# Flaccid Lower Limb Paraparesis Despite Infiltration of the Spinal Cord by a Secondary Central Nervous System T-cell Non-Hodgkin Lymphoma With Syringomyelia: A Case Report

## TL;DR

A patient with T-cell non-Hodgkin lymphoma developed flaccid lower limb weakness due to spinal cord infiltration and vincristine-induced neuropathy.

## Contribution

This is the first reported case of flaccid paraparesis in secondary CNS T-cell NHL with syringomyelia and axonal motor neuropathy.

## Key findings

- The patient exhibited flaccid paraparesis with hypotonia and absent reflexes, not typical spastic signs.
- Lymphoma infiltration of the spinal cord was associated with vincristine-induced axonal motor neuropathy.
- Secondary CNS lymphoma can present with atypical neurological features when peripheral nerves are affected.

## Abstract

Secondary central nervous system (CNS) lymphomas typically present with weakness, spasticity, exaggerated tendon reflexes, and pyramidal signs. A patient with progressive flaccid paraparesis of the lower extremities despite carcinomatosis and infiltration of T-cell non-Hodgkin lymphoma (NHL) into the spinal cord has not been described to date.

A 71-year-old man was diagnosed with T-cell NHL not otherwise specified, stage 4B, and an international prognostic index of 5 based on a lymph node biopsy and bone marrow puncture. The patient received three cycles of cyclophosphamide, hydroxydaunorubicin, vincristine, and prednisone (CHOP) chemotherapy, which had to be discontinued due to thrombocytopenia and the onset of paraparesis of the lower extremities. Examination of the paraparesis revealed lymphoma infiltrates in the brain and spinal cord. Despite these CNS lesions, the patient did not exhibit spasticity, pyramidal signs, or increased reflexes; rather, hypotonia and a general absence of reflexes were observed. These were attributed to axonal motor neuropathy due to vincristine toxicity.

T-cell NHL may not be suppressed by CHOP chemotherapy, may spread secondarily to the CNS, and may infiltrate the brain and spinal cord, manifesting as paraparesis, incontinence, muscle hypotonia, and decreased tendon reflexes. Secondary CNS lymphoma does not necessarily have to be accompanied by hyperreflexia, pyramidal signs, and spasticity if the peripheral nerves are severely affected by vincristine toxicity.