Neoplastic Parkinsonism: An illustrative case report
A 41-year-old male presented with 3 years history of progressive slowness of gait, stooped posture, and dragging of feet, especially on the left, while walking. He was diagnosed to have Parkinson's disease in the 2nd year of his illness at another center. A non-contrast magnetic resonance imaging (MRI) of the brain showed scanty, ill-defined lesions in the cerebral sub cortex and basal ganglia on T2 weighted (T2 W) images (verified by author LP), which was reported to be nonspecific. He responded poorly to Levodopa therapy which he discontinued within 6 months. In the 3rd year of his illness he become forgetful, had low volume speech and drooling of saliva. Two weeks prior to admission he became irritable, had irrelevant speech, and noticeable deterioration in his gait. On examination the patient was afebrile but disoriented and dysarthric. He had facial hypomimia, bradykinesia, cogwheel rigidity, and festinant gait. Deep tendon reflexes were exaggerated and plantar response was extensor. General examination revealed firm non tender cervical and axillary lymphadenopathy and mild hepatosplenomegaly.\nRoutine investigations were normal. He was HIV negative. Ultrasound of the abdomen revealed para aortic lympadenopathy with mild ascites. Brain MRI revealed multiple nodular enhancing lesions bilaterally in the corona radiata, centrum semiovale, bilateral basal ganglia, midbrain, pons, and cerebellum [] which were hypointense on T1 weighted (W) and hyperintense on T2 W images. Susceptibility weighted images showed multiple rounded hypointense signals suggestive of hemorrhagic lesions []. Cerebrospinal fluid examination revealed 15 cells/mm3 (all lymphocytes), protein 156 mg/dl and cytology was normal. Left axillary lymph node and right frontal wedge biopsy of the brain was done. Lymph node biopsy showed effaced architecture, neoplastic cells of intermediate size showing dense T-cell staining and absent B-cell marker consistent with the diagnosis of nodal PTCLUS. Brain biopsy revealed multiple angiocentric, neoplastic T-cell infiltrates [] with micro hemorrhages. Lymphoma was T-cell (CD3) positive [], B-cell [], CD4 and CD8 negative. The Ki-67 proliferation index was <2% in the lymph node biopsy while it was >25% in the brain sections []. After biopsy, patient received five doses of intravenous methyl prednisolone (1 g/day) followed by a 2 week oral taper. Rigidity and bradykinesia improved remarkably in the immediate period after steroid therapy and the patient was able to walk unaided and became coherent and oriented. At follow-up after 3 months, he was rigid, cognitively declined, and on a wheel chair. Patients’ relatives had declined further treatment and he was subsequently lost to follow-up.