Case Report Open Access
Volume 4 | Issue 1 | DOI: https://doi.org/10.33696/casereports.4.018

A Challenging Case of Central Nervous System Involvement (CNSi) with Chronic Lymphocytic Leukemia (CLL): A Case Report

  • 1Neurology resident, Rashid hospital, Dubai health authority, Dubai, United Arab Emirates
  • 2Consultant neurologist, Rashid hospital, Dubai health authority, Dubai, United Arab Emirates
+ Affiliations - Affiliations

Corresponding Author

Sara Ali Alshamali, dr.sara.alshamali@gmail.com

Received Date: February 08, 2022

Accepted Date: May 08, 2022


A 42 years old male, with a recent COVID-19 infection, presented with multiple progressive neurologic symptoms over one month; starting as numbness around the mouth, reduced facial sensation, and a feeling of band-like sensation below the costal margins. On further examination, he had left abduction restriction, diplopia on left gaze and upbeat nystagmus, reduced facial sensation, and hyperesthesia. The reflexes were 1+ in the upper limbs, 3+ in the lower limbs, upgoing planters, tingling from the feet up to T6 level, and postural tremor bilaterally. His cerebrospinal fluid (CSF) showed a high protein level. Magnetic resonance imaging (MRI) brain/spine revealed left frontal juxtacortical white matter and bilateral middle cerebral peduncles lesions with post-contrast enhancement and long-segment spinal cord demyelinating plaques. He was initially treated as a case of acute disseminated encephalomyelitis (ADEM) post-viral infection in a background of CLL. The delayed diagnosis was due to the temporal relation of neurological manifestation to viral infection, similar MRI lesions to ADEM, and multiple negative CSF results of cytology and flow cytometry. He was managed for ADEM based on responsiveness to the recommended therapy step by step. Firstly, he received a high dose of corticosteroids, secondly IV immunoglobulin but he was still progressing. Lastly, plasma exchange was done and he exhibited progressive symptoms with fair improvement. Interestingly, the patient showed significant improvement in the clinical and radiological parameters after starting him with anti-leukemia medication (Acalabrutinib) for his active CLL. He ran out of that chemotherapy, so he experienced a recurrence of the neurological manifestation and the previous lesions in the images. Repeated flow cytometry for the third time came positive for CLL cells and the final diagnosis of CNS involvement by CLL was established. The patient received Ibrutinib at a standard dose and as a monotherapy. The patient is back to his work and his daily activities have improved.

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