This 45 year female , came to me from Bahrain for the complaints of giddiness ,vertigo and ataxia since last 2 years . The problem started suddenly one night , when she fell down due to sudden onset sustains vertigo, She is not a known case go DM, HT or smoker. She underwent treatment for infertility and has three uneventful pregnancy.
The current problem is so severe that she became wheelchair bound . In last two year she was seen by multiple docs at UAE and India. Multiple CT ,and MRI of head and spine, nystagmogram, audiogram , could not diagnose her problems.
She has continuous ringing sensation in both ear , sleep disturbances, vomiting sensation and nystagmus in looking upwards and lateral side. There is history of evening rise fever since last 3 month. No weight loss.
Positive findings in her blood reports – Hb 8.5 gm ( confirm iron deficiency -replacement started). Heavy and prolong menstrual losses.
My 1st approach was to rule out local pathology, for which I took help of ENT & Neurophysician. We did repeat ,MRI brain & cervical spine which was normal . MRI PNS -fluid filled collected in maxillary and ethmoid sinuses.
Audiometry was normal . Nystagmus in upward gaze – ( indicates systemic disease ). So clinical diagnosis was Ataxia with upward gaze without localising signs.
So I needed to look for systemic causes and clue was from Low Hb & sinus involvement . Though the anaemia was of iron deficiency ,but causes of heavy menstrual loss could not be ascertained in view if normal ovary and uterus.
MY 1st clinical impression was RES system involvement . S I examined the patient and found mild splenomegaly with Left Supraclavicular Lymphadenopathy . USG -Abdomen confirmed the abdominal lymphadenopathy with hepatospleenomegaly . Lymph node biopsy confirmed low grade follicular lymphoma. PET -CT confirmed the extensive uptake of hot area in thorax & abdomen. After 1st dose of chemo -patient’s ataxia is gone while sitting and lying.
On literature review I found that lymphoma presenting as nystagmus /ataxia is very rare . Case explained is autoimmune antibody against balance system.
Her CSF,BONE MARROW IS UNREMARKABLE.
