HISTORY:
A 16 year-old male presented to an outpatient sports medicine clinic one month after a head-to-head collision during a soccer match with concern for concussion. There was no loss of consciousness, and he continued to play the rest of the game with a mild headache. He felt normal and asymptomatic that evening and was able to complete homework. The following morning he felt tired, but was able to perform adequately at school. Over the coming weeks, he noticed progressive worsening of his cognitive symptoms and tiredness. His athletic trainer became concerned for a concussion and held him from practice. One week prior to presentation he noted midline lower lip numbness, teeth pain while chewing, hearing his pulse in his left ear, and poor sleep due to sweatiness. He also felt progressive lethargy and difficulty concentrating and missed the last three days of school due to these symptoms. His medical history was significant only for a recently diagnosed inguinal hernia.
PHYSICAL EXAMINATION:
Mild cognitive deficits in attention and memory, impaired balance on BESS, normal motor strength. Cranial nerve exam showed ptosis of the left eye, mild left facial nerve palsy, decreased hearing in the left ear, and altered sensation to light touch over the middle lower lip. There was no focal tenderness or deformity of the skull or scalp.
DIFFERENTIAL DIAGNOSIS:
Mild traumatic brain injury
Intracranial hemorrhage
Cerebral mass
Bell’s palsy
TESTS AND RESULTS:
MRI Brain with and without contrast: Asymmetric enhancement of the left 7^th cranial nerve, asymmetric nodular enhancement along the left 5^th nerve with enhancement of muscles of mastication, diffuse bilateral pachymeningeal enhancement.
Complete Blood Count: WBC 19k, platelets 80, hematocrit 30.4
CT Chest, Abdomen, Pelvis: Large abdominal soft-tissue mass herniating through the inguinal canal, most consistent with a lymphoma
CSF Cytology: Enlarged B-cells most consistent with Burkitt lymphoma.
FINAL DIAGNOSIS:
Stage IV Burkitt lymphoma, with primary lesion in abdomen, and perimeningeal spread, causing cranial nerve V and VII palsies.
TREATMENT AND OUTCOMES:
1. Admitted for prompt initiation of chemotherapy.
2. Cranial nerve symptoms resolved with chemotherapy and steroids.
3. After multiple rounds of chemotherapy, there is no evidence of residual lymphoma.