Diagnostic Delay due to COVID-19 Pandemic - A Case of Primary CNS Lymphoma

Objective: We describe a case of primary central nervous system lymphoma (PCNSL) where diagnosis/treatment was delayed due to the coronavirus disease 2019 (COVID-19) pandemic. Background: PCNSL is a rare aggressive extranodal non-Hodgkin lymphoma, rapidly fatal if left untreated. Corticosteroids can alter imaging appearance of PCNSL, requiring a high index of suspicion to establish the diagnosis. Design/Methods: Delay in care with diagnosis and treatment of PCNSL in the COVID-19 pandemic setting. Results: This 51-year-old woman on prednisone and oral methotrexate for uveitis presented with nausea, vomiting, and fatigue following exposure to an individual with confirmed COVID19. Patient's Coronavirus testing was negative. She deteriorated, developing ataxia, depression, and hypersomnolence. Outpatient neurology evaluation was delayed by 2 months after symptom onset due to the pandemic. Initial MRI brain findings including T2 hyperintensities involving periventricular white matter, basal ganglia, and cerebellar hemispheres with limited enhancement led to hospitalization. Demyelinating disease was suspected, methylprednisolone and plasmapheresis were administered. Patient became increasingly somnolent with spastic quadriparesis. Hospital visitation was limited to one person, starting noon for six hours a day. Bedside rounds were often completed by that time. Patient's inability to advocate for herself due to altered consciousness likely added to diagnostic delay. Repeat MRI brain three weeks after admission demonstrated progressive white matter lesions with patchy enhancement. Brain biopsy confirmed diagnosis of diffuse large B-cell lymphoma (DLBCL), non-germinal center, double-expressor phenotype. She was started on high-dose methotrexate with signs of neurologic recovery. Conclusions: PCNSL has variable manifestations potentially mimicking a variety of neurologic and psychiatric disorders. In this case, outpatient workup was prolonged due to COVID-19, imaging atypical from steroid treatment, patient unable to advocate for herself due to altered level of consciousness with restricted visitation during hospitalization, leading to significant diagnostic delay and development of neurologic disability.