Category: Clinical Sciences/Health Conditions
Case Diagnosis: A 53-year-old male with multifocal motor neuropathy (MMN) and CD5+ diffuse large B cell lymphoma (DLBCL).
Case Description: This patient had a 10-year history of MMN managed well with IVIG infusions every 4 weeks. This enabled him to be functionally independent. After a poor response to his last IVIG infusion, the patients function quickly deteriorated, resulting in incomplete quadriplegia. Shortly thereafter the patient was found to have newly diagnosed CD5+ DLBCL. CD5+ B cells have been implicated in autoimmune conditions and hence determined, his poor response to his last IVIG infusion could be related to dysregulation of his immune system secondary to the lymphoma. IVIG treatment for his MMN was thus held due to its potential to interfere with the antibody-dependent cell-mediated cytotoxic mechanism of rituximab. Instead, the patient is being treated solely for his CD5+ DLBCL with dose-adjusted etoposide, prednisone, oncovin, cyclophosphamide, hydroxydaunorubicin, and rituximab (DA-EPOCH-R).
Discussions: The patient completed 6 cycles of chemotherapy, with inpatient rehabilitation (IRF) admissions between cycles. Each cycle was complicated by significant weakness, however he demonstrated improvements on previous gains with each IRF stay. Now that all cycles are completed, the patient has made steady progressive functional gains. Admission muscle strength was 1/5 in bilateral upper extremities (BUE) and 0/5 in bilateral lower extremities (BLE). Currently, muscle strength is 4+/5 in BLE and 4-/5 in BUE. He has been able to ambulate independently using forearm crutches. This is the first reported case, to our knowledge, of MMN years prior to the diagnosis of DLBCL, with CD5+ B cells impacting treatment and functional outcome of MMN. The other cases found proposed a causal relationship between DLBCL and MMN.
Conclusions: Early interdisciplinary management between PM&R and Hematology/Oncology was essential for maintaining function during treatment and subsequently making gains to return to independence post-treatment.
William White– Resident Physician, Medstar National Rehabilitation Hospital/Georgetown University Hospital
John Mansfield– Resident, MedStar Georgetown University / NRH
Benjamin Miller– Resident, MedStar Georgetown University / NRH
Matthew Weinstein– Resident, University of South Florida
Erika Gosai– Attending Physician, MedStar National Rehabilitation Network