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, LA.