Isolated oculomotor nerve palsy as a paraneoplastic manifestation of gastric diffuse large B-cell lymphoma: A case report

Abstract

Isolated oculomotor nerve palsy (ONP) is rare. The major causes are aneurysm of the posterior communicating artery, microvascular ischemia, neoplasm, inflammation and trauma. The present study reports the case of a 72-year-old female with left isolated pupil-sparing ONP and severe anemia as the initial manifestations of gastric diffuse large B-cell lymphoma (DLBCL). Systemic chemotherapy without any central nervous system (CNS)-directed treatment led to a complete resolution of the ONP, suggesting that it was most likely to be a paraneoplastic phenomenon. If CNS involvement cannot be demonstrated by brain magnetic resonance imaging and cerebrospinal fluid assessment, the present case suggests that it may be acceptable to omit CNS-directed therapy in such cases of ONP, since it may be paraneoplastic in nature and may resolve following successful treatment of the underlying malignancy.

Keywords: diffuse large B-cell lymphoma; oculomotor nerve palsy; paraneoplastic.

Figure 1

Exotropia, hypotropia, impaired adduction and ptosis of the left eye whilst gazing to the left and right in horizontal, upward and downward directions, respectively.

Figure 2

(A) Abdominal computed tomography scan showing diffuse and numerous nodular lesions over the mesentery, para-aortic spaces and bilateral iliac chains. (B) Peripheral blood smear showing a nucleated red blood cell (arrowhead) and myeloblasts (black arrow) with a high nucleus/cytoplasm ratio and conspicuous nucleoli. (C) Medium- to large-sized lymphocytes infiltrating the gastric mucosa [hematoxylin and eosin (HE) stain; magnification, ×1,000] that are (D) immunoreactive for the B lymphocyte marker, cluster of differentiation (CD)20 (magnification, ×400). (E) The intertrabecular marrow space was occupied by the same tumor cells with patches of tumor necrosis (HE; magnification, ×400) and (F) these cells were also immunoreactive for CD20 (×400).