Non-Hodgkin lymphoma presenting with ophthalmoplegia and gingival pain.
Non-Hodgkin lymphoma presenting with ophthalmoplegia and gingival pain.
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非霍奇金淋巴瘤表现为眼肌麻痹和牙龈疼痛。
DOI：
10.1097/01.wno.0000223271.78942.67
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发表时间：
2006-06
期刊：
影响因子：
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中科院分区：
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我们最近检查了一例由非霍奇金淋巴瘤(NHL)引起的急性进行性眼肌麻痹的中国患者。一位51岁的中国男性患者突然出现复视，随后出现三天的左侧牙周疼痛。他报告没有头痛、发烧、寒战、恶心、呕吐、眩晕或眩晕。他的病史包括胰腺炎和II型糖尿病。他并没有处于痛苦之中。生命体征正常。没有脑膜痉挛、淋巴结、脾或肝脏肿大。左侧下颌牙龈红肿。神经眼科检查显示视功能正常。右上睑部分下垂。右侧瞳孔在昏暗的光照下测量为5 mm，对直射光反应迟钝。左侧瞳孔大小为4 mm，对直射光反应正常。无传入性瞳孔缺损者。右眼有50%的外展、60%的内收和50%的垂直导水管。左眼引流正常。双眼角膜知觉完好无损。所有其他方面的神经学和眼科检查都正常。在我们最初检查的五天内，他出现了右眼完全没有导水管，完全的右上眼睑下垂，以及7毫米无反应的右瞳孔。一名牙医诊断为左侧牙周脓肿，并进行了切开和引流。患者接受抗生素舒巴坦/头孢哌酮和静脉胰岛素治疗。实验室数据显示，完整的血细胞计数为6500个白细胞，19.2万个血小板，血红蛋白水平为13.7g/dl。红细胞沉降率在65 mm/h(正常，2~20 mm/h)时升高，C反应蛋白水平在48 mg/L(正常，0~8 mg/L)时升高。标准血液化学检查，包括肾和肝功能检查，补体C3和C4，抗核抗体，抗双链DNA，以及HIV的ELISA法均为阴性。眼眶CT和脑MRI也正常。腹部超声检查正常。腰椎穿刺术显示开腹压、血糖、蛋白质、细胞计数和细胞学检查正常。入院15天后，患者发现双侧双腿浮肿，并伴有持续性完全性右眼肌麻痹、上睑下垂和散瞳。在接下来的两天里，血肌酐水平迅速上升到210mmoL/L(正常上限，106%)，BUN上升到16.96mmoL/L(正常上限，8.3%)。腹部CT扫描显示左肾周间隙有软组织肿块(图1)。超声检查显示脾、肝和肾增大(右肾15厘米，左肾16厘米)，无尿路梗阻迹象。肾实质呈低回声；彩色双功超声检查未发现肾动脉或静脉血栓的迹象。在接下来的13天里，连续完整的血细胞计数保持正常。第二次腰椎穿刺术在发病7天后继续显示正常的开腹压力、化学成分、细胞计数和细胞学。患者拒绝肾活检，但肿胀的牙龈的切面活检显示出伴有弥漫性浸润性肿瘤的非霍奇金淋巴瘤的特征(图2a)。免疫组织化学显示CD20呈强而弥漫阳性(图2B)，CK、CL20、Syn、CyA、S-100、CD99和CR45RO均为阴性。骨髓抽吸活组织检查发现淋巴瘤的特征。诊断为IV期B细胞非霍奇金淋巴瘤，患者接受长春新碱、阿霉素和强的松治疗一个周期，然后用环磷酰胺、阿霉素、长春新碱、强的松和利妥昔单抗治疗。在全身化疗期间，他每天都要进行血液透析。经过两周的化疗，他的右眼眼睑已经半开，右眼导液也都改善到
We recently examined a Chinese patient with acute progressive ophthalmoplegia caused by non-Hodgkin lymphoma (NHL). A 51-year-old Chinese man had the sudden onset of double vision preceded by three days of left gingival pain. He reported no headache, fever, chills, nausea, vomiting, vertigo, or dizziness. His medical history included pancreatitis and type II diabetes. He was in no distress. Vital signs were normal. There was no meningismus, lymph node, spleen, or liver enlargement. The left mandibular gingiva was red and swollen. Neuro-ophthalmologic examination showed normal visual function. There was partial right upper lid ptosis. The right pupil measured 5 mm in dim illumination and reacted sluggishly to direct light. The left pupil measured 4 mm and reacted normally to direct light. There was no afferent pupillary defect. The right eye had 50% abduction, 60% adduction, and 50% vertical ductions. The ductions of the left eye were normal. Corneal sensation was intact bilaterally. All other aspects of the neurologic and ophthalmologic examinations were normal. Within five days of our initial examination, he had developed total absence of ductions of the right eye, complete right upper lid ptosis, and a 7 mm unreactive right pupil. A dentist diagnosed a left periodontal abscess and performed incision and drainage. The patient was