Case presentation
A 48-year-old man with acquired immunodeficiency syndrome (AIDS) was referred to our center with complaints of headache from 5 days ago, ear pain, dysphagia, diplopia and vertigo. The patient also reported a 5 kg weight loss over the past two months. The diagnosis of AIDS was made 8 months ago, of which cluster of differentiation 4 (CD4) counted 62×106/l and he had poor compliance regrading antiretroviral treatment (ART). The recent CD4 count for the patient was 162×106/l. He was methadone dependent (80 mL daily) and a cigarette smoker from several years ago.
On admission, the patient exhibited normal vital signs. Head and neck examination revealed miotic pupils, diplopia, limited abduction of the left eye, facial numbness, hearing loss in the left ear, absence of the gag reflex, weakness of the left trapezius muscle, voice changing and right deviation of a protruded tongue with local palsy. In the abdominal examination, splenomegaly with no sign of hepatomegaly was noted.
The patient was examined using indirect laryngoscopy (IDL). The larynx was full of secretion and the patient was unable to swallow his sputum. There was left hemilateral paralysis with no mass.
Brain and neck CT scan with contrast revealed a hypodense mass-like lesion with mild enhancement in the left parapharyngeal space which causes carotid artery deviation to anterior and left nasopharyngeal bulging. Left jugular vein obstruction due to mass compressive effect and also an erosion in the occipital condyle and lateral atlas mass (C1) in this side were seen.
In cervical CT scan findings were included a parapharyngeal mass with no specific limitations extending from skull base to the first of oropharynx that makes obliteration in parapharyngeal fat and deviation of ICA to the lateral side. Basiocciput erosion and anterolateral of C1, anterior wall of transverse foramen of C1was seen. Compressive effect on the left jugular vein and complete obstruction was also observed. Asymmetrical uvula and vallecula showed cranial nerve palsy due to mass compression effect. Lymphadenopathy in the left side level 2 with SAD=12mm was observed.
Abdominal ultrasonography showed a large spleen with 145mm diameter and several hypoecho masses with targeted view in the spleen with mean size 30*20mm.
A core needle biopsy was performed from cervical lymph node level 2 and the pathological report was high grade diffuse large cell lymphoma activated B cell (ABC) type. Immunohistochemistry study revealed positive results for LCA, CD20, CD79a, MUM1, Bcl2, Bcl6 and negative results for CK, CD3, CD10 and Myc. Proliferation index was high (Ki67= 70%).
The patient was operated for hypersplenism and a decrease in platelet count.
Eventually, the patient deceased due to rapidly progressive respiratory distress probably opportunistic infection including pneumocystis jiroveci despite of urgent therapeutic intervention.