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The Clinical Picture

Central nervous system lymphoma mimicking Bell palsy

Kiyoshi Shikino, MD, PhD, Shingo Suzuki, MD, PhD, Takanori Uehara, MD, PhD and Masatomi Ikusaka, MD, PhD
Cleveland Clinic Journal of Medicine June 2018, 85 (6) 442-443; DOI: https://doi.org/10.3949/ccjm.85a.17061
Kiyoshi Shikino
Department of General Medicine, Chiba University Hospital, Chiba, Japan
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Shingo Suzuki
Department of General Medicine, Chiba University Hospital, Chiba, Japan
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Takanori Uehara
Department of General Medicine, Chiba University Hospital, Chiba, Japan
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Masatomi Ikusaka
Department of General Medicine, Chiba University Hospital, Chiba, Japan
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A 59-year-old woman presented with drooling out of the left side of her mouth and inability to close her left eye. She had no ear pain, hearing loss, or skin rash. The facial palsy affected all branches of the left facial nerve. This explained her inability to close her left eyelid and the generalized weakness of the left side of the face, including her forehead and angle of the mouth. No other signs of pontine dysfunction were noted.

See related editorial, page 444

The symptoms had begun 2 months earlier, and computed tomography (CT) of the head performed at a nearby clinic 3 days after the onset of symptoms showed no abnormalities. She was given a diagnosis of incomplete Bell palsy and was prescribed prednisolone and valacyclovir. However, her symptoms had not improved after 2 months of treatment, and so she presented to our hospital.

Physical examination revealed moderate nerve dysfunction (House-Brackmann grade III, with grade I normal and grade VI total paralysis) and generalized weakness on the left side of her face including her forehead.1 She had no loss in facial sensation or hearing and no ataxia or ocular motility disorders.

CT revealed a low-density lesion in the pons (Figure 1), and T2-weighted magnetic resonance imaging with intravenous contrast revealed a high-intensity lesion in the left middle cerebellar peduncle (Figure 2). Laboratory testing was negative for human immunodeficiency virus antibodies.

Figure 1
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Figure 1

Computed tomography 2 months after the onset of symptoms showed a low-density lesion in the left middle cerebellar peduncle (arrow).

Figure 2
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Figure 2

T2-weighted magnetic resonance imaging with contrast revealed a cystic enhancing lesion in the left middle cerebellar peduncle (arrow).

Study of an excision biopsy of the lesion confirmed diffuse large B-cell lymphoma. Whole-body CT revealed no other lesions, leading to a diagnosis of primary diffuse large B-cell lymphoma. Although the patient’s symptoms partially improved with dexamethasone and methotrexate, she died 4 months later.

BELL PALSY

Peripheral facial nerve palsy is classified either as Bell palsy, which is idiopathic, or as secondary facial nerve palsy. Because Bell palsy accounts for 60% to 70% of all cases,2 treatment with oral steroids is indicated when no abnormal findings other than lateral peripheral facial nerve palsy are observed. Antiviral drugs may provide added benefit, although academic societies do not currently recommend combined therapy.3 However, 85% of patients with Bell palsy improve within 3 weeks without treatment, and 94% of patients with incomplete Bell palsy—defined by normal to severe dysfunction, ie, not total paralysis, based on House-Brackmann score—eventually achieve complete remission.2

Therefore, although progression of symptoms or lack of improvement at 2 months does not rule out Bell palsy, it should prompt a detailed imaging evaluation to rule out an underlying condition such as tumor (in the pons, cerebellopontine angle, parotid gland, middle ear, or petrosal bone), infection (herpes simplex, varicella zoster, Ramsey-Hunt syndrome, or otitis media), trauma, or systemic disease (diabetes mellitus, multiple sclerosis, sarcoidosis, or systemic lupus erythematosus).4

According to a review of common causes of facial nerve palsy, the most common finding in 224 patients misdiagnosed with Bell palsy was tumor (38%).5 This indicates the value of magnetic resonance imaging of the head rather than CT when secondary facial nerve palsy is suspected, as CT is not sensitive to brainstem lesions.

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REFERENCES

  1. ↵
    1. House JW,
    2. Brackmann DE
    . Facial nerve grading system. Otolaryngol Head Neck 1985; 93(2):146–147. doi:10.1177/019459988509300202
    OpenUrlCrossRef
  2. ↵
    1. Peitersen E
    . Bell’s palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Otolaryngol Suppl 2002; suppl 549:4–30. pmid:12482166
    OpenUrlPubMed
  3. ↵
    1. De Almeida JR,
    2. Al Khabori M,
    3. Guyatt GH,
    4. et al
    . Combined corticosteroid and antiviral treatment for Bell palsy: a systematic review and meta-analysis. JAMA 2009; 302(9):985–993. doi:10.1001/jama.2009.1243.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Alaani A,
    2. Hogg R,
    3. Saravanappa N,
    4. Irving RM
    . An analysis of diagnostic delay in unilateral facial paralysis. J Laryngol Otol 2005; 119(3):184–188. pmid:15845188
    OpenUrlPubMed
  5. ↵
    1. May M,
    2. Klein SR
    . Differential diagnosis of facial nerve palsy. Otolaryngol Clin North Am 1991; 24(3):613–645. pmid:1762779
    OpenUrlPubMed
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Cleveland Clinic Journal of Medicine: 85 (6)
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1 Jun 2018
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Central nervous system lymphoma mimicking Bell palsy
Kiyoshi Shikino, Shingo Suzuki, Takanori Uehara, Masatomi Ikusaka
Cleveland Clinic Journal of Medicine Jun 2018, 85 (6) 442-443; DOI: 10.3949/ccjm.85a.17061

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Central nervous system lymphoma mimicking Bell palsy
Kiyoshi Shikino, Shingo Suzuki, Takanori Uehara, Masatomi Ikusaka
Cleveland Clinic Journal of Medicine Jun 2018, 85 (6) 442-443; DOI: 10.3949/ccjm.85a.17061
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