title: Diffuse large B-cell lymphoma presenting with central pontine myelinolysis: a case report.
abstract: BACKGROUND
  The most common cause of central pontine myelinolysis is an overly rapid correction of hyponatremia, although it can also occur in patients with any condition leading to nutritional or electrolyte stress. We report a case of diffuse large B-cell lymphoma with central pontine myelinolysis developing at the onset of disease. To the best of our knowledge, hematological malignancies presenting with central pontine myelinolysis have been rarely reported, especially in previously untreated patients, as in our case report.
  
  
  METHODS
  A 78-year-old Japanese woman presented to a neighborhood clinic with persistent high fever, edema, and general weakness. Despite the absence of specific neurological findings, brain magnetic resonance imaging showed an abnormal lesion in the central pons area of her brain (hyperintense on T2-weighted and hypointense on T1-weighted sequences), compatible with central pontine myelinolysis. She was admitted to our emergency department in a state of shock one month later. The results of her blood tests showed greatly elevated C-reactive protein and lactate dehydrogenase levels. She had severe hypoalbuminemia and mild hyponatremia, and showed signs of disseminated intravascular coagulation. Mild bilateral pleural effusion, prominent subcutaneous edema, and splenomegaly were detected on her systemic computed tomography scan. Her body fluid cultures did not show signs of infection and her spinal aspiration did not show pleocytosis or abnormal cells. A diagnosis of diffuse large B-cell lymphoma was made based on the results of her bone marrow examination. As she was critically ill before the diagnosis was made, she was treated with methylprednisolone pulse therapy, followed by systemic chemotherapy (rituximab with modified THP-COP regimen, including cyclophosphamide, pirarubicin, vindesine, and prednisolone), which resulted in complete remission and recovery without any neurological defects, and resolution of her abnormal findings on magnetic resonance imaging.
  
  
  CONCLUSIONS
  Central pontine myelinolysis is a serious condition that may result in neuropathological sequelae and mortality, and clinicians should be aware of its potential presence in patients with malignancies.
authors.affiliation: Department of Hematology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-cho, Kamigyo-ku, Kyoto, 602-8026, Japan. kawatae@kyoto2.jrc.or.jp.
authors.forename: Eri
authors.initials: E
authors.lastname: Kawata
authors.affiliation: Department of Hematology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-cho, Kamigyo-ku, Kyoto, 602-8026, Japan. reiko.isa826@gmail.com.
authors.forename: Reiko
authors.initials: R
authors.lastname: Isa
authors.affiliation: Department of Hematology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-cho, Kamigyo-ku, Kyoto, 602-8026, Japan. junko_y_0917@yahoo.co.jp.
authors.forename: Junko
authors.initials: J
authors.lastname: Yamaguchi
authors.affiliation: Department of Hematology and Oncology, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 602-8566, Japan. whitelie0117@yahoo.co.jp.
authors.forename: Kazuna
authors.initials: K
authors.lastname: Tanba
authors.affiliation: Department of Hematology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-cho, Kamigyo-ku, Kyoto, 602-8026, Japan. yasuadd@koto.kpu-m.ac.jp.
authors.forename: Yasuhiko
authors.initials: Y
authors.lastname: Tsutsumi
authors.affiliation: Department of Neurology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-cho, Kamigyo-ku, Kyoto, 602-8026, Japan. ynagakane@gmail.com.
authors.forename: Yoshinari
authors.initials: Y
authors.lastname: Nagakane
authors.affiliation: Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, 15-749 Honmachi, Higashiyama-ku, Kyoto, 605-0981, Japan. huchiyam@koto.kpu-m.ac.jp.
authors.forename: Hitoji
authors.initials: H
authors.lastname: Uchiyama
authors.affiliation: Department of Hematology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-cho, Kamigyo-ku, Kyoto, 602-8026, Japan. akaogit@kyoto2.jrc.or.jp.
authors.forename: Teruaki
authors.initials: T
authors.lastname: Akaogi
authors.affiliation: Department of Hematology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-cho, Kamigyo-ku, Kyoto, 602-8026, Japan. kobataka@koto.kpu-m.ac.jp.
authors.forename: Yutaka
authors.initials: Y
authors.lastname: Kobayashi
authors.affiliation: Department of Hematology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi-cho, Kamigyo-ku, Kyoto, 602-8026, Japan. uoshiman@kyoto2.jrc.or.jp.
authors.forename: Nobuhiko
authors.initials: N
authors.lastname: Uoshima
mesh_terms: D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D001921:Brain / Q000473:pathology; D005260:Female; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D007010:Hyponatremia / Q000150:complications / Q000188:drug therapy; D016403:Lymphoma, Large B-Cell, Diffuse / Q000150:complications* / Q000188:drug therapy*; D008279:Magnetic Resonance Imaging; D008775:Methylprednisolone / Q000627:therapeutic use; D017590:Myelinolysis, Central Pontine / Q000150:complications* / Q000188:drug therapy*
chemical_list: D005938:Glucocorticoids; D008775:Methylprednisolone