Some Like it Hot

Abstract

History & ExamA 71 year old Caucasian man with a past medical history of hypertension, hyperlipidemia, Type 2 DM,ESRD status post renal transplant, facial melanoma, currently on ASA for a stable left sided putaminalhemorrhage presented with new right sided ptosis and lower extremity weakness. Brain MRI obtainedon admission showed small cortical hemorrhages consistent with prior stroke, without evidence of acutepathologic changes. Repeat fine cut MRI of the brain and orbits with and without contrast showed anenhancing lesion in the right parietal bone, clinoid process, and associated abnormal soft tissue changesextending into the right orbital apex, adjacent superior right sphenoid sinus, and the right anterolateralcavernous sinus.EMG showed no evidence of a neuromuscular disorder. Lung and parietal bone biopsy revealed CD10positive atypical lymphoid cells. On laboratory evaluation, a CBC revealed a low red blood cellcount. A lumbar puncture revealed an opening pressure of 12.5 mmHg with an Epstein Barr Virus loadof 115 with normal cell counts otherwise. Lymphoma panel showed no abnormal lymphaticcells. Additional CT of the chest, abdomen, and pelvis revealed multiple well-circumscribed pulmonarynodules suspicious for pan-lobar metastatic disease involving both the right and left lungs in addition toprofound mesenteric lymphadenopathy. Bone scan showed evidence of multiple areas of involvement inthe skull, right humerus and left tibia.Vital signs were normal. Visual acuity was 20/60 OD and 20/30 OS, color vision was intact, visualfields were normal and pupils were anisocoric (R 4mm, L 3mm both reactive) with near complete ptosison the right with severely depressed levator function. His right eye was unable to adduct past themidline while the left eye had normal range of motion. There was an associated right-sided facial droop.Motor testing showed normal bulk and tone with normal reflexes. There were no sensory deficits