedure. Biopsy of the lesion revealed fibrosis and granulation tissue consistent with radiation–induced injury. No evidence of malignancy or glioma was identified. The patient was treated with a tapered dose of steroids and intensive physical therapy. A month post–discharge the patient was ambulating with a walker with significant improvement of associated symptoms.
Radiation induced myelopathy and tumor growth has been described extensively in the literature, however onset is not usually as delayed as in this case. A comparable clinical course was described by Carey and Long in 1973 (NEJM) in a patient undergoing repeated radiation therapy for Hodgkin lymphoma, but not in the context of recent immunosuppression such as bone marrow transplantation.
This case seeks to highlight potential emerging issues in long term Hodgkin disease survivors undergoing current medical therapy.
Figure 1MRI of the thoracic spine demonstrating intramedullary enhancing lesion.