treated with the antibiotic sulbactam/cefoperazone and intravenous insulin. Laboratory data disclosed a complete blood cell count of 6,500 white blood cells, 192,000 platelets, and a hemoglobin level of 13.7 g/dl. The erythrocyte sedimentation rate was elevated at 65 mm/h (normal, 2–20 mm/h), and the C-reactive protein level was elevated at 48 mg/l (normal, 0–8 mg/l). Standard blood chemistries, including renal and liver function studies, C3 and C4 complement, antinuclear antibody, anti–double-stranded DNA, and ELISA for HIV were negative. Orbit CT and brain MRI were also normal. Abdominal ultrasonography was normal. Lumbar puncture revealed a normal opening pressure, glucose, protein, cell count, and cytology. Fifteen days after admission, the patient noted bilateral edema of the legs with persistent complete right ophthalmoplegia, ptosis, and mydriasis. Over the next two days, blood creatinine level rose rapidly to 210 mmol/l (normal upper limit, 106) and BUN to 16.96 mmol/l (normal upper limit, 8.3). An abdominal CT scan demonstrated the presence of a soft tissue mass in the left perirenal space (Fig. 1). Ultrasound examination showed an enlarged spleen, liver, and kidneys (right kidney, 15 cm; left kidney, 16 cm) without signs of urinary obstruction. The kidney parenchyma was hypoechogenic; color-coded duplex sonography revealed no signs of renal artery or vein thrombosis. Serial complete blood counts remained normal for the next 13 days. A second lumbar puncture performed seven days after presentation continued to show normal opening pressure, chemistries, cell count, and cytology. The patient refused renal biopsy, but incisional biopsy of the swollen gingiva demonstrated features of NHL with diffusely infiltrating tumor (Fig. 2A). Immunohistochemistry was strongly and diffusely positive for CD20 (Fig. 2B) and negative for CK, CL20, Syn, CyA, S-100, CD99, and CR 45RO. Bone marrow aspiration biopsy disclosed features of lymphoma. With a diagnosis of stage IV B-cell NHL, the patient was treated with vincristine, adriamycin, and prednisone for one cycle, followed by cyclophosphamide, doxorubicin, vincristine, and prednisone as well as rituximab. He underwent daily hemodialysis during the systemic chemotherapy. After two weeks of chemotherapy, his right lid had opened halfway, and right eye ductions had all improved to
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DOI：
10.1097/01.wno.0000205622.45263.ad
发表时间：
2006-03
期刊：
Journal of neuro-ophthalmology : the official journal of the North American Neuro-Ophthalmology Society
影响因子：
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作者：
Frederick W. Fraunfelder;T. Shults
通讯作者：
Frederick W. Fraunfelder;T. Shults
影响因子：
4.2
作者：
HAYREH, SS;ZIMMERMAN, MB;ALWARD, WLM
通讯作者：
ALWARD, WLM
影响因子：
20.3
作者：
Marcus, R;Imrie, K;Smith, P
通讯作者：
Smith, P
影响因子：
4.2
作者：
Hayreh, SS;Podhajsky, PA;Zimmerman, B
通讯作者：
Zimmerman, B
影响因子：
--
作者：
S. Hayreh
通讯作者：
S. Hayreh