AIDS-related lymphoma (ARL) presenting as cauda equina syndrome.
Burkitt and Burkitt-like lymphomas account for 3% of AIDS-defining
malignancies. Potentially involving any organ system, Burkitt (-like)
lymphoma at presentation rarely compresses the lumbo-sacral spine/cauda
equina. We describe ARL in an HIV-positive patient without history of
AIDS-defining disease presenting as cauda equina syndrome. A 49-year-old
male with stable human immunodeficiency virus (HIV) infection for 11
years presented with lower extremity weakness and pain unrelieved with
high dose oral aspirin, and incontinence of both bowel and bladder.
Recently taken off highly active antiretroviral therapy (HAART) for a
dermatologic reaction, he had never experienced an opportunistic
infection or AIDS-defining illness; his last CD4+ cell count was
421/[micro]L, HIV viral load was 93/[micro]L. His exam revealed
bilateral lower extremity weakness and hyporeflexia with intact
sensation, and saddle anesthesia with absence of rectal tone. MRI
revealed a presacral mass invading the lumbosacral canal. Intravenous
dexamethasone, a four-drug antituberculous regimen, and broad-spectrum
antibiotics were begun empirically. After a nondiagnostic CT-guided
biopsy, laminectomy and biopsy of an epidural mass showed small blue
cells with noncleaved nuclei. Pathology confirmed the "starry
sky" appearance of Burkitt or Burkitt-like lymphoma. Bone marrow
was negative for lymphomatous involvement. Spinal radiotherapy was
begun, HAART was restarted, and oncology was consulted. Patients who are
HIV-positive are several hundred times more likely to develop a NHL than
HIV-negative patients. Unlike diffuse high grade B cell lymphoma,
Burkitt (-like) lymphoma often develops at relatively high CD4+ cell
counts. Eighty percent of patients present with stage four disease and
most develop extranodal spread occasionally involving the leptomeninges.
However, it rarely exists as a solitary extramedullary compressive mass.
No other published case has been found describing Burkitt (-like) ARL
presenting as cauda equina syndrome.
Robert Holmes, DO, Jason Tompkins, MD, and Ruth Berggren, MD.
Keesler Medical Center, Keesler AFB, MS. Charity Hospital, New Orleans,