Unusual orbital lymphoma undetectable by magnetic resonance imaging: a case report

Abstract

Introduction: We report the case of a patient with orbital malignant lymphoma that was not detected by imaging studies when she presented with impaired vision, which lead to her eventual loss of sight.

Case presentation: A 71-year-old Japanese woman complained of deteriorating vision in her left eye. On examination, papilledema was detected, but magnetic resonance imaging only showed slight thickening and enhancement of the left optic nerve. A diagnosis of idiopathic optic neuritis was made and corticosteroid pulse therapy was administered. During the next four months, the patient received a total of four courses of corticosteroid pulse therapy, but she still suffered from bilateral loss of vision. A second magnetic resonance imaging procedure revealed tumors in both orbits and a biopsy showed diffuse large B-cell malignant lymphoma.

Conclusion: The possibility of malignant lymphoma should be considered in patients with recurrent optic neuropathy despite administration of corticosteroid pulse therapy, even when there are no abnormalities on cerebrospinal fluid examination or magnetic resonance imaging.

Figure 1

Magnetic resonance images of the head and orbits. (a) Initial coronal image (unenhanced T2-weighted) showing the left optic nerve to be thicker and more enhanced than the right optic nerve. (b) Transverse (enhanced T1-weighted) coronal image showing the left optic nerve to be thicker and more enhanced than the right optic nerve. (c) Coronal (enhanced T2-weighted) image obtained after loss of vision in both eyes, which shows that the right optic nerve has high signal intensity while the left optic nerve is swollen. (d) Transverse (enhanced T1-weighted) coronal image obtained after loss of vision in both eyes, which shows that the right optic nerve has high signal intensity while the left optic nerve is swollen. (e) Coronal (enhanced T1-weighted) image obtained six months after presentation displays bilateral orbital tumors. (f) Transverse (enhanced T1-weighted) coronal image obtained six months after presentation displays bilateral orbital tumors.

Figure 2

The resected orbital tumor shows infiltration of the extraocular muscles. Tumor biopsy was carried out six months after presentation. The tumor cells are large, polygonal, or round and the nuclei are folded, cleaved, or kidney-shaped. Mitoses and prominent nuclear abnormalities can be seen. The pathological diagnosis was diffuse large B cell lymphoma (hematoxylin-eosin, × 50).