An unusual cause of encephalopathy in the setting of a new diagnosis of DLBCL

Bryan Still,Harsh Shah,Isabella Frances Mcnamara,Scott Rizzi

doi:10.5348/100094z10im2021cr

Abstract

A 69-year-old woman presented with progressive lethargy and encephalopathy of two weeks duration. Initial laboratory workup revealed hypercalcemia; imaging was notable for a 16 cm by 16 cm right lower quadrant abdominal mass. Core biopsy revealed germinal center Diffuse Large B-Cell Lymphoma (DLBCL). Despite correction of her hypercalcemia, the patient’s encephalopathy persisted. Brain imaging, thyroid stimulating hormone (TSH), folate, B12, urinalysis and culture, antinuclear antibody (ANA), and ammonia were normal. Cerebrospinal fluid (CSF) was negative for leptomeningeal disease. A thiamine level was sent and found to be low. Aggressive repletion was pursued; following the first cycle of chemotherapy, the patient’s mental status normalized. This is a rare case in which the rapid turnover of cells in the setting of active malignancy is believed to play a role in the development of thiamine depletion and resultant encephalopathy.

Highlights

Encephalopathy is a broad spectrum of disease secondary to an insult to the brain that changes its function
Repeat magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) brain were negative for central nervous system (CNS) disease and did not show concerning signs of Creutzfeldt-Jakob disease (CJD)
After receiving thiamine replacement and completing the first cycle of R-CHOP with intrathecal methotrexate, her mental status and gait returned to baseline

Summary

Introduction

Encephalopathy is a broad spectrum of disease secondary to an insult to the brain that changes its function. The differential diagnosis for encephalopathy is broad and can be caused by medications, toxins, metabolites, nutritional deficiencies, and more. Wernicke encephalopathy (WE) and Korsakoff syndrome (KS) are widely recognized complications of excessive alcohol consumption, poor nutritional intake, and resultant thiamine deficiency. Thiamine deficiency can be seen in other nutritional deficiencies and high metabolic states such as systemic infection, malignancy, and post-transplant [1]. Demand for thiamine positively correlates with high metabolic demand states as well as elevated rates of glucose consumption. Thiamine deficiency may occur as a result of impaired utilization through inactivating medications, or through excessive losses as reported with diuretic use, diabetes, and hemodialysis [2,3,4].

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Discussion

Conclusion