Recurrent cerebral infarcts and cortical microbleeds in a patient with diffuse large B-cell lymphoma: a case report

While stroke caused by intravascular large B-cell lymphoma (IVLBCL) has been increasingly recognized, diffuse large B-cell lymphoma (DLBCL)-associated stroke remains poorly understood. We describe a patient with adrenal DLBCL whose neuroimaging resembled findings reported in IVLBCL. A 53-year-old male presented with bilateral limb weakness evolving over one month, particularly in the lower limbs. On evaluation, he showed persistent white matter hyperintensities on serial brain diffusion-weighted imaging (DWI) and multiple cortical microbleeds on brain susceptibility-weighted imaging (SWI). Finally, systemic evaluation revealed a markedly hypermetabolic soft tissue mass in the left adrenal gland, which biopsy confirmed as DLBCL. He achieved complete resolution of limb weakness after the first cycle of treatment for DLBCL. Two-month follow-up imaging demonstrated a 77% reduction in the cross-sectional area of the left adrenal mass. The neurological course suggested lymphoma-associated cerebrovascular involvement. Persistent white matter hyperintensities on DWI and cortical microbleeds on SWI should prompt consideration of lymphoma in patients with unexplained recurrent infarcts. When lymphoma is suspected, further evaluation of an indeterminate systemic mass may help identify a suitable biopsy site, even if computed tomography (CT) initially suggests a benign lesion.