Table 1.
Clinical course timeline
| Date | Event |
|---|---|
| October 10–15, 2009 | A 57 year-old woman with no significant past medical history presents with 6 weeks of fatigue, confusion and headache, with physical exam revealing right inferior homonymous quadrantanopsia, mild right hemiparesis and a wide-based gait admitted for evaluation of multiple brain lesions |
| Brain MRI revealed multiple enhancing lesions, including right frontal and left parieto-occipital mass lesions concerning for neoplasm | |
| Patient was treated with pre-operative corticosteroids for 3 days | |
| October 28 | Biopsy of the left parieto-occipital lesion revealed mononuclear infiltrates with evidence of demyelination, but without evidence of malignancy |
| Patient was treated with a second round of intravenous corticosteroids for presumed acute disseminated encephalomyelitis or tumefactive multiple sclerosis | |
| Patient was discharged home after showing rapid clinical improvement | |
| November 23 | Over the course of several weeks, the patient developed progressive dysarthria and right-sided weakness, prompting readmission to the hospital |
| A repeat brain MRI showed an increase in the size of the left-sided lesions, with vasogenic edema and subfalcine herniation | |
| November 25 | Patient refused a repeat brain biopsy |
| November 27 | Patient was treated with a third round of intravenous corticosteroids and rituximab infusions, resulting in symptomatic improvement and discharge from the hospital |
| April 13, 2010 | Over the following five months, after initial improvement, the patient again developed progressively worsening right hemiparesis and dysarthria, resulting in a second hospital readmission |
| MRI of the brain showed enlargement of the prior intracranial lesions with nodular enhancement suggestive of neoplasm | |
| May 25 | A second brain biopsy of the left parietal lesion was consistent with diffuse large B-cell lymphoma |
| Patient was treated with high dose methotrexate and leucovorin | |
| June 7 | In light of her continued clinical deterioration despite treatment, the patient was transferred to hospice care |
| Patient passed away in hospice care |